ACS Surgery - Principles and Practice (PDFDrive) PDF

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ACS Surgery: Principles and Practice

ELEMENTS OF CONTEMPORARY PRACTICE 1 Professionalism in Surgery — 1
1 PROFESSIONALISM IN SURGERY
Wiley W. Souba, M.D., SC.D., F.A.C.S.
Over the past decade, the American health care system has had to of technical and specialized knowledge that it both teaches and
cope with and manage an unprecedented amount of change. As a advances; it sets and enforces its own standards; and it has a ser-
consequence, the medical profession has been challenged along vice orientation, rather than a profit orientation, enshrined in a
the entire range of its cultural values and its traditional roles and code of ethics.3-5 To put it more succinctly, a profession has cogni-
responsibilities. It would be difficult, if not impossible, to find tive, collegial, and moral attributes. These qualities are well
another social issue directly affecting all Americans that has under- expressed in the familiar sentence from the Hippocratic oath: “I
gone as rapid and remarkable a transformation—and oddly, a will practice my art with purity and holiness and for the benefit of
transformation in which the most important protagonists (i.e., the the sick.”
patients and the doctors) remain dissatisfied.1 The escalating commercialization and secularization of medicine
Nowhere is this metamorphosis more evident than in the field have evoked in many physicians a passionate desire to reconnect
of surgery. Marked reductions in reimbursement, explosions in with the core values, practices, and behaviors that they see as exem-
surgical device biotechnology, a national medical malpractice cri- plifying the very best of what medicine is about. This tension
sis, and the disturbing emphasis on commercialized medicine have between commercialism on the one hand and humanism and
forever changed the surgical landscape, or so it seems. The very altruism on the other is a central part of the professionalism chal-
foundation of patient care—the doctor-patient relationship—is in lenge we face today.6 As the journalist Loretta McLaughlin once
jeopardy. Surgeons find it increasingly difficult to meet their wrote, “The rush to transform patients into units on an assembly
responsibilities to patients and to society as a whole. In these cir- line demeans medicine as a caring as well as curative field, demeans
cumstances, it is critical for us to reaffirm our commitment to the the respect due every patient and ultimately demeans illness itself
fundamental and universal principles and values of medical as a significant human condition.”7
professionalism. Historically, the legitimacy of medical authority is based on
The concept of medicine as a profession grounded in com- three distinct claims2,8: first, that the knowledge and competence
passion and sympathy for the sick has come under serious chal- of the professional have been validated by a community of peers;
lenge.2 One eroding force has been the growth and sovereignty second, that this knowledge has a scientific basis; and third, that
of biomedical research. Given the high position of science and the professional’s judgment and advice are oriented toward a set
technology in our societal hierarchy, we may be headed for a of values. These aspects of legitimacy correspond to the collegial,
form of medicine that includes little caring but becomes exclu- cognitive, and moral attributes that define a profession.
sively focused on the mechanics of treatment, so that we deal Competence and expertise are certainly the basis of patient
with sick patients much as we would a flat tire or a leaky faucet. care, but other characteristics of a profession are equally important
In such a form of medicine, healing becomes little more than a [see Table 1]. Being a professional implies a commitment to excel-
technical exercise, and any talk of morality that is unsubstantiat- lence and integrity in all undertakings. It places the responsibility
ed by hard facts is considered mere opinion and therefore car- to serve (care for) others above self-interest and reward. Accord-
ries little weight. ingly, we, as practicing medical professionals, must act as role
The rise of entrepreneurialism and the growing corporatization models by exemplifying this commitment and responsibility, so
of medicine also challenge the traditions of virtue-based medical that medical students and residents are exposed to and learn the
care. When these processes are allowed to dominate medicine, kinds of behaviors that constitute professionalism [see Sidebar
health care becomes a commodity. As Pellegrino and Thomasma Elizabeth Blackwell: A Model of Professionalism].
remark, “When economics and entrepreneurism drive the profes- The medical profession is not infrequently referred to as a voca-
sions, they admit only self-interest and the working of the market- tion. For most people, this word merely refers to what one does for
place as the motives for professional activity. In a free-market a living; indeed, its common definition implies income-generating
economy, effacement of self-interest, or any conduct shaped pri- activity. Literally, however, the word vocation means “calling,” and
marily by the idea of altruism or virtue, is simply inconsistent with the application of this definition to the medical profession yields a
survival.”2
These changes have caused a great deal of anxiety and fear
among both patients and surgeons nationwide. The risk to the
profession is that it will lose its sovereignty, becoming a passive Table 1—Elements of a Profession
rather than an active participant in shaping and formulating health
policy in the future. The risks to the public are that issues of cost A profession
will take precedence over issues of quality and access to care and • Is a learned discipline with high standards of knowledge and
performance
that health care will be treated as a commodity—that is, as a priv-
• Regulates itself via a social contract with society
ilege rather than a right. • Places responsibility for serving others above self-interest and reward
• Is characterized by a commitment to excellence in all undertakings
• Is practiced with unwavering personal integrity and compassion
The Meaning of Professionalism
• Requires role-modeling of right behavior
A profession is a collegial discipline that regulates itself by • Is more than a job—it is a calling and a privilege
means of mandatory, systematic training. It has a base in a body
© 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
more profound meaning. According to Webster’s Third New

International Dictionary,9 a profession may be defined as Elizabeth Blackwell: A Model of Professionalism17
a calling requiring specialized knowledge and often long acade- Elizabeth Blackwell was born in England in 1821, the daughter of a sug-
mic preparation, including instruction in skills and methods as ar refiner. When she was 10 years old, her family emigrated to New York
well as in the scientific, historical, or scholarly principles under- City. Discovering in herself a strong desire to practice medicine and care
lying such skills and methods, maintaining by force of organiza- for the underserved, she took up residence in a physician’s household,
tion or concerted opinion high standards of achievement and using her time there to study using books in the family’s medical library.
conduct, and committing its members to continued study and to As a young woman, Blackwell applied to several prominent medical
a kind of work which has for its prime purpose the rendering of schools but was snubbed by all of them. After 29 rejections, she sent her
a public service[.] second round of applications to smaller colleges, including Geneva Col-
lege in New York. She was accepted at Geneva—according to an anec-
Most of us went to medical school because we wanted to help and dote, because the faculty put the matter to a student vote, and the stu-
care for people who are ill. This genuine desire to care is unam- dents thought her application a hoax. She braved the prejudice of some
biguously apparent in the vast majority of personal statements of the professors and students to complete her training, eventually rank-
that medical students prepare as part of their application process. ing first in her class. On January 23, 1849, at the age of 27, Elizabeth
Blackwell became the first woman to earn a medical degree in the United
To quote William Osler, “You are in this profession as a calling, States. Her goal was to become a surgeon.
not as a business; as a calling which extracts from you at every After several months in Pennsylvania, during which time she became
turn self-sacrifice, devotion, love and tenderness to your fellow a naturalized citizen of the United States, Blackwell traveled to Paris,
man.We must work in the missionary spirit with a breath of char- where she hoped to study with one of the leading French surgeons. De-
ity that raises you far above the petty jealousies of life.”10 To keep nied access to Parisian hospitals because of her gender, she enrolled in-
medicine a calling, we must explicitly incorporate into the mean- stead at La Maternité, a highly regarded midwifery school, in the summer
of 1849. While attending to a child some 4 months after enrolling, Black-
ing of professionalism those nontechnical practices, habits, and well inadvertently spattered some pus from the child’s eyes into her own
attributes that the compassionate, caring, and competent physi- left eye. The child was infected with gonorrhea, and Blackwell contracted
cian exemplifies. We must remind ourselves that a true profes- a severe case of ophthalmia neonatorum, which later necessitated the
sional places service to the patient above self-interest and above removal of the infected eye. Although the loss of an eye made it impossi-
reward. ble for her to become a surgeon, it did not dampen her passion for be-
Professionalism is the basis of our contract with society. To coming a practicing physician.
By mid-1851, when Blackwell returned to the United States, she was
maintain our professionalism, and thus to preserve the contract well prepared for private practice. However, no male doctor would even
with society, it is essential to reestablish the doctor-patient rela- consider the idea of a female associate, no matter how well trained.
tionship as the foundation of patient care. Barred from practice in most hospitals, Blackwell founded her own infir-
mary, the New York Infirmary for Indigent Women and Children, in 1857.
When the American Civil War began, Blackwell trained nurses, and in
The Surgeon-Patient Relationship 1868 she founded a women’s medical college at the Infirmary so that
women could be formally trained as physicians. In 1869, she returned to
The underpinning of medicine as a compassionate, caring pro- England and, with Florence Nightingale, opened the Women’s Medical
fession is the doctor-patient relationship, a relationship that has College. Blackwell taught at the newly created London School of Medi-
become jeopardized and sometimes fractured over the past cine for Women and became the first female physician in the United
decade. Our individual perceptions of what this relationship is and Kingdom Medical Register. She set up a private practice in her own
how it should work will inevitably have a great impact on how we home, where she saw women and children, many of whom were of less-
approach the care of our patients.2 er means and were unable to pay. In addition, Blackwell mentored other
women who subsequently pursued careers in medicine. She retired at
The fundamental question to be answered is, what should the the age of 86.
surgeon-patient relationship be governed by? If this relationship is In short, Elizabeth Blackwell embodied professionalism in her work. In
viewed solely as a contract for services rendered, it is subject to the 1889 she wrote, “There is no career nobler than that of the physician.
law and the courts; if it is viewed simply as an issue of applied biol- The progress and welfare of society is more intimately bound up with the
ogy, it is governed by science; and if it is viewed exclusively as a prevailing tone and influence of the medical profession than with the sta-
commercially driven business transaction, it is regulated by the tus of any other class.”
marketplace. If, however, our relationship with our patients is
understood as going beyond basic delivery of care and as consti-
tuting a covenant in which we act in the patient’s best interest even charity and compassion for a contract based solely on the delivery
if that means providing free care, it is based on the virtue of char- of goods and services is something none of us would want for our-
ity. Such a perspective transcends questions of contracts, politics, selves. The nature of the healing relationship is itself the founda-
economics, physiology, and molecular genetics—all of which tion of the special obligations of physicians as physicians.2
rightly influence treatment strategies but none of which is any
substitute for authentic caring.
The view of the physician-patient relationship as a covenant Translation of Theory into Practice
does not demand devotion to medicine at the exclusion of other The American College of Surgeons (ACS) Task Force on Pro-
responsibilities, and it is not inconsistent with the fact that medi- fessionalism has developed a Code of Professional Conduct,11
cine is also a science, an art, and a business.2 Nevertheless, in our which emphasizes the following four aspects of professionalism:
struggle to remain viable in a health care environment that has
become a commercial enterprise, efforts to preserve market share 1. A competent surgeon is more than a competent technician.
cannot take precedence over the provision of care that is ground- 2. Whereas ethical practice and professionalism are closely relat-
ed in charity and compassion. It is exactly for this reason that med- ed, professionalism also incorporates surgeons’ relationships
icine always will be, and should be, a relationship between people. with patients and society.
To fracture that relationship by exchanging a covenant based on 3. Unprofessional behavior must have consequences.
4. Professional organizations are responsible for fostering profes- employees destroyed reports revealing that University doctors sub-
sionalism in their membership. mitted inflated billings to Medicare and Medicaid.The department
chair lost his job, was barred from participation in Medicare, and,
If professionalism is indeed embodied in the principles dis-
as part of his plea bargain, had to pay a $500,000 fine, perform
cussed [see Table 1], the next question that arises is, how do we
1,000 hours of community service, and write an article in a med-
translate theory into practice? That is, what do these principles look
ical journal about billing errors. The University spent many mil-
like in action? To begin with, a competent surgeon must possess
lions in legal fees and eventually settled the billing issues with the
the medical knowledge, judgment, technical ability, professional-
ism, clinical excellence, and communication skills required for pro- Federal government for one of the highest Physicians at Teaching
vision of high-quality patient-centered care. Furthermore, this Hospitals (PATH) settlements ever.
expertise must be demonstrated to the satisfaction of the profes- Fortunately, such extreme cases of unprofessionalism are quite
sion as a whole. The Accreditation Council on Graduate Medical uncommon. Nevertheless, it remains our responsibility as profes-
Education (ACGME) has identified six competencies that must be sionals to prevent such behaviors from developing and from being
demonstrated by the surgeon: (1) patient care, (2) medical knowl- reinforced. To this end, we must lead by example. A study pub-
edge, (3) practice-based learning and improvement, (4) interper- lished in 2004 demonstrated an association between displays of
sonal and communication skills, (5) professionalism, and (6) sys- unprofessional behavior in medical school and subsequent discipli-
tems-based practice. These competencies are now being integrat- nary action by a state medical board.14 The authors concluded that
ed into the training programs of all accredited surgical residencies. professionalism is an essential competency that students must
A surgical professional must also be willing and able to take demonstrate to graduate from medical school.Who could disagree?
responsibility. Such responsibility includes, but is not necessarily
limited to, the following three areas: (1) provision of the highest- The Future of Surgical Professionalism
quality care, (2) maintenance of the dignity of patients and co-
workers, and (3) open, honest communication. Assumption of It is often subtly implied—or even candidly stated—that no
responsibility as a professional involves leading by example, placing matter how well we adjust to the changing health care environ-
the delivery of quality care above the patient’s ability to pay, and ment, the practice of surgery will never again be quite as reward-
displaying compassion. Cassell reminds us that a sick person is not ing as it once was. This need not be the case. The ongoing
just “a well person with a knapsack of illness strapped to his back”12 advances in surgical technology, the increasing opportunities for
and that whereas “it is possible to know the suffering of others, to community-based surgeons to enroll their patients into clinical tri-
help them, and to relieve their distress, [it is not possible] to als, and the growing emphasis on lifelong learning as part of main-
become one with them in their torment.”13 Illness and suffering are tenance of certification are factors that not only help satisfy social
not just biologic problems to be solved by biomedical research and and organizational demands for quality care but also are in the
technology: they are also enigmas that can serve to point out the best interest of our patients.
limitations, vulnerabilities, and frailties that we want so much to In the near future, maintenance of certification for surgeons will
deny, as well as to reaffirm our links with one another. involve much more than taking an examination every decade.The
Most important, professionalism demands unwavering person- ACS is taking the lead in helping to develop new measures of com-
al integrity. Regrettably, examples of unprofessional behavior exist. petence.Whatever specific form such measures may take, display-
An excerpt from a note from a third-year medical student to the ing professionalism and living up to a set of uncompromisable
core clerkship director reads as follows: “I have seen attendings core values15 will always be central indicators of the performance
make sexist, racist jokes or remarks during surgery. I have met res- of the individual surgeon and the integrity of the discipline of
idents who joke about deaf patients and female patients with facial surgery as a whole.
hair. [I have encountered] teams joking and counting down the Although surgeons vary enormously with respect to personali-
days until patients die.” This kind of exposure to unprofessional ty, practice preferences, areas of specialization, and style of relating
conduct and language can influence young people negatively, and to others, they all have one role in common: that of healer. Indeed,
it must change. it is the highest of privileges to be able to care for the sick. As the
It is encouraging to note that many instances of unprofessional playwright Howard Sackler once wrote, “To intervene, even
conduct that once were routinely overlooked—such as mistreating briefly, between our fellow creatures and their suffering or death,
medical students, speaking disrespectfully to coworkers, and fraud- is our most authentic answer to the question of our humanity.”
ulent behavior—now are being dealt with. Still, from time to time Inseparable from this privilege is a set of responsibilities that are
an incident is made public that makes us all feel shame. In March not to be taken lightly: a pledge to offer our patients the best care
2003, the Seattle Times carried a story about the chief of neuro- possible and a commitment to teach and advance the science and
surgery at the University of Washington, who pleaded guilty to a practice of medicine. Commitment to the practice of patient-cen-
felony charge of obstructing the government’s investigation and tered, high-quality, cost-effective care is what gives our work
admitted that he asked others to lie for him and created an atmos- meaning and provides us with a sense of purpose.16 We as surgeons
phere of fear in the neurosurgery department. According to the must participate actively in the current evolution of integrated
United States Attorney in Seattle, University of Washington health care; by doing so, we help build our own future.
References
1. Fein R:The HMO revolution. Dissent, spring 1998, April 24, 1995 13. Cassell EJ: Recognizing suffering. Hastings Center
p 29 8. Starr PD: The social transformation of American Report 21:24, 1991
2. Pellegrino ED, Thomasma DC: Helping and Heal- medicine. Basic Books, New York, 1982 14. Papadakis M, Hodgson C, Teherani A, et al: Un-
ing. Georgetown University Press,Washington, DC, 9. Webster’s Third New International Dictionary of professional behavior in medical school is associat-
1997 the English Language, Unabridged. Gove PB, Ed. ed with subsequent disciplinary action by a state
3. Brandeis LD: Familiar medical quotations. Merriam-Webster Inc, Springfield, Massachusetts, medical board. Acad Med 79:244, 2004
Business—A Profession. Maurice Strauss, Ed. Little 1986, p 1811 15. Souba W: Academic medicine’s core values: what
Brown & Co, Boston, 1986 do they mean? J Surg Res 115:171, 2003
10. Osler’s “Way of Life” and Other Addresses, with
4. Cogan ML: Toward a definition of profession. Commentary and Annotations. Hinohara S, Niki 16. Souba W: Academic medicine and our search for
Harvard Educational Reviews 23:33, 1953 H, Eds. Duke University Press, Durham, North meaning and purpose. Acad Med 77:139, 2002
5. Greenwood E: Attributes of a profession. Social Carolina, 2001
17. Speigel R: Elizabeth Blackwell: the first woman
Work 22:44, 1957 11. Gruen RI, Arya J, Cosgrove EM, et al: Profession- doctor. Snapshots In Science and Medicine,
6. Souba W, Day D: Leadership values in academic alism in surgery. J Am Coll Surg 197:605, 2003 http://science-education.nih.gov/snapshots.
medicine. Acad Med (in press) 12. Cassell EJ: The function of medicine. Hastings nsf/story?openform&pds~Elizabeth_Blackwell_
7. McLaughlin L:The surgical express. Boston Globe, Center Report 7:16, 1977 Doctor
ELEMENTS OF CONTEMPORARY PRACTICE 2 PERFORMANCE MEASURES IN SURGICAL PRACTICE — 1
2 PERFORMANCE MEASURES IN
SURGICAL PRACTICE
John D. Birkmeyer, M.D., F.A.C.S.
With the growing recognition that the quality of surgical care tations, and offering recommendations for selecting the optimal
varies widely, there is a rising demand for good measures of surgi- quality measure.
cal performance. Patients and their families need to be able to
make better-informed decisions about where to get their surgical
care—and from whom.1 Employers and payers need data on Overview of Current Performance Measures
which to base their contracting decisions and pay-for-performance The number of performance measures that have been devel-
initiatives.2 Finally, clinical leaders need tools that can help them oped for the assessment of surgical quality is already large and
identify “best practices” and guide their quality-improvement efforts. continues to grow. For present purposes, it should be sufficient to
To meet these different needs, an ever-broadening array of perfor- consider a representative list of commonly used quality indicators
mance measures is being developed. that have been endorsed by leading quality-measurement organi-
The consensus about the general desirability of surgical perfor- zations or have already been applied in hospital accreditation, pay-
mance measurement notwithstanding, there remains considerable for-performance, or public reporting efforts [see Table 2]. A more
uncertainty about which specific measures are most effective in exhaustive list of performance measures is available on the
measuring surgical quality. The measures currently in use are National Quality Measures Clearinghouse (NQMC) Web site,
remarkably heterogeneous, encompassing a range of different ele- sponsored by the Agency for Healthcare Research and Quality
ments. In broad terms, they can be grouped into three main cate- (AHRQ) (http://www.qualitymeasures.ahrq.gov).
gories: measures of health care structure, process-of-care measures, To date, the National Quality Forum (NQF), the Joint Com-
and measures reflecting patient outcomes. Although each of these mission on Accreditation of Healthcare Organizations (JCAHO),
three types of performance measure has its unique strengths, each and the Center for Medicare and Medicaid Services (CMS) have
is also associated with conceptual, methodological, or practical focused primarily on preventive care and hospital-based medical
problems [see Table 1]. Obviously, the baseline risk and frequency care, with an emphasis on process-of-care variables. In surgery,
of the procedure are important considerations in weighing the these groups have all endorsed one process measure—appropriate
strengths and weaknesses of different measures.3 So too is the un- and timely use of prophylactic antibiotics [see Table 2]—in partner-
derlying purpose of performance measurement; for example, mea- ship with the Centers for Disease Control and Prevention (CDC).
sures that work well when the primary intent is to steer patients to In 2006, CMS, as part of its Surgical Care Improvement Program
the best hospitals or surgeons (selective referral) may not be opti- (SCIP), is also endorsing process measures related to prevention of
mal for quality-improvement purposes. postoperative cardiac events, venous thromboembolism, and res-
Several reviews of performance measurement have been pub- piratory complications.
lished in the past few years.3-5 In what follows, I expand on these The AHRQ has focused primarily on quality measures that take
reviews, providing an overview of the measures commonly used to advantage of readily available administrative data. Because little
assess surgical quality, considering their main strengths and limi- information on process of care is available in these datasets, these
Table 1 Primary Strengths and Limitations of Structural, Process, and Outcome Measures
Type of
Examples Strengths Limitations
Measure
Measures are expedient and inexpensive

Number of measures is limited
Measures are efficient—a single one may relate to
Procedure volume several outcomes Measures are generally not actionable
Structural
Intensivist-managed ICU For some procedures, measures predict subse- Measures do not reflect individual performance and are consid-
quent performance better than process or out- ered unfair by providers
come measures do
Measures reflect care that patients actually

Many measures are hard to define with existing databases
receive—hence, greater buy-in from providers
Process of Appropriate use of Extent of linkage between measures and important patient
Measures are directly actionable for quality-improve-
care prophylactic antibiotics outcomes is variable
ment activities
High-leverage, procedure-specific measures are lacking
For many measures, risk adjustment is unnecessary
Risk-adjusted mortalities Face validity Sample sizes are limited

Direct
outcome for CABG from state or Measurement may improve outcomes in and of Clinical data collection is expensive
national registries itself (Hawthorne effect) Concerns exist about risk adjustment with administrative data
CABG—coronary artery bypass grafting

measures are mainly structural (e.g., hospital procedure volume) Table 2 Performance Measures Currently
or outcome-based (e.g., risk-adjusted mortality).
Used in Surgical Practice
The Leapfrog Group (http://www.leapfroggroup.org), a coali-
tion of large employers and purchasers, developed perhaps the
most visible set of surgical quality indicators for its value-based Performance Measure
Diagnosis or Procedure
Developer/Endorser
purchasing initiative.The organization’s original (2000) standards
focused exclusively on procedure volume, but these were expand- Critical illness Staffing with board-certified intensivists (LF)
ed in 2003 to include selected process variables (e.g., the use of
Appropriate antibiotic prophylaxis (correct
beta blockers in patients undergoing abdominal aortic aneurysm Any surgical procedure approach: give 1 hr preoperatively, discon-
repair) and outcome measures. tinue within 24 hr) (NQF, JCAHO, CMS)
Hospital volume (AHRQ, LF)

Structural Measures Abdominal aneurysm repair Risk-adjusted mortality (AHRQ)
Prophylactic beta blockers (LF)
The term health care structure refers to the setting or system in
which care is delivered. Many structural performance measures Carotid endarterectomy Hospital volume (AHRQ)
reflect hospital-level attributes, such as the physical plant and
Esophageal resection
resources or the coordination and organization of the staff (e.g., for cancer
Hospital volume (AHRQ)
the registered nurse–bed ratio and the designation of a hospital as
Hospital volume (NQF, AHRQ, LF)
a level I trauma center). Other structural measures reflect physi-
Coronary artery bypass grafting Risk-adjusted mortality (NQF, AHRQ, LF)
cian-level attributes (e.g., board certification, subspecialty train-
Use of internal mammary artery (NQF, LF)
ing, and procedure volume).
Hospital volume (AHRQ, LF)
STRENGTHS Pancreatic resection
Risk-adjusted mortality (AHRQ)
Structural performance measures have several attractive fea-
Hospital volume (AHRQ)
tures. A strength of such measures is that many of them are Pediatric cardiac surgery
Risk-adjusted mortality (AHRQ)
strongly related to outcomes. For example, with esophagectomy
and pancreatic resection for cancer, operative mortality is as much Hip replacement Risk-adjusted mortality (AHRQ)
as 10% lower, in absolute terms, at very high volume hospitals
Craniotomy Risk-adjusted mortality (AHRQ)
than at lower-volume centers.6,7 In some instances, structural
measures (e.g., procedure volume) are better predictors of subse- Cholecystectomy Laparoscopic approach (AHRQ)
quent hospital performance than any known process or outcome
Appendectomy Avoidance of incidental appendectomy (AHRQ)
measures are [see Figure 1].8
A second strength is efficiency. A single structural measure may AHRQ—Agency for Healthcare Research and Quality CMS—Center for Medicare and
be associated with numerous outcomes. For example, with some Medicaid Services JCAHO—Joint Commission on Accreditation of Healthcare
Organizations LF—Leapfrog Group NQF—National Quality Forum
types of cancer surgery, higher hospital or surgeon procedure volume
is associated not only with lower operative mortality but also with
lower perioperative morbidity and improved late survival.9-11 In- have a low mortality (though the latter possibility may be difficult to
tensivist-staffed intensive care units are linked to shorter lengths of confirm because of the smaller sample sizes involved).14 For this rea-
stay and reduced use of resources, as well as to lower mortality.12,13 son, many providers view structural performance measures as unfair.
The third, and perhaps most important, strength of structural
measures is expediency. Many such measures can easily be as-
sessed with readily available administrative data. Although some Process Measures
structural measures require surveying of hospitals or providers, Processes of care are the clinical interventions and services pro-
such data are much less expensive to collect than data obtained vided to patients. Process measures have long been the predomi-
through review of individual patients’ medical records. nant quality indicators for both inpatient and outpatient medical
care, and their popularity as quality measures for surgical care is
LIMITATIONS
growing rapidly.
Relatively few structural performance measures are strongly
STRENGTHS
linked to patients and thus potentially useful as quality indicators.
Another limitation is that most structural measures, unlike most A strength of process measures is their direct connection to patient
process measures, are not readily actionable. For example, a small management. Because they reflect the care that physicians actually
hospital can increase the percentage of its surgical patients who deliver, they have substantial face validity and hence greater “buy-
receive antibiotic prophylaxis, but it cannot easily make itself a in” from providers. Such measures are usually directly actionable
high-volume center. Thus, although some structural measures and thus are a good substrate for quality-improvement activities.
may be useful for selective referral initiatives, they are of limited A second strength is that risk adjustment, though important for
value for quality improvement. outcome measures, is not required for many process measures.
Whereas some structural measures can identify groups of hospi- For example, appropriate prophylaxis against postoperative venous
tals or providers that perform better on average, they are not ade- thromboembolism is one performance measure in CMS’s ex-
quate discriminators of performance among individuals. For expanding pay-for-performance initiative and is part of SCIP. Be-
ample, in the aggregate, high-volume hospitals have a much lower cause it is widely agreed that virtually all patients undergoing open
operative mortality for pancreatic resection than lower-volume abdominal procedures should be offered some form of prophy-
centers do. Nevertheless, some individual high-volume hospitals may laxis, there is little need to collect detailed clinical data about ill-
have a high mortality, and some individual low-volume centers may ness severity for the purposes of risk adjustment.
Another strength is that process measures are generally less con- ity indicators, including complications, hospital readmission, and
strained by sample-size problems than outcome measures are. various patient-centered measures of satisfaction or health status.
Important outcome measures (e.g., perioperative death) are rela- Several large-scale initiatives involving direct outcome assess-
tively rare, but most targeted process measures are relevant to a ment in surgery are currently under way. For example, proprietary
much larger proportion of patients. Moreover, because process health care rating firms (e.g., Healthgrades) and state agencies are
measures generally target aspects of general perioperative care, assessing risk-adjusted mortalities by using Medicare or state-level
they can often be applied to patients who are undergoing numer- administrative datasets. Most of the current outcome-measure-
ous different procedures, thereby increasing sample sizes and, ulti- ment initiatives, however, involve the use of large clinical registries,
mately, improving the precision of the measurements. of which the cardiac surgery registries in New York, Pennsylvania,
and a growing number of other states are perhaps the most visible
LIMITATIONS
examples. At the national level, the Society for Thoracic Surgeons
At present, a major limitation of process measures is the lack of a and the American College of Cardiology have implemented sys-
reliable data infrastructure. Administrative datasets do not have the tems for tracking the morbidity and mortality associated with car-
clinical detail and specificity required for close evaluation of process- diac surgery and percutaneous coronary interventions, respective-
es of care. Measurement systems based on clinical data, including ly. Although the majority of the outcome-measurement efforts to
that of the National Surgical Quality Improvement Program date have been procedure-specific (and largely limited to cardiac
(NSQIP) of the Department of Veterans Affairs (VA),15 focus on procedures), NSQIP has assessed hospital-specific morbidities
patient characteristics and outcomes and do not collect information and mortalities aggregated across surgical specialties and proce-
on processes of care. Currently, most pay-for-performance programs dures. Efforts to apply the same measurement approach outside
rely on self-reported information from hospitals, but the reliability of the VA are now being implemented.16
such data is uncertain (particularly when reimbursement is at stake).
STRENGTHS
A second limitation is that at present, targeted process measures
in surgery pertain primarily to general perioperative care and often Direct outcome measures have at least two major strengths.
relate to secondary rather than primary outcomes. Although the First, they have obvious face validity and thus are likely to garner a
value of antibiotic prophylaxis in reducing the risk of superficial high degree of support from hospitals and surgeons. Second, out-
surgical site infection (SSI) should not be underestimated, super- come measurement, in and of itself, may improve performance—
ficial SSI is not among the most important adverse events of major the so-called Hawthorne effect. For example, surgical morbidity
surgery (including death). Thus, improvements in the use of pro- and mortality in VA hospitals have fallen dramatically since the
phylactic antibiotics will not address the fundamental problem of implementation of NSQIP in 1991.15 Undoubtedly, many surgical
variation in the rates of important outcomes from one hospital to leaders at individual hospitals made specific organizational or
another and from one surgeon to another. Except, possibly, in the process improvements after they began receiving feedback on their
case of coronary artery bypass grafting (CABG), the processes hospitals’ performance. However, it is very unlikely that even a full
that determine the success of individual procedures have yet to be inventory of these specific changes would explain such broad-
identified. based and substantial improvements in morbidity and mortality.
LIMITATIONS
Outcome Measures One limitation of hospital- or surgeon-specific outcome mea-
Direct outcome measures reflect the end result of care, either sures is that they are severely constrained by small sample sizes.
from a clinical perspective or from the patient’s viewpoint. Mor- For the large majority of surgical procedures, very few hospitals
tality is by far the most commonly used surgical outcome mea- (or surgeons) have sufficient adverse events (numerators) and
sure, but there are other outcomes that could also be used as qual- cases (denominators) to be able to generate meaningful, proce-
a b
20.0 20.0
16.0 16.0
Mortality (%), 1998–99
Mortality (%), 1998–99
12.0 12.0
8.0 8.0
4.0 4.0
0 0
Highest Lowest Lowest Highest Highest Lowest Lowest Highest
Unadjusted Mortality for Hospital Volume, Unadjusted Mortality for Hospital Volume,
Resection of Esophageal 1994–1997 Resection of Pancreatic 1994–1997
Cancer, 1994–1997 Cancer, 1994–1997
Figure 1 Illustrated is the relative ability of historical (1994–1997) measures of hospital volume and risk-
adjusted mortality to predict subsequent (1998–1999) risk-adjusted mortality in Medicare patients undergoing
(a) esophageal or (b) pancreatic resection for cancer.8
dure-specific measures of morbidity or mortality. For example, a a

4.0
2004 study used data from the Nationwide Inpatient Sample to
Correlation = 0.95
study seven procedures for which mortality was advocated as a 3.5
quality indicator by the AHRQ.17 For six of the seven procedures,
Risk-Adjusted Mortality (%)

only a very small proportion of hospitals in the United States had 3.0
large enough caseloads to rule out a mortality that was twice the
national average. Although identifying poor-quality outliers is an 2.5
important function of outcome measurement, to focus on this goal
alone is to underestimate the problems associated with small sam- 2.0
ple sizes. Distinguishing among individual hospitals with interme-
diate levels of performance is even more difficult. 1.5
Other limitations of direct outcome assessment depend on
whether the assessment is based on administrative data or on clin- 1.0
ical information abstracted from medical records. For outcome
measures based on clinical data, the major problem is expense. For 0.5
example, it costs more than $100,000 annually for a private-sec-
tor hospital to participate in NSQIP.
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
For outcome measures based on administrative data, a major
concern is the adequacy of risk adjustment. For outcome mea- Observed Mortality (%)
sures to have face validity with providers, high-quality risk adjust- b
4.0
ment may be essential. It may also be useful for discouraging gam-
ing of the system (e.g., hospitals or providers avoiding high-risk
patients to optimize their performance measures). It is unclear,
3.0
however, to what extent the scientific validity of outcome measures
Mortality (%), 2002
is threatened by imperfect risk adjustment with administrative

data. Although administrative data lack clinical detail on many
2.0
variables related to baseline risk,18-21 the degree to which case mix
varies systematically across hospitals or surgeons has not been
determined. Among patients who are undergoing the same surgi-
1.0
cal procedure, there is often surprisingly little variation. For exam-
ple, among patients undergoing CABG in New York State, unad-
justed hospital mortality and adjusted hospital mortality (as derived
0
from clinical registries) were nearly identical in most years (with Best Middle Worst Best Middle Worst
correlations exceeding 0.90) [see Figure 2].22 Moreover, hospital
rankings based on unadjusted mortality and those based on ad- Unadjusted Mortality Ratings, Risk-Adjusted Mortality Ratings,
justed mortality were equally useful in predicting subsequent hos- New York State Hospital New York State Hospitals, 2001
pital performance. Figure 2 Shown are mortality figures from CABG in New York
State hospitals, based on data from the state’s clinical outcomes
registry. (a) Depicted is the correlation between adjusted and
Matching the Performance Measure to the Underlying Goal
unadjusted mortalities for all state hospitals in 2001. (b) Illus-
Performance measures will never be perfect. Certainly, over trated is the relative ability of adjusted mortality and unadjusted
time, better analytic methods will be developed, and better access mortality to predict performance in the subsequent year.
to higher-quality data may be gained with the addition of clinical
elements to administrative datasets or the broader adoption of
electronic medical records. There are, however, some problems patients to higher-quality hospitals or providers). Although some
with performance measurement (e.g., sample-size limitations) that pay-for-performance initiatives may have both goals, one usually
are inherent and thus not fully correctable. Consequently, clinical predominates. For example, the ultimate objective of CMS’s pay-
leaders, patient advocates, payers, and policy makers will all have for-performance initiative with prophylactic antibiotics is to im-
to make decisions about when imperfect measures are nonetheless prove quality at all hospitals, not to direct patients to centers with
good enough to act on. high compliance rates. Conversely, the Leapfrog Group’s efforts in
A measure should be implemented only with the expectation surgery are primarily aimed at selective referral, though they may
that acting on it will yield a net improvement in health quality. In indirectly provide incentives for quality improvement.
other words, the direct benefits of implementing a particular mea- For the purposes of quality improvement, a good performance
sure cannot be outweighed by the indirect harm. Unfortunately, measure—most often, a process-of-care variable—must be action-
benefits and harm are often difficult to measure. Moreover, mea- able. Measurable improvements in the given process should trans-
surement is heavily influenced by the specific context and by late into clinically meaningful improvements in patient outcomes.
who—patients, payers, or providers—is doing the accounting. For Although quality-improvement activities are rarely actually harm-
this reason, the question of where to set the bar, so to speak, has ful, they do have potential downsides, mainly related to their op-
no simple answer. portunity cost. Initiatives that hinge on bad performance measures
It is important to ensure a good match between the perfor- siphon away resources (e.g., time and focus) from more productive
mance measure and the primary goal of measurement. It is par- activities.
ticularly important to be clear about whether the underlying goal For the purposes of selective referral, a good performance mea-
is (1) quality improvement or (2) selective referral (i.e., directing sure is one that steers patients toward better hospitals or physicians
(or away from worse ones). For example, a measure based on pre- ble of distinguishing levels of performance on an individual basis.
vious performance should reliably identify providers who are likely From the perspective of providers in particular, a measure cannot
to have superior performance now and in the future. At the same be considered fair unless it reliably reflects the performance of in-
time, a good performance measure should not provide incentives dividual hospitals or physicians. Unfortunately, as noted (see above),
for perverse behaviors (e.g., carrying out unnecessary procedures to small caseloads (and, sometimes, variations in the case mix) make
meet a specific volume standard) or negatively affect other domains this degree of discrimination difficult or impossible to achieve with
of quality (e.g., patient autonomy, access, and satisfaction). most procedures. Even so, information that at least improves the
Measures that work well for quality improvement may not be chances of a good outcome on average is still of real value to patients.
particularly useful for selective referral; the converse is also true. Many performance measures can achieve this less demanding ob-
For example, appropriate use of perioperative antibiotics in surgi- jective even if they do not reliably reflect individual performance.
cal patients is a good quality-improvement measure: it is clinical- For example, a 2002 study used clinical data from the Cooper-
ly meaningful, linked to lower SSI rates, and directly actionable. ative Cardiovascular Project to assess the usefulness of the Health-
This process of care would not, however, be particularly useful for grades hospital ratings for acute myocardial infarction (based pri-
selective referral purposes. In the first place, patients are unlikely marily on risk-adjusted mortality from Medicare data).24 Compared
to base their decision about where to undergo surgery on patterns with the one-star (worst) hospitals, the five-star (best) hospitals had
of perioperative antibiotic use. Moreover, surgeons with high rates a significantly lower mortality (16% versus 22%) after risk adjust-
of appropriate antibiotic use do not necessarily do better with ment with clinical data; they also discharged significantly more
respect to more important outcomes (e.g., mortality). A physi- patients on appropriate aspirin, beta-blocker, and angiotensin-
cian’s performance on one quality indicator often correlates poor- converting enzyme inhibitor regimens. However, the Healthgrades
ly with his or her performance on other indicators for the same or ratings proved not to be useful for discriminating between any two
other clinical conditions.23 individual hospitals. In only 3% of the head-to-head comparisons
As a counterexample, the two main performance measures for did five-star hospitals have a statistically lower mortality than one-
pancreatic cancer surgery—hospital volume and operative mor- star hospitals.
tality—are very informative in the context of selective referral: Thus, some performances measures that clearly identify groups
patients can markedly improve their chances of surviving surgery of hospitals or providers that exhibit superior performance may be
by selecting hospitals highly ranked on either measure [see Figure 1]. limited in their ability to differentiate individual hospitals from
Neither of these measures, however, is particularly useful for qual- one another. There may be no simple way of resolving the basic
ity-improvement purposes. Volume is not readily actionable, and tension implied by performance measures that are unfair to
mortality is too unstable at the level of individual hospitals (again, providers yet informative for patients.This tension does, however,
because of the small sample sizes) to serve as a means of identify- underscore the importance of being clear about (1) what the pri-
ing top performers, determining best practices, or evaluating the mary purpose of performance measurement is (quality improve-
effects of improvement activities. ment or selective referral) and (2) whose interests are receiving top
Many believe that a good performance measure must be capa- priority (the provider or the patient).
References
1. Lee TH, Meyer GS, Brennan TA: A middle tion for lung cancer. N Engl J Med 345:181, 236:344, 2002
ground on public accountability. N Engl J Med 2001 17. Dimick JB, Welch HG, Birkmeyer JD: Surgical
350:2409, 2004 10. Begg CB, Reidel ER, Bach PB, et al: Variations mortality as an indicator of hospital quality: the
2. Galvin R, Milstein A: Large employers’ new strain morbidity after radical prostatectomy. N Engl problem with small sample size. JAMA 292:847,
tegies in health care. N Engl J Med 347:939, J Med 346:1138, 2002 2004
2002 18. Finlayson EV, Birkmeyer JD, Stukel TA, et al:
11. Finlayson EVA, Birkmeyer JD: Effects of hospi-
3. Birkmeyer JD, Birkmeyer NJ, Dimick JB: Mea- tal volume on life expectancy after selected can- Adjusting surgical mortality rates for patient co-
suring the quality of surgical care: structure, pro- cer operations in older adults: a decision analy- morbidities: more harm than good? Surg
cess, or outcomes? J Am Coll Surg 198:626, 2004 sis. J Am Coll Surg 196:410, 2002 132:787, 2002
4. Landon BE, Normand SL, Blumenthal D, et al: 12. Pronovost PJ, Angus DC, Dorman T, et al: 19. Fisher ES, Whaley FS, Krushat WM, et al: The
Physician clinical performance assessment: pros- Physician staffing patterns and clinical outcomes accuracy of Medicare’s hospital claims data: prog-
pects and barriers. JAMA 290:1183, 2003 in critically ill patients: a systematic review. JAMA ress, but problems remain. Am J Public Health
5. Bird SM, Cox D, Farewell VT, et al: Perform- 288:2151, 2002 82:243, 1992
ance indicators: good, bad, and ugly. J R Statist 13. Pronovost PJ, Needham DM, Waters H, et al: 20. Iezzoni LI, Foley SM, Daley J, et al: Com-
Soc 168:1, 2005 Intensive care unit physician staffing: financial orbidities, complications, and coding bias. Does
6. Halm EA, Lee C, Chassin MR: Is volume relat- modeling of the Leapfrog standard. Crit Care the number of diagnosis codes matter in pre-
ed to outcome in health care? A systematic re- Med 32:1247, 2004 dicting in-hospital mortality? JAMA 267:2197,
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14. Shahian DM, Normand SL: The volume-out-
Ann Intern Med 137:511, 2002 come relationship: from Luft to Leapfrog. Ann 21. Iezzoni LI: The risks of risk adjustment. JAMA
7. Dudley RA, Johansen KL, Brand R, et al: Se- Thorac Surg 75:1048, 2003 278:1600, 1997
lective referral to high volume hospitals: estimat- 15. Khuri SF, Daley J, Henderson WG: The com- 22. Birkmeyer J: Unpublished data, 2005
ing potentially avoidable deaths. JAMA 283:1159, parative assessment and improvement of quality 23. Palmer RH, Wright EA, Orav EJ, et al: Con-
2000 of surgical care in the Department of Veterans sistency in performance among primary care
8. Birkmeyer JD, Dimick JB, Staiger DO: Hospital Affairs. Arch Surg 137:20, 2002 practitioners. Med Care 34(9 suppl):SS52, 1996
volume and operative mortality as predictors of 16. Fink A, Campbell DJ, Mentzer RJ, et al: The 24. Krumholz HM, Rathore SS, Chen J, et al: Eval-
subsequent performance. Ann Surg (in press) National Surgical Quality Improvement Pro- uation of a consumer-oriented internet health
9. Bach PB, Cramer LD, Schrag D, et al:The influ- gram in non–Veterans Administration hospitals: care report card: the risk of quality ratings based
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© 2003 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 1
3 PATIENT SAFETY IN SURGICAL

CARE: A SYSTEMS APPROACH
Robert S. Rhodes, M.D., F.A.C.S.
In high-profile events such as the explosion at Chernobyl, the where a systems approach might contribute to improving surgical
near meltdown at Three Mile Island, the explosion of the chemi- care. In addition, I consider current obstacles to quality improve-
cal plant in Bhopal, the collision of a U.S. submarine with a ment and discuss how surgeons can take the lead in overcoming
Japanese fishing boat, and the explosion of the space shuttle these obstacles. Finally, I consider patient safety in the broader
Challenger, the casualties are notable for their number and their context: the lessons learned from exploring patient safety issues
celebrity. The differences between these events notwithstanding, are likely to be equally applicable to wider quality of care issues.
each one arose in large part from faults in a complex system.
Human error played a role as well, but it was generally under-
stood to be only a relatively small part of a larger systemic failure. The Magnitude of the Problem
In contrast, medical injuries affect one patient at a time and, The two most widely cited estimates of adverse medical events
until recently, rarely received much publicity. Nevertheless, there are the Harvard Medical Practice Study (HMPS)10 and the study
is now considerable public concern about patient safety and the of adverse surgical events in Colorado and Utah.11 The HMPS,
overall quality of patient care.1-3 It is estimated that there may be a population-based study of hospitalized patients in New York
nearly 100,000 error-related deaths each year in the United State during 1984, found that nearly 4% of patients experienced
States.4 This estimate far exceeds the casualties from more pub- an adverse event (i.e., an unintended injury caused by treatment
licized nonmedical disasters and, if anywhere near correct, makes that resulted in a prolonged hospital stay or a measurable dis-
medically related injuries one of the leading causes of death, ability at discharge) and that about half of such events occurred
according to the Centers for Disease Control and Prevention in surgical patients. The Colorado/Utah study, using a random
(CDC) (http://www.cdc.gov/scientific.htm). Perhaps surprising- sample of 15,000 nonpsychiatric discharges during 1992, found
ly, however, both patients and physicians still appear to place that the annual incidence of adverse surgical events was 3.0%
much less emphasis on system flaws as a cause of medical injury and that 54% of these events were preventable. Nearly half of all
than on individual human error.2 One reason for this may be that adverse surgical events were accounted for by technique-related
“error in medicine is almost always seen as a special case of med- complications, wound infections, and postoperative bleeding.
icine rather than as a special case of error.… The unfortunate Eleven common operations were associated with a significantly
result has been the isolation of medical errors from much of the higher risk of an adverse event [see Table 1], and eight were asso-
body of theory, analysis, and application that has developed to
deal with error in fields such as aviation and nuclear power.”5 In
Table 1 Procedures Associated with a Significantly
addition, within the field of medicine, it is accepted that compli-
cations or bad outcomes can occur even in the best circum- Higher Incidence of Adverse Surgical Events11
stances. When a system is not expected to work perfectly at all
times, it is difficult to distinguish problems related to individual Incidence of Adverse Confidence
Procedure
error from those related to flaws in the system. Events (%) Interval (%)
Various organizations—including the National Patient Safety AAA repair 18.9 8.3–37.5
Foundation (http://www.npsf.org), the National Quality Forum
(NQF) (http://www.qualityforum.org), and the Institute of Lower extremity arterial bypass 14.1 6.0–29.7
Medicine (IOM) (http://www.iom.edu)—are responding to the CABG/valve replacement 12.3 7.9–18.7
concerns about patient safety and the quality of medical care.6-8
In addition to the basic professional obligation to provide high- Colon resection 6.8 2.9–14.8
quality care, there is evidence that such care is less expensive and Cholecystectomy 5.9 3.7–9.3
is therefore crucial for cost control. Moreover, the growing con-
Prostatectomy 5.9 2.3–14.3
cern about patient safety has begun to change the way patients
select providers. For example, one survey found that between TURP/TURBT 5.5 2.7–10.7
1996 and 2000, the percentage of patients who would choose a
Knee/hip replacements 4.9 2.9–8.4
highly rated surgeon whom they had not seen before in prefer-
ence to a less highly rated one whom they had seen before Spinal surgery 4.5 2.8–7.3
increased substantially.9 Thus, improving patient safety is also an
Hysterectomy 4.4 2.9–6.8
issue of provider self-interest.
In what follows, I attempt to evaluate current information on Appendectomy 3.0 1.4–6.6
patient safety and the quality of surgical care in the context of sys- AAA—abdominal aortic aneurysm CABG—coronary artery bypass grafting
tem failure, with a particular emphasis on indicating how and TURP—transurethral prostatectomy TURBT—transurethral resection of bladder tumor
CP Elements of Contemporary Practice 3 Patient Safety in Surgical Care: A Systems Approach — 2
Table 2 Procedures Associated with a Significantly characterizing adverse events as either preventable or unpre-
Higher Incidence of Preventable Adverse ventable given the prevailing state of knowledge. Preventable
Surgical Events11 errors were further subclassified as diagnostic errors or treatment
errors; treatment errors included preventive errors such as failure
of prophylaxis and failure to monitor and follow up treat-
Incidence of Confidence ment.10,30 The HMPS found preventability to vary according to
Procedure Preventable Adverse Interval (%)
Events (%)
the type of event: 74% of early surgical adverse events were
judged preventable, compared with 65% of nonsurgical adverse
AAA repair 8.1 2.2–25.5 events; and more than 90% of late surgical failures, diagnostic
mishaps, and nonprocedural therapeutic mishaps were judged
Lower extremity arterial bypass 11.0 4.2–26.1
preventable.
CABG/valve replacement 4.7 2.3–9.7 In an attempt to make study data more directly comparable,
Federal agencies developed standard definitions of the applicable
Colon resection 5.9 2.4–13.8
terms [see Sidebar Definitions of Terms Related to Patient
Cholecystectomy 3.0 1.6–5.8 Safety].31 Even when terms are agreed on, however, differences in
TURP/TURBT 3.9 1.7–8.7
end points may render studies noncomparable or lead to differ-
ing conclusions. For instance, a study of Veterans Affairs (VA)
Hysterectomy 2.8 1.6–4.7 hospitals reported much lower estimates of preventable deaths
Appendectomy 1.5 0.5–4.5 than those cited by the HMPS.32 The study authors noted that
many of the patients who died “preventable” deaths would have
died of natural causes anyway within a few months even if they
ciated with a significantly higher risk of a preventable event [see had received optimal care. However, to argue that a patient would
Table 2]. Other noteworthy studies have reported comparable or have died soon regardless of care does not mean that flaws do not
higher estimates.12-18 exist in the care system.
A well-publicized 2003 report estimated that retention of Judgments of causality are affected by hindsight bias, as illus-
sponges or surgical instruments occurred in between 1/8,801 trated by a study of anesthetic care in which outcome differences
and 1/18,760 inpatient operations at nonspecialty acute care significantly influenced the perception of negligence, even when
hospitals.19 This figure is probably an underestimate. the care provided was equivalent in all other respects.33
Wrong-site surgery, brought to public attention by a wrong- Accordingly, there is often a tendency to focus too narrowly on
sided amputation in Florida, has proved to be more than an iso- adverse outcomes while paying insufficient attention to the
lated event. The Florida Board of Medicine tabulated 44 wrong- processes that give rise to these outcomes.
site operations in 1999–2000,20 and a database begun in 1998 by The situation is further complicated by underreporting of
the Joint Commission for Accreditation of Healthcare Organi- error. Underreporting is more likely if side effects are delayed or
zations (JCAHO) contained 150 cases of wrong-site, wrong-per- unpredictable, if there is a longer survival or latent interval, or if
son, or wrong-procedure surgery as of December 2001.21 The in- a patient has been transferred from one facility to another.
creased frequency of reports of wrong-site surgery since the initial Inadequate doses of antibiotics or anesthetics may not be report-
headlines probably reflects earlier underreporting.22 ed if they cause no immediately evident injury.The lack of detail
Medication errors (e.g., wrong drug, wrong dose, wrong in many medical records may contribute to underreporting as
patient, wrong time, or wrong route of administration) are alarm- well. A major cause of underreporting is the use of a punitive
ingly frequent.23-27 A study of radiopharmaceutical misadminis-
trations showed that 68.9% of such errors involved the wrong iso-
tope, 24% the wrong patient, 6.5% the wrong dose, and 0.6% the
wrong route.28 Blood transfusions continue to be plagued by
Definitions of Terms Related to Patient Safety31
patient misidentification as well. Device-related deaths and seri-
ous injuries also occur at an alarming rate, even after premarket • An adverse event is an injury that was caused by medical man-
agement and that results in measurable disability.
safety testing.29 In 2002, the Food and Drug Administration
• An error is the failure of a planned action to be completed as
(FDA) received more than 2,500 such reports from clinical intended or the use of a wrong plan to achieve an aim. Errors can
facilities and more than 3,500 from health professionals and include problems in practice, products, procedures, and systems.
consumers. • A preventable adverse event is an adverse event that is attrib-
There remain significant differences of opinion regarding sur- utable to error.
gically related adverse events, with some disputing the published • An unpreventable adverse event is an adverse event resulting
estimates and others arguing about the extent to which such from a complication that cannot be prevented given the current
state of knowledge.
events are preventable. Furthermore, not everyone agrees with
• A near miss is an event or situation that could have resulted in
the HMPS definition of medical error. Some argue that iatro- accident, injury, or illness but did not, either by chance or
genic illnesses caused by conceptual error (e.g., a contraindicat- through timely intervention.
ed, unsound, or inappropriate medical approach) should be dis- • A medical error is an adverse event or near miss that is pre-
tinguished from the side effects of an intended action that was ventable with the current state of medical knowledge.
correct in the circumstances (e.g., an indicated diagnostic or • A system is a regularly interacting or interdependent group of
therapeutic procedure).29 Others would distinguish accidents items forming a unified whole.
(i.e., unplanned, unexpected, and undesired events) from true • A systems error is an error that is not the result of an individual’s
side effects (which result from correct management and which actions but the predictable outcome of a series of actions and
factors that make up a diagnostic or treatment process.
are often accepted as reasonable therapeutic tradeoffs).
The HMPS attempted to address some of these issues by
reporting system. In such systems, caregivers are often reluctant as other undesired consequences.53 For instance, physicians who
to discuss error out of concern that the error reports might be relinquish privileges on their own initiative may be more lenient-
used against them.34 If protected from disciplinary actions, how- ly treated than those against whom action was initiated by a peer
ever, they seem more willing to report problems.35,36 It is essen- review committee. The data reviewed by such committees often
tial to recognize that when the introduction of an anonymous, are legally discoverable, and the lack of anonymity and confiden-
nonpunitive reporting system leads to an increased number of tiality of the data deters voluntary participation. Even when peer
error reports, this is more likely to be a reflection of previous review does identify problems, it may be unable to implement
underreporting than of deteriorating safety or quality.37 solutions.
Because of all these factors, it remains difficult to estimate the The shortcomings of hospital incident reports are similar to
number of error-related medical injuries with precision.To some, those of peer review. Incident reports also place limited emphasis
that the rate of adverse events was lower in the Colorado/Utah on close calls and tend to lack systematic follow-up. Frequently,
study than in the HMPS suggests that safety is improving. This reporters are reluctant to file their reports out of fear that their
is encouraging if true, but there is still a great deal of room for employment might be jeopardized or that the reported party
further improvement.38 Even if one accepts the more conserva- might seek retribution.
tive estimates of error frequency, the aggregate number of fatal The present professional liability system is particularly contro-
medical errors far exceeds that of more publicized nonmedical versial. Two of its most notable shortcomings are (1) that only a
disasters. These lower estimates would not be tolerated in non- small percentage of cases of true medical injury ever become the
medical settings and should not be tolerated in patient care. basis of legal action and (2) that many of the claims that are
brought have no merit.54 In addition, the liability system com-
pensates fewer than one in eight patients who are harmed;
Shortcomings of Existing Quality-Improvement Methods awards such compensation only after years of litigation; is based
Clearly, there is no lack of efforts aimed at quality improve- on determination of fault where experts cannot agree (often as a
ment. Unfortunately, many such efforts have notable shortcom- result of hindsight bias); and causes devastating emotional dam-
ings that prevent them from addressing current concerns about age to physicians (and their families),12,55,56 which may adversely
safety and quality in an optimal fashion. affect their problem-solving abilities. To the extent that experi-
Morbidity and mortality (M & M) conferences are perhaps the ence with or fear of a malpractice action deters efforts at quality
most traditional venue for discussion of adverse events. They do improvement, it is counterproductive. Yet another shortcoming
not consider all complications, however, nor are they consistent- of the liability system is that insurance premiums often are deter-
ly well attended.39-41 Furthermore, M & M conferences tend to mined by economic factors outside the field of medicine and are
be intradepartmental, which means that there is often little not adjusted for claims experience. State legislative policy, osten-
opportunity to discuss system problems that may involve other sibly aimed at moderating liability crises, may have counterintu-
departments. In addition, M & M conferences typically do not itive effects on median awards: whereas limits on awards for pain
consider “near misses” (i.e., close calls), even though close calls and suffering reduce total awards, limits on lawyers’ fees actual-
are important in identifying both actual and potential system ly increase them.57
defects. Finally, M & M conferences have a tradition of blaming The National Practitioner Data Bank (NPDB) has many of
individuals rather than focusing on the circumstances within the limitations of the liability system. It also contains information
which the individuals acted. This tradition serves to perpetuate a on settlements in which the merits of the case may not have been
defensive attitude among trainees that is counterproductive. fully considered; to the extent that settlements may reflect mon-
Continuing Medical Education (CME) focuses on the link etary convenience or legal philosophy more than practitioner
between knowledge and quality of patient care. Although there is performance, this information may be misleading. The NPDB
a clear relationship between CME and performance on board may also contain other inaccurate, incomplete, or inappropriate
recertification examinations,42 the actual relationship between information.
CME and better patient care is far more complex. There is evi-
dence suggesting that performance on cognitive examinations is
related to performance in practice43,44 and that board certification Patient Care as a System
is linked with improved outcomes,45 but the data are not conclu- The magnitude of the medical quality problem and the short-
sive. Systematic reviews of differences in the impact of various comings of current efforts to address this problem indicate that a
CME strategies on actual practice change have raised serious con- change of approach is needed. Given the impressive success of
cerns about the value of some current CME.46 The most effective systems approaches to safety and quality improvement in non-
change strategies (e.g., reminders, patient-mediated interventions, medical settings, it is worthwhile to consider taking a similar
outreach visits, input from opinion leaders, and multifaceted activ- approach to patient care.
ities) appear to be those that place substantial emphasis on per- A system may be broadly defined as a regularly interacting or
formance change rather than just on learning.47,48 interdependent group of items that form a unified whole; in the
Clinical pathways and guidelines, by standardizing medical context of patient safety, the term system refers to the individual
processes, may help improve safety and quality, especially in components of care. A simple system may involve a specific task;
high-risk procedures.49 Some critics argue, however, that guide- a complex system may involve smaller, simpler subsystems. The
lines often do not apply to particular patients and can be difficult complexity of a system derives both from the number of compo-
to use in patients with other, more urgent medical problems. nent subsystems and the interactions among them.
Others suggest that guidelines are mostly beneficial in treatment Systems become flawed when a problem in one or more steps
and prevention and contribute little to diagnosis.50,51 Finally, or subsystems can lead to an undesired outcome. Overt problems
guidelines may become outdated quickly.52 are relatively easy to identify and correct; latent errors are more
Peer review, originally intended as a mechanism for profes- insidious. Latent errors are often introduced by people who work
sional self-evaluation, is subject to anticompetitive abuse as well at the “blunt end” of the system (e.g., management or house-
keeping) but are not active participants. Such errors can then trap to be a tradeoff between problems related to fatigue and those
“sharp end” participants (e.g., anesthesiologists, nurses, or sur- related to handoffs: reducing the former increases the latter, and
geons) into overt errors. A typical accident pathway is one in vice versa.
which organizational processes give rise to latent errors, latent The similarities between medical and nonmedical systems
errors produce system defects that may interact with external notwithstanding, it must be recognized that medical systems are
events in generating unsafe acts, and unsafe acts precipitate an distinctive with respect to complexity of content and organiza-
active failure that then penetrates a safety barrier.58 Indeed, in a tional structure. Whereas nonmedical systems are typically man-
complex system, the greatest risk of an adverse event may come aged vertically through hierarchical control, patient care systems
not from a major subsystem breakdown or isolated operator errors tend to comprise numerous diverse components that are only
but from the unrecognized accumulation of latent errors.59-61 loosely aggregated.71 Within the patient care system, subsystems
Such was the case with the explosion of the Challenger.62 (including quality improvement components) tend to function in
The probability that a system flaw will result in an adverse isolation, and intrasystem changes tend to be managed laterally
outcome reflects the probability of error within each step or across individual subsystems. The result, all too often, is ineffi-
component of the larger system, the total number of steps or cient or even contradictory policies, which increase the chances
components, and the degree of coupling among the steps or of error.
components. Errors in tightly coupled systems are more likely to
propagate than those in loosely coupled systems. For example,
the probability of a successful outcome in a tightly coupled, lin- Basic Principles of Human Performance and Human
ear 20-step process with a 1% error rate per step is 0.99 factored Error
20 times, or 0.818. In loosely coupled systems, a successful out- Systemic factors are not the sole cause of system failure:
come is less dependent on satisfactory completion of each step. human factors play a role as well. A great deal of work has been
The usual trade-off for this additional safety is greater system done on analyzing human error and its relationship to perfor-
complexity, which can itself introduce errors. It also must be kept mance.72 The overall implication of this work is that to achieve
in mind that the presence of latent errors can make systems meaningful improvements in safety and quality, it is necessary to
appear to be more loosely coupled than they actually are. shift the focus from fallible individuals to the situational and
Consideration of these general characteristics of systems organizational latent failures that these individuals inherit.58
reveals many areas where they are applicable to medicine—in Human performance may be classified as skill-based, rule-
particular, to surgery and anesthesiology. Moreover, in a number based, or knowledge-based behavior, as follows73:
of respects, the habitats of surgeons (e.g., the OR, the ICU, and
1. Skill-based performance is governed by stored patterns of pre-
the ED) resemble those seen in various high-tech, high-risk non-
programmed instructions, and it occurs without conscious
medical industries, and strong parallels have been noted between
control. Such performance makes use of long-term memory.
behavioral issues on the flight deck and observed behavior in the
2. Rule-based performance involves solving problems through
OR.63,64 It is more than coincidence that the ICU, with its
stored rules of the if-then variety. Like skill-based perfor-
emphasis on technology, is a common site of adverse events.65,66
mance, it uses long-term memory; however, unlike skill-based
The usefulness of considering patient care as a system may be
performance, it is associated with a consciousness that a prob-
seen by examining some of the issues surrounding technology.To
lem exists.59 The rules are usually based on experience from
understand the role of technology in a system, it is necessary to
previous similar situations and are structured hierarchically,
understand not only the devices and techniques involved but also
with the main rules on top; their strength is an apparent func-
the people using the technology and the means by which they
tion of how recently and how frequently they are used.72 Rule-
interact with the system. Each change in technology initiates a
based performance varies according to expertise: novices tend
new learning cycle, and the resulting environment is one that is
to rely on a few main rules, whereas experts have many side
especially conducive to error.67 It is relatively unusual, however,
rules and exceptions.
for an isolated error to lead to a system failure; instead, such fail-
3. Knowledge-based performance involves conscious analytic
ures typically involve multiple malfunctions, either occurring
processes and stored knowledge. It relies on working memo-
within a single element of the system or spread out across more
ry, which is comparatively slow and of relatively limited capac-
than one element.
ity. Typically, people resort to knowledge-based performance
The potential value of a systems approach to patient care is
when their skills are inapplicable or their repertoire of rules
further suggested by data associating improved outcomes associ-
has been exhausted.
ated with higher hospital or surgeon volume.68,69 Whether “prac-
tice makes perfect” or “perfect makes practice” remains unre- Successful problem solving has three main phases: planning,
solved, but in either case, it seems likely that the improved out- storage, and execution. The errors resulting from failures in per-
comes are a reflection of better care systems. That some high- formance may be classified as slips, lapses, or mistakes,60 depend-
volume hospitals and surgeons have below-average outcomes ing on which phase of the problem-solving sequence is involved.
and many low-volume hospitals and surgeons have excellent ones Slips are failures of the execution phase or storage phase, or both,
is consistent with this view.70 and may occur regardless of whether the plan from which they
Additional supportive evidence comes from critical incident arose was adequate; lapses are storage failures. Generally, slips are
analyses of adverse surgical events,41 which reveal that the same overt, whereas lapses are covert. Mistakes are failures of planning,
types of factors that contribute to nonmedical system failures reflecting basic deficiencies or failures in selecting an objective or
also contribute to adverse surgical events. Of these factors, the specifying the means to achieve it, regardless of how well the plan
three most common are inexperience (on the part of both resi- was executed.
dents and attending surgeons), breakdowns in communication Specific types of errors tend to be associated with specific
(e.g., handoffs and personnel conflicts), and fatigue or excessive modes of failure [see Table 3].60 Slips and lapses are failures of
workload. Often, these factors interact. For example, there seems skill-based performance and generally precede recognition of a
Table 3 Common Modes of Failure Associated The above classifications explain basic behavioral mechanisms
with Specific Types of Performance60 but may be modified to meet specific needs.34 Some authorities
classify error according to whether it can be addressed by engi-
neering, design, societal, or procedural changes; others empha-
Failures of Skill-Based Performance
size psychological intervention and modification; and still others
Inattention Overattention classify errors by their mode of appearance. As an example, clas-
sification by mode of appearance might include errors of omis-
Double-capture slips Omissions sion, errors of insertion, errors of repetition, and errors of substi-
Omissions following interruptions Repetitions
tution (e.g., misadministration of lidocaine, heparin, or potassi-
Reduced intentionality Reversals
Perceptual confusions
um chloride as a result of poor package labeling).
Interference errors
Failures of Rule-Based Performance Performance and Error in Clinical Context

Misapplication of Good Rules Application of Bad Rules The application of the above concepts of performance and
error to patient care is hampered by disagreements over whether
First exceptions Encoding deficiencies human error is distinct from human performance.58,59,75 It has
Countersigns and nonsigns Action deficiencies been argued (1) that assignment of error is often retrospective
Informational overload Wrong rules
and subject to hindsight bias and (2) that the term error is inher-
Rule strength Inelegant rules
ently prejudicial, retarding rather than advancing understanding
General rules Inadvisable rules
Redundancy
of system failure and tending to evoke defensiveness from physi-
Rigidity cians rather than constructive action.59 These arguments notwith-
standing, elimination of human errors is clearly an impossible
Failures of Knowledge-Based Performance goal: a more realistic goal is to understand what causes errors and
Selectivity Biased reviewing to minimize or, if possible, eliminate their consequences.
Workspace limitations Illusory correlation There is also some disagreement about the applicability of
Out of sight, out of mind Halo effects these concepts (which derive from analysis of well-structured,
Confirmation bias Problems with causality well-understood technical systems) to the more complex issues
Overconfidence Problems with complexity of patient safety and quality of care.61 Besides the possible rela-
tionships already suggested, the concepts of performance and
error can in fact be explicitly linked with two widely accepted
problem. Mistakes may be either failures of knowledge-based quality-of-care paradigms. In the IOM paradigm, inappropriate
performance (i.e., attributable to lack of expertise) or failures of care is categorized as attributable to overuse, misuse, or under-
rule-based performance (i.e., attributable to failure of expertise). use.76 Overuse is triggered by mistakes (sometimes rule-based
They typically arise during attempts to solve a problem. Mistakes but more often knowledge-based) but rarely, if ever, by slips or
tend to be more subtle, more complex, and less well understood lapses. Underuse is triggered by mistakes or lapses, but not by
than slips or lapses and thus more dangerous. slips. Misuse is caused by all three kinds of errors.77 In the
Two other important sources of error are underspecification of Donabedian paradigm, quality is framed in terms of structure,
the problem and confirmation bias. Underspecification occurs process, and outcome.78 Faulty processes do not always result in
when a problem seems ill-defined, whether because limited atten- adverse outcomes, but considering the process of care is as
tion is paid, because the wrong cues are picked up, because the important as considering the outcome.
problem is truly ill-defined, or because the problem falls outside Regardless of which psychological construct of performance
the rules known. Underspecification is more likely to occur in sit- and error one may subscribe to, there is substantial evidence that
uations where cues change dynamically or are ambiguous— performance is affected by the context of the problem.The main
notable characteristics of surgical practice.The two most common elements that define context are knowledge factors, attentional
error forms associated with underspecification are similarity dynamics, and strategic factors.25 The first two elements are self-
matching and frequency bias (or frequency gambling). In similar- explanatory. Strategic factors include an individual’s physical and
ity matching, a present situation is thought to resemble a previous psychological well-being, and in this regard, the effects of sleep
one and consequently is addressed in the same (not necessarily deprivation and fatigue on performance and learning are major
appropriate) way. In frequency gambling, a course of action is cho- concerns.79,80 Fatigue, by impairing vigilance, can accentuate
sen that has worked before; the more often that course of action confirmation bias. In addition, errors increase as time on task
has been successfully used, the more likely it is to be chosen.These increases; no other hazardous industry permits, let alone
behavior patterns have been confirmed among anesthesiologists, requires, employees to regularly work the long hours common in
who, like many dynamic decision makers, use approximation hospitals.74 Stress may increase the likelihood of error, but it is
strategies (or heuristics) to handle ambiguous situations.5 clearly neither necessary nor sufficient for cognitive failure.60
Confirmation bias is the propensity to stick with a chosen Unfortunately, some physicians hold unrealistic beliefs about
course of action and to either interpret new information so as to their ability to deal with stress and fatigue and so may not seek
favor the original choice or else disregard such information help when they need it.81
entirely. Also referred to as cognitive fixation, cognitive lockup, or In situations involving a plethora of tasks, mental overload may
fixation error, it is often associated with knowledge-based perfor- compromise the ability to respond to secondary tasks. Errors
mance.74 Confirmation bias is particularly likely in unusual or related to loss of vigilance include not observing a data stream at
evolving situations and when there is concomitant pressure to all, not observing a data stream frequently enough, and not
maintain coherence25—again, notable characteristics of surgical observing the optimal data stream for the existing situation.
practice. Although vigilance is essential, even vigilant practitioners may
experience failures of observation that lead to adverse events. In is delivered. In addition, nonphysicans will have important roles
watching for rare occurrences, it is difficult to remain alert for to play, as illustrated by studies relating nurse staffing levels to
longer than 10 to 20 minutes; thus, knowing when and how to quality of care.86,87
verify data is an important metacognitive skill.
Psychological framing effects also play a role in error.
Examples of such effects are the irrational preference for estab- Examples of Systems Approaches to Improving Quality
lished treatments when outcomes are framed in terms of gain Given the complexity of health care, embarking on a systems
(e.g., survival) and the similarly irrational preference for risky approach to safety improvement may seem a daunting prospect.
treatments when outcomes are framed in terms of loss (e.g., mor- Accordingly, it is worthwhile to look at examples of successful
tality). The impetus to “do the right thing” can facilitate error.62 quality improvement systems that have already been implemented.
Patient care often involves team behavior, and such behavior Anesthesiologists were among the first physicians to take such
can affect individual performance.5,74 Lack of cohesion and an approach to safety, and the success of their efforts is irrefutable:
mutual support among team members can compromise perfor- anesthesia-related mortality has fallen from approximately
mance. Too informal a team structure may undermine patterns 2/10,000 to the current 1/200,000 to 1/300,00088-90—a degree of
of authority and responsibility and hinder effective decision-mak- safety approaching that advocated for nonmedical industries (i.e.,
ing. Conversely, too strong a hierarchy may make it excessively < 3.4 defects or errors/106 products or events).91 This improve-
difficult for juniors to question decisions made by those at high- ment is primarily the result of a broad effort involving teamwork,
er levels of authority. Rigid behavior may impair the ability to practice guidelines, automation, procedure simplification, and
cope with unforeseen events and discourage initiative. standardization of many functions. Previously, for instance, there
For good teamwork, it is essential that team members share a was no standard design for anesthesia machines, and it was not
clear understanding of what is happening and what should hap- unusual for more than one type to be in use in the same hospital.
pen. This understanding is referred to as situational awareness.74 This is no longer the case. It is clear that considerable benefit can
Unfortunately, there is a common tendency to believe that the be derived from a better appreciation of the human-technology
prevailing level of situational awareness is higher than it is. For interface and the ergonomics of equipment design.92
example, the aviation industry improved its safety record when it Successful surgical examples exist as well, such as the Northern
identified and removed barriers impeding junior officers from New England Cardiovascular Disease Study Group,93 Inter-
communicating with the captain, and these improvements mountain Health Systems in Utah, and the Maine Medical
occurred after good communication was already thought to Assessment Foundation.94 These examples share four important
exist.82 characteristics: (1) providers responded to practice variations by
In the OR, teams consist of crews from nursing, surgery, and participating in outcomes research; (2) voluntary, physician-initi-
anesthesia. As an example of suboptimal situational awareness, ated interventions were as effective as, if not more effective than,
the various crews often have fundamentally different perceptions external regulatory mechanisms in reducing morbidity and mor-
of their respective roles. Anesthesiologists and nurse anesthetists tality; (3) a systems approach to quality improvement produced
are much more likely to feel that a preoperative briefing is impor- better results than a bad-apple approach; and (4) quality-
tant for team effectiveness than surgeons and surgical nurses are, improvement programs successfully included groups that other-
whereas surgeons and surgical nurses are more likely to feel that wise might have been competitors. None of these efforts increased
junior team members should not question the decisions of senior liability exposure; often, they reduced it. Because the practice pro-
staff members.83 Such varying perceptions not only can compro- files were physician-initiated, there was little risk that the findings
mise patient safety but also represent lost opportunities for teach- would be used to make decisions about credentialing, reimburse-
ing or learning. Unfortunately, there is often little consensus on ment, or contracting.94 In addition, the funding parties (including
how optimal team coordination should be achieved. insurers) usually agreed to confidentiality in return for the bene-
The importance of teamwork issues in the OR is illustrated by fit associated with voluntary physician involvement.
a study that analyzed time needed to learn minimally invasive Trauma care has also benefited from a systems approach. A
cardiac surgery.84 On the fast-learning teams, the members had study of 22,000 patients from a regional trauma system conclud-
worked well together in the past, they went through the early ed that the most common single error across all phases of care
learning phase together before adding new members, they sched- was failure to evaluate the abdomen appropriately.95 Errors in the
uled several of the new procedures close together, they discussed resuscitative and operative phases were more common, but
each case in detail beforehand and afterward, and they carefully errors in critical care had the greatest impact on preventable
tracked results. Of particular interest was that surgeons on the mortality. The perception of preventability increased in parallel
fast-learning teams were less experienced than those on the slow- with appreciation of the importance of the system.
learning teams but more willing to accept input from the rest of Another example is the Veterans Affairs National Surgical
the team. Quality Improvement Project (NSQIP),96 which consists of com-
Communication and teamwork are also important in the emer- parative, site-specific, and outcomes-based annual reports; peri-
gency department. One study reported an average of 8.8 team- odic assessment of performance; self-assessment tools; struc-
work failures per malpractice incident, with more than half of the tured site visits; and dissemination of best practices. After the
deaths and permanent disabilities judged to be avoidable.85 inception of data collection, 30-day mortality after major proce-
The key message is that errors frequently are a product of the dures decreased by 27% and 30-day morbidity by 45%. The
context in which they occur. It is tempting to assume that a few NSQIP also identified risk factors for prolonged length of stay
“bad apples” are responsible for most safety and quality prob- after major elective surgery; the most important of these were
lems. In reality, however, bad apples are relatively few, and they intraoperative processes of care and postoperative adverse
account for only a small percentage of medical errors.To achieve events.97 Other notable findings of the project were (1) that for a
significant overall improvements in quality, all physicians will number of common procedures, there were no statistically sig-
have to make efforts to improve the context in which patient care nificant associations between procedure or specialty volume and
30-day mortality and (2) that savings from improved surgical emphasis on evidence-based data might lead to skewed prioriti-
care far exceeded investment in the project.98 The NSQIP is now zation of safety measures and thus might prevent relatively few
expanding into academic medical centers with the aim of achiev- adverse events.105
ing comparable results there. Finally, one might focus on an area where there is unexplained
The conspicuous success of these large-scale examples should variation in a relevant outcome measure. Such variation might
not obscure the fact that most successful efforts have been on a exist in reference to either an internal or an external benchmark
smaller scale in single institutions.77,99 Thus, individual efforts at (the latter being preferable).49
quality improvement are not incidental but essential. An area for evaluation having been identified, the second step
is to identify the relevant subsystems and all of their components.
This can be challenging, particularly with complex systems. It is
Identifying Systems and System Failures advisable to start by assembling a team whose members repre-
The intensive systematic investigation of quality problems is sent all the possible components. Being inclusive rather than
known as root cause analysis (RCA).The first step in such analy- exclusive minimizes the chances of missing latent errors; it also,
sis is to identify the specific area to be studied. One approach is at least potentially, maximizes the number of possible solutions.
to focus on an area of recurring concern (e.g., habitual misuse of The next step is to determine the appropriate data source.
medical devices) or on the result of a particular critical incident Medical-record audits yield far greater detail than claims data do,
that should never have happened or must never happen again. but such audits are expensive, labor-intensive, and time-consum-
Both the JCAHO and the NQF have identified some of these ing. Moreover, the information the records contain on environ-
“never” events and suggested methods for avoiding them; the ment or behavior may be irrelevant or even contradictory.
NQF has also drafted additional proposals suitable for evidence- Screening criteria can help identify and reduce some of these
based practices. Another approach is to monitor an area where problems.106 Use of administrative data can help avoid many of
there is no immediate concern but where a recent change in pol- the shortcomings of medical-record review, but such data often
icy or equipment might introduce unanticipated problems. A use- lack the requisite accuracy. In either type of analysis, it is impor-
ful source for specific topics is the online journal created by the tant to remember that the process is evolutionary: it is rare that
Agency for Healthcare Research and Quality, AHRQ WebM&M one starts with a perfect set of measures.
(www.webmm.ahrq.gov).This free site includes expert analysis of It may be difficult to generate interest in analyses of a critical
medical errors in five specialty areas (including surgery), as well incident whose causes are so unusual that they are unlikely ever
as interactive learning modules on patient safety. to combine in the same way again in a given institution. Although
In the absence of a specific safety or quality concern, it may be the findings from such an analysis might seem to be of little use,
worthwhile to focus on an area where quality-improvement the incident might occur frequently enough at a regional or
efforts are likely to be fruitful—for instance, patient notification national level to make the analysis worthwhile. Thus, it is impor-
systems,77 patient safety systems,100 analyses of system failures in tant to tabulate such seemingly rare incidents (including near
laparoscopic surgery,101 or analyses of medical microsystems.102 misses) even if there is little direct or immediate institutional ben-
Critical analyses of evidence-based practices identified 11 surgi- efit. Besides their potential value in larger contexts, such data
cally relevant quality-improvement practices for which the data might help the institution predict, and thereby avoid, other forms
are strong enough to support more widespread implementation of errors (especially latent ones) and system failures. The strate-
[see Table 4].103,104 It has been argued, however, that exclusive gy of making potential adverse consequences of latent errors vis-
ible to those who manage and operate similar systems is the basis
of the highly successful Aviation Safety Reporting System.58
Some industries have modified RCA to meet particular needs,
Table 4 Surgically Relevant Quality- including health care.67,73 A manual for RCA use in patient care
Improvement Practices Appropriate is available through the JCAHO, and various centers and hospi-
for Widespread Implementation103 tals have reported on RCA use.107,108 RCA can be automated,109
but the potential advantages of automation may be offset by
Appropriate use of prophylaxis to prevent venous thromboembolism in dependence on the developer’s interpretation of the risk reduc-
patients at risk tion process or by the factors identified as the principal event.
Use of perioperative beta blockers in appropriate patients to prevent
perioperative morbidity and mortality
Use of maximum sterile barriers while placing central venous catheters General Techniques for Safety Improvement
to prevent infection
Appropriate use of antibiotic prophylaxis to prevent postoperative infec- Many safety-improvement techniques derived from nonmed-
tions ical systems have been successfully applied to medical systems
Requesting that patients recall and state what they have been told dur- [see Table 5].110,111 Other successful strategies include prioritiza-
ing the informed consent process
Continuous aspiration of subglottic secretions to prevent ventilator-
tion of tasks, distribution of the work load over time or resources,
associated pneumonia changing the nature of the task, monitoring and checking all
Use of pressure-relieving bedding materials to prevent pressure ulcers available data, effective leadership, open communication, mobi-
Use of real-time ultrasound guidance during central line placement to lization and use of all available resources, and team building.5
prevent complications The general idea is to redesign the problem space to reduce the
Patient self-management for warfarin to achieve appropriate outpatient cognitive work load.73,112
anticoagulation and prevent complications
Appropriate provision of nutrition, with particular emphasis on early
A key step in improving patient safety is the establishment of a
enteral nutrition in critically ill and surgical patients safety culture throughout the workplace. An appropriate culture
Use of antibiotic-impregnated central venous catheters to prevent views errors as they are viewed in control theory—namely, as sig-
catheter-related infections nals for needed changes. The focus should be on learning rather
than on accountability. If the team or organization is designed to
Accordingly, it is not surprising that the variable incentives and

Table 5 Nonmedical System Techniques structure of health care in the United States lead to highly vari-
able patterns of care and a widespread failure to implement evi-
Also Applicable to Medical Systems
dence-based practice.119 The result has been described as a cycle
of unaccountability, in which no component of the system is will-
Simplify or reduce handoffs Adjust work schedules ing to take substantial responsibility for safety and quality. Each
Reduce reliance on memory Adjust the environment component defers to another: regulators to accreditors, accredi-
Standardize procedures Improve communication and
teamwork
tors to providers, providers to insurers, insurers to purchasers,
Improve information access
Decrease reliance on vigilance purchasers to consumers, and consumers to regulators, complet-
Use constraining or forcing
functions Provide adequate safety training ing the cycle.
Design for errors Choose the right staff for the job Specific obstacles to improving patient safety in the United
States include (1) unawareness that a problem exists; (2) a tra-
ditional medical culture based on individual responsibility and
blame; (3) vulnerability to legal discovery and liability; (4) prim-
learn from and benefit from experience, its collective wisdom itive medical information systems; (5) the considerable time and
should be greater than the sum of the wisdom of its individual expense involved in defining and implementing evidence-based
members. Needed changes often involve difficult choices among practice; (6) inadequate resources for quality improvement
strategic factors, and sometimes, they introduce new latent and error prevention; (7) the absence of a demand for improve-
errors.41,102 Accordingly, once a change in procedure or policy has ment; (8) the local nature of health care; and (9) the perception
been implemented, its impact must be closely monitored.113 of a poor return on investment (i.e., the lack of a business
Some unintended consequences may result from the inherent case).120,121 Several of these obstacles are worth addressing in
limitations of a safety-improvement strategy. For example, sim- greater detail.
plification is desirable, but oversimplification can itself generate The traditional paradigm of surgical care is founded on the
problems.25 As another example, tightly coupled high-risk indus- concept of physician autonomy and holds the individual surgeon
tries (e.g., aviation and nuclear power) commonly use redundant accountable as the “captain of the ship.” Undoubtedly, this par-
processes to enhance reliability; yet the benefits of such redun- adigm has enabled great achievements in surgical care; however,
dancy are frequently offset by greater complexity and a conse- it has also, in some cases, become associated with a dangerous
quent increase in the risk of human failure.74 In addition, the sense of infallibility. With this paradigm as a conceptual back-
more complex the system, the greater the chance that a change drop, errors tend to be equated with negligence, and questions of
will have effects beyond the local. A central problem in error professional liability tend to involve blaming individuals. Indeed,
management is how to control particular errors without relaxing the very willingness of professionals to accept responsibility for
control over others.74,114 their actions makes it convenient for lawyers to chase individual
Computer-based technology is often touted as a valuable tool errors rather than collective ones.58 Moreover, an individual sur-
for improving safety and quality.74,115 For instance, there is strong geon is a more satisfactory target for an individual’s anger and
evidence that computers can reduce medication errors116 and facil- grief than a faceless organization is. The point is not that sur-
itate weaning from ventilators.117 Nevertheless, acceptance of geons should avoid responsibility but rather that focusing on
computerization has been neither easy nor universal. Computer- individual errors does not address underlying system flaws.
ized ventilator weaning, though ultimately successful, was initially With the evolution of contemporary surgical practice, this par-
resisted,118 and programs developed for hematology and rheuma- adigm may have to be rethought. The burgeoning growth of
tology appear not to have gained clinical favor.115 A greater empha- knowledge, the attendant increase in specialization, the expand-
sis on computer literacy during training might facilitate effective ing role of technology, and the rising complexity of practice are
incorporation of computer technology into subsequent practice. making surgeons more and more dependent on persons or fac-
One concern that has arisen with respect to computer tech- tors beyond their immediate control. As a result, surgeons are
nology in medical systems is that if computerized advice-giving finding it more and more difficult to appreciate, let alone man-
systems become widespread, caregivers might become excessive- age, the larger context within which they provide care, and they
ly dependent on them, perfunctorily acceding to the computer’s are finding that the traditional paradigm, once so successful, is
advice at the expense of their own judgment. Issues of legal lia- becoming less useful [see Table 6].122 In an apparent paradox,
bility might then arise as to how much computer advice is too improving patient safety demands an understanding of patient
much and whether relying on such advice is tantamount to aban- care systems—at the very time when those systems are becoming
doning responsibility for critical independent thought. increasingly difficult to understand.
Many patient care tasks may in fact be too complex for com-
puterization and therefore better suited to human performance.
The trade-off for retaining human ability to deal with such com-
plexity is human susceptibility to error, which means that sys- Table 6 Contrasting Characteristics of Medical
tems relying on error-free human performance are destined to Practice in the 20th and 21st Centuries122
experience failures. Because the kinds of transitory mental states
that cause errors are both unintended and largely unpredictable, 20th-Century Characteristics 21st-Century Characteristics
they are the last and least manageable links in the error chain.
Autonomy Teamwork/systems
Solo practice Group practice
Obstacles to Safety Improvement Continuous learning Continuous improvement
Infallibility Multidisciplinary problem solving
It has been observed, perhaps somewhat cynically, that every Knowledge Change
system is perfectly designed to achieve the results it gets.
The current system of professional liability is frequently cited it is by no means evident that improving quality would cost more.
as an obstacle to quality improvement. Unfortunately, there is lit- Correcting underuse might increase costs, but such increases
tle incentive for change among many of the vested interests might well be outweighed by savings from correcting overuse and
involved. The many millions of dollars spent on public advertis- misuse. Given that current market approaches to health care
ing and political lobbying are likely to produce little change and have yet to contain costs, it would seem appropriate to at least
could be better spent in direct efforts to improve safety. No-fault attempt quality improvement before resorting to rationing.
compensation, no-fault reporting systems, and a program of Other economic considerations also factor into the lack of a
research have been proposed as alternatives,123,124 but all of these coherent business case for quality improvement. For instance,
proposals appear to have shortcomings.125 Moreover, patients’ sophisticated medical information systems are a necessity today;
loss of trust in many health care providers has allowed lawyers to however, such systems often remain in a relatively primitive state
gain leverage with the argument that they act on behalf of the “lit- because the fear of technical obsolescence makes buyers reluc-
tle guy.” tant to capitalize new systems.Thus, while potentially usable data
Many physicians believe that for significant improvements in accumulate, the ability to extract meaningful information may
quality to be achieved, a major reform of the professional liabili- deteriorate, making it more difficult and costly to define and
ty system is essential. Certainly, tort reform is necessary, but the implement evidence-based practice.
real prerequisite for better identification and management of sys-
tem failures is increased protection for privileged discussion of
such failures.122 Indeed, the Quality Interagency Coordination Future Implementation of Quality-Improvement Efforts
Task Force argues that RCAs undertaken to determine the inter- Given that quality improvement is both necessary and possi-
nal shortcomings of hospital care systems should not be subject ble, the question then becomes, who should spearhead this
to discovery in litigation and that appropriate legislation should process? Although consumers, purchasers, government, insurers,
be enacted in conjunction with or before the implementation of academic medicine, organized medicine, and health care
any reporting systems.31 The IOM supports a larger federal role providers all hold stakes in the process, it is physicians, with their
in these efforts. history of patient advocacy and scientific innovation, who are
The importance of liability reform notwithstanding, the issues best situated to provide the needed leadership.121,128 Such advo-
involved in enhancing safety and quality are more involved than cacy and innovation are a primary basis of the trust placed in the
can be addressed solely by changes in the liability system. For medical profession; to decline the challenge to improve health
instance, safety and quality problems are known to exist in care quality may seriously undermine this trust. When trust is
nations where professional liability is not an issue. In addition, it forfeited, the consequences can be dire, as the recent history of
is clear that physicians still tend to act defensively even in a no- the accounting industry illustrates.
fault liability system. Minimizing such defensiveness requires Excellent examples of physician-led efforts at quality improve-
that greater emphasis be placed on measurement for improvement exist, but they remain relatively isolated. Unless physicians
ment than on measurement for judgment.126,127 act to expand such efforts significantly, groups outside the pro-
Fortunately, there appears to be a growing sense that open dis- fession are likely to fill the void and possibly close the window of
cussion of medical errors is appropriate.60 Moreover, it seems opportunity for physician leadership. For instance, the Leapfrog
that such open communication may both reduce the probability Group (http://www.leapfroggroup.org), which represents more
of legal action and enhance public confidence in providers. than 26 million Americans, has already conducted hospital sur-
Nevertheless, some hospitals continue to separate risk manage- veys regarding computerized drug orders, ICU physician
ment from quality-assurance issues, to the detriment of both.128 staffing, coronary artery bypass surgery, coronary angioplasty,
Building a strong business case for quality improvement is abdominal aortic aneurysm repair, carotid endarterectomy,
complicated because even when there is good evidence that esophageal cancer surgery, high-risk obstetrics, and neonatal crit-
improving quality is cost-effective, the parties involved may dis- ical care, with a particular eye to identifying preventable adverse
agree on who should be rewarded and what the reward should events and evaluating the relation between volume and outcome.
be.119,120,129 Thus, if physician-related quality improvements One potential policy implication of these findings is that health
financially benefit a managed care company rather than a physi- care purchasers might adopt policies that transfer patients need-
cian, physicians might have little incentive to implement them— ing a particular procedure to high-volume providers with demon-
or even some incentive not to. Accordingly, it would seem sensi- strated good outcomes.132 Such policies might affect the overall
ble to focus initial quality-improvement efforts on areas where distribution of health care services and unfairly penalize low-vol-
the various interests are aligned.130 Even then, however, caution ume, high-quality providers, while teaching us little or nothing
is needed. For example, one study found that 24% of physicians about precisely which system components are relevant to
faced incentives derived from patient-satisfaction surveys, 19% improved outcome. The data on volume-outcome relations are
faced incentives derived from quality-of-care measures, and 14% intriguing, but many of the studies done to date have major
faced incentives derived from profiling based on use of medical methodological problems.68-70,102 Moreover, the majority of
resources.131 Patient satisfaction is important from the perspec- patients and physicians are not convinced that such regionaliza-
tive of continuity of care, but it is not clear how improved patient tion would be effective.2 For now, at least, it seems premature to
satisfaction alone might address problems of overuse and misuse. adopt such a policy.
Some have suggested that aggressive quality-improvement For any successful improvement in patient safety, an effective
efforts might make health care costs more difficult to control. It reporting system is vital. It is generally agreed that such systems
must be acknowledged, however, that to date, neither voluntary should be being nonpunitive and strictly confidential (if not
action by the health care industry, managed care, nor market anonymous).133 There is some debate, however, as to whether
competition appears to have achieved such control. For the most they should be voluntary or mandatory. On one hand, voluntary
part, the emphasis has been on managing cost rather than reduc- reporting has a high inaccuracy rate even when mandated by
ing waste.Yet waste is essentially a synonym for poor quality, and state or federal regulations. On the other hand, many surgeons
believe that mandatory reporting may increase the pressure to tendencies in the presence of uncertainty, residents (like pilots)
conceal errors rather than analyze them; that it is unworkable in may develop better responses to underspecified situations.
the current legal system; and that it may result not in construc- Residents should also be monitored to ensure that they learn to
tive error-reducing solutions but merely in more punishment or assess and address knowledge deficits as well as learn healthy
censure.134 habits in responding to errors. In this way, the learning curve can
There is also some debate as to whether patient-safety efforts be made less painful for all concerned.140
should (at least initially) focus on medical injuries or on medical
errors.135,136 An approach focusing on injuries recognizes the dif-
ficulty of identifying medical errors and is based on a public Conclusion
health improvement model that has proved useful in addressing Error in medicine is a dauntingly complex topic, and the
other types of injuries; it also recognizes that most medical injuries progress made in reducing such errors has, in many cases, been
are not caused by negligence. Such an approach seems more com- disappointingly slow. Unfortunately, changing the traditional par-
patible with the current liability system and may help restore adigm is a far more complex task than the simplistic solutions
physicians’ stature as patient advocates. An approach focusing on often made by the popular media would suggest. A call for sur-
errors suggests that focusing on injuries diverts attention from geons to report results, issued roughly 100 years ago, was largely
cases where there is an underlying system flaw, with the result that ignored.141 At that time, however, the basic principles of human
the flaw is not corrected. Although this is probably true, the first performance and error were not as well understood as they now
approach is likely to achieve greater initial buy-in on the part of are, and the tools necessary for systems analysis did not exist.
physicians and thus may be a more pragmatic first step. It is crucial for all parties involved in health care to acknowledge
Successful change requires not only agreement that a change is that most medical errors are attributable to system flaws rather
necessary and desirable but also agreement on what the change than to incompetence or neglect. Moreover, it is important for
should be. In that regard, the aviation industry is frequently pro- physicians to lead the changes needed to make systems-based
posed as a model for health care. However, aviation safety is practice the norm. Support for such initiatives, if needed, will
enhanced by the availability of various monitors (e.g., flight data come from multiple sources, including patients, public and private
recorders) that supply information on aircraft position and flight sector purchasers, and specialty boards and societies.142 Making
conditions. A model applying these techniques to surgery has efforts to improve surgeon performance, patient safety, and the
been described,101 but independent confirmation of relevant fac- overall quality of surgical care not only is the right thing to do but
tors still seems impractical in most clinical surgical situations. also is in surgeons’ own best interests.9 There is little doubt that
Actually, surgery may be more akin to the maritime industry, in performance assessment will increase; surgeons who do not assess
which the ship captain makes judgments about circumstances their performance will be at a disadvantage to those who do.
that are difficult to verify, than it is to the aviation industry. If so, Part of what is at stake is physicians’ authority, in more than
it is probably relevant that the maritime industry has been less one sense of the word. Physicians do continue to enjoy unchal-
successful at safety improvement than the aviation industry has. lenged authority, in the sense of being conceded to possess spe-
In any case, there are many underutilized opportunities for qual- cialized knowledge. However, in the sense of being able to con-
ity improvement in health care, and the training lessons of avia- trol one’s destiny, physicians’ authority often seems to be slip-
tion, whereby pilots are forced to deal with unusual situations ping away into the hands of outside agencies. Much of the
that help reveal gaps or errors in their understanding, are one decline in the latter type of authority is a reflection of a decline
such opportunity. Even if the aviation model does not fully apply, in the public’s overall trust in the profession. If physicians turn
its level of success should remain a goal. down the opportunity to lead the necessary efforts to improve
Particular attention should be paid to incorporating current patient safety and quality of care, they may anticipate further
concepts of performance and error into surgical education.137 An erosion of public trust and further loss of their remaining auton-
optimal structure for such education might be an objective-based omy. The growing demand for accountability seems unstop-
curriculum that provides residents with defined skills, rules, and pable. If surgeons provide the requisite leadership now, their
knowledge.138,139 The blame-and-shame approach must be elimi- ability to control their destiny is likely to be enhanced rather than
nated from the learning atmosphere. Once made aware of their further diminished.
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97. Collins TC, Daley J, Henderson WH, et al: Risk fac-
tors for prolonged length of stay after major elective Improv 27:589, 2001 140. Gawande A: The learning curve. New Yorker,
surgery. Ann Surg 230:251, 1999 117. Horst HM, Mouro D, Hall-Jenssens RA, et al: De- January 28, 2002, p 52
98. Khuri SF, Daley J, Henderson W, et al: Relation of crease in ventilation time with a standardized wean- 141. Codman EA: A Study in Hospital Efficiency. Joint
surgical volume to outcome in eight common oper- ing process. Arch Surg 133:483, 1998 Commission on Accreditation of Healthcare
ations: results from the VA National Surgical 118. Thomsen GE, Pope D, East TD, et al: Clinical per- Organizations, Oakbrook Terrace, Illinois, 1996
Quality Improvement Program. Ann Surg 230:414, formance of a rule-based decision support system 142. Gallagher TH, Waterman AD, Ebers AG, et al:
1999 for mechanical ventilation of ARDS patients. Proc Patients’ and physicians’ attitudes regarding the dis-
99. Cohn LH, Rosborough D, Fernandez J: Reducing Annu Symp Computer Appl Med Care 1993, p 339 closure of medical errors. JAMA 289:1001, 2003
ELEMENTS OF CONTEMPORARY PRACTICE 4 RISK STRATIFICATION — 1
4 RISK STRATIFICATION,
PREOPERATIVE TESTING, AND
OPERATIVE PLANNING
Cyrus J. Parsa, M.D., Andrew E. Luckey, M.D., Nicolas V. Christou, M.D., F.A.C.S., and Alden H. Harken, M.D., F.A.C.S.
Assessment of Surgical Risk

In the midst of [the lungs] is seated a hot organ, the heart,
which is the origin of life and respiration. It imparts to the Continuing refinement of the tools used to delineate levels of
lungs the desire of drawing in cold air, for it raises a heat preoperative risk is permitting surgeons to “handicap” both
in them; but it is the heart which attracts. If, therefore, the patients and surgical procedures with greater and greater preci-
heart suffer primarily, death is not far off. sion.3,4 It is clear, for example, that outcome assessment must
—Aretaeus of Cappadocia incorporate a so-called sickness quotient—typically expressed in
terms of the ratio of observed outcome to expected outcome
Although no one truly wants to undergo a surgical procedure, the (O/E)—into the assessment of therapeutic value.5 Obviously, if a
results of surgery can be highly gratifying to both patient and sur- surgeon operates only on Olympic-level athletes with single organ
geon when the right operation is performed for the right reasons, disease (or no disease at all), his or her patients will almost always
accurately and expeditiously, on the right patient at the right do very well (or at least survive); one who operates on a more var-
time. In attempting to bring about this state of affairs, surgeons ied group of patients will have quite different results.
must consciously and honestly balance the physiologic, psycho- The most universally used classification system is the one
logical, social, and financial insults of surgery against the antici- developed by the American Society of Anesthesiologists (ASA),
pated benefits.1 Of course, surgeons are not the only medical pro- which is based on the patient’s functional status and comorbid
fessionals who must perform this kind of balancing act; however, conditions (e.g., diabetes mellitus, peripheral vascular disease,
they are probably the most conspicuous. renal dysfunction, and chronic pulmonary disease) [see Table 1].6
Currently, the measures of both anticipated surgical risk and The ASA index generally associates poorer overall health with
expected outcome are being assessed in an increasingly sophisti- increased postoperative complications, longer hospital stay, and
cated manner under the umbrella of health care quality.2 Mortal- higher mortality. ASA classes I and II correspond to low risk, class
ity alone is no longer considered a sufficient indicator of the suc- III to moderate risk, and classes IV and V to high risk.
cess or failure of treatment. Cost is no longer addressed only in Besides functional capacity and comorbid conditions, age has
absolute terms but is (appropriately) related to years of life saved. also been shown to be a determinant of operative risk, as has the
Therapeutic morbidity is now taken into account in figuring the type of operation being performed (with vascular procedures and
cost of each quality-adjusted life year (QALY) saved. Age is con- prolonged, complicated thoracic, abdominal, and head and neck
sidered not merely in terms of distance from the beginning of life procedures carrying higher levels of risk).
but also, more importantly, in terms of proximity to the end of life.
HISTORY AND PHYSICAL EXAMINATION
It goes without saying that in balancing risks against benefits,
surgeons as a group should make use of the best available evi- The initial history, physical examination, chest x-ray, and elec-
dence (e.g., from rigorous prospective trials). In the end, howev- trocardiographic assessment should focus on the identification of
er, it is the responsibility of the individual surgeon to examine, potential respiratory or cardiac disorders [see Table 2],7 emphasiz-
digest, and individualize the morass of medical material relevant ing evaluation of the patient’s cardiac status. High-risk cardiac con-
to each patient’s disease and expected surgical outcome. This is ditions include recent myocardial infarction (MI), decompensated
key for developing not only the surgeon’s ability to provide care heart failure, unstable angina, symptomatic dysrhythmias, and
but also the patient’s ability to respond to it. Sensitive communi- symptomatic valvular heart disease. Underlying less acute cardiac
cation of the nature and severity of the disease and clear expla- conditions, though apparently stable at the time of assessment,
nation of the proposed treatment are integral parts of the thera- may become manifest during perioperative stresses.8 Such condi-
peutic process. A knowledgeable patient who participates in his or tions include stable angina, distant MI, previous heart failure, and
her treatment will get better faster. Finally, it is also incumbent on moderate valvular disease.The review of symptoms should identi-
the surgeon to honor the extraordinary trust inherent in his or her fy serious comorbid conditions such as diabetes, stroke, renal
relationship with the patient by providing ongoing psychological insufficiency, blood dyscrasias, and pulmonary disease.
and social support during surgical therapy—even after such sup-
port might be deemed excessive. A patient must not be allowed
to give up hope. Smoking
Our main aims in this chapter are (1) to assess approaches to According to the American Heart Association, smokers made
the delineation of surgical risk, (2) to outline current thinking on up a 40% smaller percentage of the U.S. population in 2003 than
the appropriate use of preoperative testing, (3) to highlight the they did in 1965.9 Nevertheless, approximately one third of sur-
importance of the patient’s mental and emotional satisfaction gical patients are still smokers. Smoking is clearly a risk factor for
with care as a component of outcome, and (4) to describe ways perioperative complications,10 including pulmonary complica-
of reducing perioperative cardiac risk. tions, circulatory complications, and an increased incidence of
Table 1 American Society of Anesthesiologists’ Physical Status Classification: Nonemergency Surgery6
Classification Description Examples
Class I Normal, healthy patient An inguinal hernia in a fit patient or a fibroid uterus in a healthy woman
Patient with mild systemic disease—a mild to moderate

Moderate obesity, extremes of age, diet-controlled diabetes, mild hypertension,
Class II systemic disorder related to the condition to be
chronic obstructive pulmonary disease
treated or to some other, unrelated process
Morbid obesity, severely limiting heart disease, angina pectoris, healed myocardial
Patient with severe systemic disease that limits activity
Class III infarction, insulin-dependent diabetes, moderate to severe pulmonary
but is not incapacitating
insufficiency
Organic heart disease with signs of cardiac insufficiency; unstable angina;

Patient with incapacitating systemic disease that is
Class IV refractory arrhythmia; advanced pulmonary, renal, hepatic, or endocrine
life threatening
disease
Moribund patient not expected to survive 24 hr without Ruptured aortic aneurysm with profound shock, massive pulmonary embolus,
Class V
an operation major cerebral trauma with increasing intracranial pressure
surgical site infection. Numerous mechanisms contribute to the such tests are ordered, there is a 50% probability of an abnormal
deleterious effects of smoking: smoking inhibits clearance of pul- test result.15 When an SMA-20 is ordered, the probability of an
monary secretions, adversely affects the immune system and col- abnormal test result is quite high. Moreover, although these
lagen production, and contributes to wound hypoxia (thereby abnormalities are reported, they rarely alter the physician’s behav-
increasing susceptibility to infection).11 Some studies have sug- ior or result in cancellation or postponement of the operation [see
gested that even passive smoking can reduce blood flow velocity Table 3].15 Accordingly, current practice is to a take a much more
in the coronary arteries of healthy young adults.12 selective approach to preoperative laboratory evaluation.
A 2002 trial demonstrated that preoperative smoking cessation
FACTORS AFFECTING CARDIAC RISK
reduced the incidence of postoperative complications from 52%
to 18%.10 A 2003 study reported similar results: patients who
stopped smoking 4 weeks before operation had significantly lower Previous and Current Cardiovascular Disease
postoperative wound infection rates than patients who continued In the United States, approximately 30% of the 27 million
to smoke up to the time of operation.11 Ideally, cessation of smok- patients scheduled to undergo anesthesia for surgical procedures
ing at least 4 to 6 weeks before operation is recommended. yearly are known to have risk factors for coronary artery disease
(CAD).8 Given that cardiovascular disease is the leading cause of
Alcohol Abuse death in the United States,9 it is not altogether surprising that
The effects of chronic alcohol abuse on perioperative risk are cardiovascular factors account for the greatest proportion of
not as well studied as those of smoking. Alcohol abuse has been operative risk. Significant cardiovascular risk factors include
defined as the consumption of at least five drinks (containing angina pectoris, dyspnea and evidence of right-side or left-side
more than 60 g of ethanol) daily for several months or years.13 heart failure, any cardiac rhythm other than sinus rhythm, more
(These numbers are probably appropriate for 70 kg men but may than five ectopic ventricular beats per minute, aortic stenosis
be modified in other populations.) The pathogenic mechanism is with left ventricular hypertrophy, mitral regurgitation, and previ-
certainly multifactorial but is postulated to involve ethanol-medi- ous MI. An estimated 1 million patients scheduled to undergo
ated suppression of the immune system; this immune suppression elective noncardiac surgical procedures experience a periopera-
is reversible, at least during abstinence in nonsurgical patients. tive complication each year in the United States, and another
Other deleterious effects of chronic alcohol ingestion include
alcoholic cardiomyopathy, decreased platelet count and function,
reduced fibrinogen level, and compromised wound healing. Table 2 Minimal Preoperative Test Requirements*
Various alcohol abstinence periods, ranging from 1 week to 3
months, have been reported to decrease these adverse effects.14
at the Mayo Clinic7
Long-term abuse of alcohol is often associated with central
nervous system impairment and hepatic dysfunction, as well as Age (yr) Tests Required
malnutrition. Alcohol abusers, even those who exhibit no overt < 40 None
alcohol-related organ dysfunction, experience greater morbidity
than nonabusers and exhibit longer recovery times.14 40–59 Electrocardiography, measurement of creatinine and
glucose
PREOPERATIVE TESTING
≥ 60 Complete blood cell count, electrocardiography,
It was once generally agreed that surgical patients should chest roentgenography, measurement of creati-
nine and glucose
undergo a series of routine screening tests before operation. This
approach has proved not only unhelpful but also confusing and *In addition, the following guidelines apply. (1) A complete blood cell count is indicated in
all patients who undergo blood typing and who are crossmatched. (2) Measurement of
expensive. Perhaps predictably, it has been observed that the potassium is indicated in patients taking diuretics or undergoing bowel preparation.
more tests are ordered, the more abnormal values are obtained. (3) Chest roentgenography is indicated in patients with a history of cardiac or pulmonary
disease or with recent respiratory symptoms. (4) A history of cigarette smoking in patients
On the reasonable assumption that a test performed in a healthy older than 40 years who are scheduled for an upper abdominal or thoracic surgical proce-
person will yield an abnormal result 5% of the time, when 10 dure is an indication for spirometry (forced vital capacity).
Table 3 Effect of Abnormal Screening Test Results patients older than 50 years, but it is 3.1% in comparable vascu-
on Physician Behavior15 lar surgery patients, in whom the prevalence of asymptomatic
CAD is predictably high.17
Abnormal Test Resulting Management
Screening Test Results (%) Change (%) Functional Capacity
Hemoglobin level 5 (for < 10 g/dl; Abnormal result rarely led to Patients who are able to exercise on a regular basis without lim-
< 9 g/dl was rare) change itations generally have sufficient cardiovascular reserve to allow
Abnormal result rarely led to them to withstand stressful operations. Those with limited exer-
Total leukocyte count <1
change cise capacity often have poor cardiovascular reserve, which may
Bleeding time 3.8
become manifest after noncardiac surgery. Poor functional status
(and exercise capacity) is associated with worse short- and long-
Coagulation time 4.8 Abnormal result rarely led to
change term outcomes in patients undergoing noncardiac operations, as
Partial thromboplastin 15.6 well as with shorter nonoperative lifespans.18
time
Functional capacity is readily expressed in terms of metabolic
Chest x-ray 2.5–3.7 2.1 equivalents (METs). One MET is equivalent to the energy
ECG 4.6–31.7 0–2.2
expended (or the oxygen used) in sitting and reading (3.5 ml
O2/kg/min). For a 70 kg person, one MET amounts to 245 ml
1.4 O2/min. Multiples of the baseline MET value can then be used to
Sodium, potassium Abnormal result rarely led to quantify the aerobic demands posed by specific activities, as in
2.5
change
5.2 the Duke Activity Status Index [see Table 4].19
Energy expenditures for activities such as eating, dressing, walk-
Urinalysis 1–34.1 0.1–2.8 ing around the house, and dishwashing range from 1 to 4 METs.
Climbing a flight of stairs, walking on level ground at 6.4 km/hr,
running a short distance, scrubbing floors, and playing golf repre-
50,000 have a perioperative MI. The risk of intraoperative or sent expenditures of 4 to 10 METs. Strenuous sports (e.g., swim-
postoperative MI is much higher in patients who have suffered ming, singles tennis, and football) often demand expenditures
heart muscle damage within the preceding 6 months. In large ret- exceeding 10 METs. It has been established that perioperative
rospective reviews, 37% of patients experienced reinfarction cardiac and long-term risks are increased in patients unable to
when they underwent operation within 3 months of an infarction; meet the 4-MET demand associated with most normal daily
however, the incidence of reinfarction decreased to 16% when activities. Thus, the surgeon’s assessment of the patient’s exercise
the operation was performed between 3 and 6 months after the capacity is a practical, inexpensive, and gratifyingly accurate pre-
first infarction and to 4.5% when the operation was performed dictor of that patient’s ability to tolerate a surgical stress.
more than 6 months afterward.16 The estimated economic impact
of these complications is $20 billion annually.8 Type of Surgical Procedure
There is currently a trend toward more aggressive surgery in The procedure-specific cardiac risk associated with a noncar-
sicker patients, among whom the prevalence of ischemic heart diac operation is related almost exclusively to the duration and
disease is increasing. As a result, there is a growing need for expert intensity of the myocardial stressors involved. Procedure-specific
guidance in the preoperative evaluation of patients who are risk for noncardiac surgery can be classified as high, intermediate,
known to have or to be at risk for CAD. Although the literature is or low [see Table 5].20 High-risk procedures include major emer-
replete with suggested management algorithms, no firm consen- gency surgery, particularly in the elderly; aortic and other major
sus has been reached. Much of the continuing controversy is vascular operations; peripheral vascular surgery; and any opera-
related to the obvious difficulties of conducting large randomized, tion that is expected to be prolonged and to be associated with
controlled clinical trials on this topic, as well as to the relatively large fluid shifts or substantial blood loss. Intermediate-risk pro-
low incidence of perioperative cardiac events (< 10%). The inci- cedures include intraperitoneal and intrathoracic operations,
dence of postoperative MI is 0.7% in male general surgery carotid endarterectomy, head and neck procedures, orthopedic
surgery, and prostate operations. Low-risk procedures include
Table 4 MET Scores for Selected Activities endoscopic and superficial procedures, cataract operations, and
(Duke Activity Status Index) breast surgery.
Despite the prevalence of cardiovascular disease, many patients
presenting for noncardiac surgery have never received a meticu-
MET Score Activity
lous (or even a superficial) cardiovascular evaluation. Further-
Light activities of daily home life (e.g., eating, getting more, the proposed operations themselves may create sustained
1–4 dressed, using the toilet, cooking, washing dishes) cardiovascular stresses that are quite beyond what patients may
Walking 1–2 blocks on level ground at 2–3 mph
have experienced in daily life. It is therefore crucial for the car-
Climbing one flight of stairs diovascular consultant to identify underlying conditions and to
Walking up a hill evaluate and treat them using cost-effective and evidence-based
Walking on level ground at rate > 4 mph
5–9 Running a short distance guidelines, thereby benefiting patients both in the short term and
More strenuous household chores (e.g., scrubbing floors, in the long term.The goal of the consultation is to determine the
moving furniture) most appropriate testing and treatment strategies for optimizing
Moderate recreational activities (e.g., hiking, dancing, golf)
patient care while avoiding unnecessary testing.
Strenuous athletic activities (e.g., tennis, running, basketball,
> 10 swimming) Specialized Testing
Heavy professional work
Recognition of the limitations of routine testing [see Preopera-
Table 5 Selected Surgical Procedures Stratified by Ambulatory electrocardiography Preoperative ambula-

Degree of Cardiac Risk tory ECG (Holter monitoring) is relatively inexpensive, but the
recordings may be difficult to analyze because of electrocardio-
graphic abnormalities, which preclude adequate interpretation in
Degree of Cardiac
Type of Procedure as many as 50% of patients.24 Several studies have suggested an
Risk
association between ST segment changes detected during normal
Endoscopic procedures
Ambulatory procedures
daily activities and subsequent cardiac events in patients with sta-
Low (< 1%) ble or unstable angina and previous or recent MI.27 Some 33% of
Ophthalmic procedures
Aesthetic procedures surgical patients who have or are at risk for CAD experience fre-
quent ischemic episodes before operation, with most (> 75%) of
Minor vascular procedures (e.g., carotid endarterectomy)
Abdominal procedures these episodes being clinically silent.28 Several investigators have
Intermediate Thoracic procedures suggested an association between these electrocardiographically
(1%–5%) Neurosurgical procedures silent changes and adverse outcomes.24 Unfortunately, a nonis-
Otolaryngologic procedures chemic ambulatory ECG does not preclude the diagnosis of car-
Orthopedic procedures
Urologic procedures
diac muscle damage as identified by perfusion imaging.29 If
myocardial perfusion scanning is taken as the standard, ambula-
Emergency procedures (intermediate or high risk) tory ECG has both low sensitivity and low specificity for the
Major vascular procedures (e.g., peripheral vascular
surgery, AAA repair)
detection of ischemic heart disease.30
High (> 5%) Extensive surgical procedures with profound estimat-
ed blood loss, large fluid shifts, or both Radionuclide ventriculography Initial results in patients
Unstable hemodynamic situations undergoing vascular surgery suggested that the ejection fraction,
AAA—abdominal aortic aneurysm as determined by preoperative multiple gated acquisition (MUGA)
scanning, was an independent predictor of perioperative cardiac
morbidity. Subsequently, a study of 457 patients undergoing
tive Testing, above] led to suggestions in favor of specialized pre- abdominal aortic surgery found that a depressed ejection fraction
operative cardiac testing instead.21 Since the 1980s, innumerable (50%) predicted postoperative left ventricular dysfunction but not
studies have attempted to establish the utility of this approach, other cardiac complications.31 Thus, quantification of the resting
but results have differed markedly across studies, making inter- ejection fraction by means of radionuclide (technetium-99m) ven-
pretation and recommendation difficult.22 It is now understood triculography appears not to contribute a great deal beyond the
that no single test can replicate all of the components of surgical information already supplied by the routine history and physical
stress. This being the case, the challenge is to develop a preoper- examination, though exercise radionuclide ventriculography does
ative assessment approach that makes appropriate use of specific appear to have some prognostic value.
tests tailored to specific patients undergoing specific procedures.
In general, indications for further cardiac tests and treatments Echocardiography Precordial echocardiography has been
are the same in the operative setting as in the nonoperative set- suggested as a means of identifying high-risk patients. In a study
ting. The timing of these interventions, however, depends on the of 334 patients,32 however, preoperative transthoracic echocar-
urgency of the noncardiac procedure, the risk factors present, and diography had limited incremental value for predicting ischemic
specific considerations associated with the procedure. Coronary outcomes (cardiac death, MI, or unstable angina) in comparison
revascularization before noncardiac surgery has sometimes been with routine clinical evaluation and intraoperative ECG, and the
advocated as a way of enabling the patient to get through a non- echocardiographic findings served only as a univariate predictor
cardiac procedure, but it is appropriate only for a small subset of of congestive heart failure (CHF) and ventricular tachycardia. In
very high risk patients.23 a multivariate analysis that included clinical information (e.g., a
history of CHF or CAD), none of the preoperative echocardio-
Exercise treadmill testing Increases in heart rate are com- graphic measurements were significantly associated with heart
mon during and after operation; nearly one half of all periopera- failure or ventricular tachycardia. Thus, until subsets of patients
tive ischemic events are associated with tachycardia.24 Use of who may benefit are identified, the indications for preoperative
exercise treadmill testing (ETT) therefore appears reasonable, echocardiography in surgical patients appear to be similar to
and it is supported by several studies demonstrating that a posi- those in nonsurgical patients and are restricted to focused evalu-
tive ischemic response and low exercise capacity predict an unto- ation of ventricular or valvular function.
ward outcome after noncardiac surgery.8 A level II study of inter- Stress echocardiography, on the other hand, may offer unique
mediate-risk patients confirmed that ST segment depression of prognostic information: it appears to be as successful as radionu-
0.1 mV or greater during exercise was an independent predictor clide stress imaging at identifying jeopardized zones of ischemic
of perioperative ischemic events.25 Early studies indicated that myocardial tissue.33 The strength of stress cardiac imaging is its
perioperative myocardial infarction occurred in 37% of vascular ability to differentiate healthy from ischemic from scarred myo-
surgery patients who demonstrated a positive ischemic response cardium. Patients demonstrating extensive ischemia (more than
on ETT but in only 1.5% of those who did not.8 In patients five left ventricular segments involved) with exercise provocation
whose anticipated risk of CAD is low, however, the sensitivity of experience 10 times more cardiac events than patients with lim-
an exercise ECG may be as low as 45%.26 Notably, other studies ited stress-induced ischemia (fewer than four segments in-
reported that routine 12-lead resting preoperative ECG and eval- volved).34 An increase in oxygen demand after dobutamine infu-
uation of exercise capacity were independent and superior pre- sion may elicit wall-motion abnormalities pathognomonic of
dictors of perioperative cardiac morbidity.8,18 Like all other com- ischemic myocardium. A study of 1,351 consecutive patients who
ponents of preoperative risk evaluation, ETT should never be underwent major vascular procedures found that dobutamine
considered in a vacuum. stress echocardiography effectively identified the 2% of patients
at high ischemic risk for whom consideration of coronary angiog- ed only when invasive delineation of CAD would be indicated in
raphy and possible revascularization was appropriate.34 Patients the absence of the noncardiac surgical problem.
at moderate ischemic risk (fewer than four segments) were able
to proceed with surgery under beta-blockade therapy. In a study ACC/AHA Guidelines
of 136 patients undergoing vascular surgery, all 15 postoperative Comprehensive identification of patients who are at substantial
complications occurred in the 35 patients who had a positive risk for perioperative cardiac morbidity remains a difficult task.
response to dobutamine stress echocardiography.35 Other investi- As noted [see Preoperative Testing, above], routine preoperative
gators subsequently confirmed that stress echocardiography testing has significant inherent limitations. An evaluation strategy
using either dobutamine or dipyridamole offered useful prognos- that avoids these limitations has been proposed by combined task
tic information that facilitated the development of treatment forces from the American College of Cardiology and the AHA.39
algorithms.8 This strategy bases diagnostic and therapeutic approaches on
clinical screening for disease state and functional capacity. It
Thallium scintigraphy Radionuclide scanning with thalli- employs specialized testing conservatively—that is, only when the
um-201 after exercise or pharmacologically induced stress is a additional information provided by the proposed test is likely to
useful method of identifying zones of potential ischemia; provoca- have an impact on outcome. The ACC/AHA strategy has proved
tive coronary perfusion imaging studies provide a great deal of efficient and cost-effective in vascular surgery patients.
valuable data. The highest-risk patients undergoing noncardiac The ACC/AHA guidelines take the form of an eight-step algo-
surgery, however, are those with exercise limitations, who typical- rithm for patient risk stratification and subsequent determination
ly have peripheral vascular, orthopedic, or neurologic disease. As of appropriate cardiac evaluation; this algorithm is available on
a result, various pharmacologic methods of modeling the effects the ACC’s web site (www.acc.org/clinical/guidelines/perio/update/
of exercise have been developed, including those that induce fig1.htm). Steps 1 through 3 of the algorithm are concerned with
coronary vasodilation (using dipyridamole or adenosine) or assessing the urgency of the operation and determining whether
increase heart work (using dobutamine or arbutamine).The most a cardiac evaluation or intervention has recently been performed.
extensively investigated of these methods is dipyridamole thalli- If there has been no recent cardiac evaluation or intervention and
um scintigraphy.36 the operation is elective, steps 4 through 7 are activated. These
In the mid-1980s, the usefulness of scintigraphy was assessed steps are concerned with identifying clinical predictors of cardiac
in vascular surgical patients. It was found that nearly all periop- risk, assessing functional status, and estimating the risk of the
erative adverse events occurred in patients with redistribution proposed operation. Specifically, the surgeon must determine
defects; few, if any, occurred in patients without preoperative whether the patient has a major clinical predictor of cardiac risk.
redistribution abnormalities. These findings led to widespread As defined by the ACC/AHA task force,39 major clinical predic-
use of dipyridamole thallium, generating more than $500 million tors include unstable coronary syndrome, decompensated CHF,
in national health care costs annually.8 In the early 1990s, inves- significant arrhythmias, and severe valvular disease. Intermediate
tigators challenged previous findings in a prospective, triple- clinical predictors include mild angina pectoris, diabetes mellitus,
blinded study that assessed both adverse outcome and perioper- chronic renal failure with serum creatinine levels higher than 2
ative MI (by means of continuous ECG and transesophageal mg/dl, and a history of MI or CHF. Poor functional status is
echocardiography).37 In contrast to previous reports, no associa- defined as inability to perform activities involving energy expen-
tion between redistribution defects and perioperative ischemia or ditures greater than 4 METs. Step 8 of the algorithm—noninva-
adverse events was noted, and the majority of episodes occurred sive cardiac testing for further determination of cardiac risk—is
in patients without redistribution defects. These findings pro- employed in accordance with the information gained from steps
voked a more extensive study involving 457 consecutive unselect- 1 through 7 [see Table 6].39 The purpose is to identify patients who
ed patients undergoing abdominal aortic surgery.29 The investiga- need further cardiac evaluation and aggressive cardiac stabiliza-
tors found that thallium redistribution was not significantly tion in the perioperative period.
associated with perioperative MI, prolonged ischemia, or other
FACTORS AFFECTING NONCARDIAC RISK
adverse events. The current consensus is that routine thallium
scintigraphy has no real screening value when applied to a large
unselected vascular or nonvascular population or to patients Respiratory Status
already classified clinically as low- or high-risk candidates for Testing of pulmonary function may be indicated on the basis
noncardiac surgery. of physical findings (e.g. cough, wheezing, dyspnea on exertion,
rales or rhonchi) or a history of cigarette smoking. Limited pul-
Coronary angiography Coronary angiography is an inva- monary reserve may be revealed by observing the patient for dys-
sive procedure that even today is associated with a mortality of pnea while he or she is climbing one or two flights of stairs.
0.01% to 0.05% and a morbidity rate of 0.03% to 0.25%.38 It is Forced expiratory volume can be directly measured with a hand-
indicated only for patients who have unstable coronary syn- held spirometer whenever there is a question of possible pul-
dromes, those who are undergoing intermediate- or high-risk monary compromise.40 Once identified, patients with pulmonary
noncardiac procedures after equivocal noninvasive test results, insufficiency [see 8:4 Pulmonary Insufficiency] may benefit from a
and those who may have an indication for elective coronary revas- preoperative program that includes smoking cessation,9 use of
cularization.23 Although antecedent myocardial revascularization bronchodilators, physiotherapy, and specific antibiotics.
appears to reduce the risk associated with subsequent noncardiac
surgery,8 the efficacy of elective preoperative revascularization Nutritional Status
remains controversial.This latter measure probably is not benefi- In 1936, Studley demonstrated that weight loss was a robust
cial; in fact, the incidence of complications during or after revas- predictor of operative risk.41 Loss of more that 15% of body
cularization is often comparable to that during or after the non- weight during the previous 6 months is associated with an
cardiac surgical procedure itself. Routine angiography is indicat- increased incidence of postoperative complications, including
Table 6 Predictors of Cardiac Risk for Noncardiac ade, or by administration of stress-dose steroids [see 8:10 Endo-
Surgical Procedures39 crine Problems].
Uncontrolled hypertension
Diabetes mellitus As of 2003, 10.9 million persons were
Family history of CAD known to have diabetes mellitus in the United States, and anoth-
Hypercholesterolemia er 5.7 million were estimated to be harboring the disease without
Smoking history being aware of it.9 In diabetic patients, the risk of CAD is two to
Minor risk factors ECG abnormalities (dysrhythmia, bundle branch
(probable CAD) block, LVH)
four times higher than it is in the general population.47 Diabetic
Peripheral vascular disease autonomic neuropathy is associated with an impaired vasodilator
MI > 3 mo previously, asymptomatic without treatment response of coronary resistance vessels to increased sympathetic
CABG or PTCA > 3 mo but < 6 yr previously, without stimulation.48 Moreover, diabetes is frequently associated with
anginal symptoms or anginal medications
silent ischemia; if detected by Holter monitoring, it has a positive
Angina class I or II predictive value of 35% for perioperative cardiac events.49 The
Compensated or previous heart failure, ejection frac- incidence of ischemic events in asymptomatic diabetic patients is
tion < 0.35
Physiologic age > 70 yr
similar to that in patients with stable CAD.50 Accordingly, clini-
Intermediate risk fac- Diabetes mellitus cians should lower their threshold for cardiac testing when man-
tors (stable CAD) Ventricular arrhythmia aging diabetic patients.
History of perioperative ischemia Asymptomatic diabetic patients with two or more cardiac risk
Absence of symptoms after infarction with maximal
therapy
factors should be evaluated by means of stress testing if their
CABG or PTCA > 6 wk but < 3 mo previously, or functional capacity is low or if they are to undergo a vascular pro-
> 6 yr previously, or with antianginal therapy cedure or any major operation. Only those diabetics who have
MI > 6 wk but < 3 mo previously good functional capacity and are undergoing minor or interme-
Clinical ischemia plus malignant arrhythmia diate-risk procedures should proceed directly to operation.This is
Clinical ischemia plus congestive heart failure a more aggressive interventional approach than is followed for the
Major risk factors Residual ischemia after MI general population. It should be kept in mind that, common
(unstable CAD) Angina class III or IV
assumptions notwithstanding, perioperative beta blockade is not
CABG or PTCA within past 6 wk
MI within past 6 wk precluded in diabetic patients and can offer substantial protection
against ischemia. A 2003 study reported a 50% reduction in car-
CABG—coronary artery bypass grafting CAD—coronary artery disease LVH—left
ventricular hypertrophy MI—myocardial infarction PTCA—percutaneous transluminal diovascular and microvascular complications in diabetic patients
coronary angioplasty who underwent intensive glucose control, exercise therapy, and
preventive medical management.51
delayed wound healing, decreased immunologic competence, Hematologic States

and inability to meet the metabolic demand for respiratory effort. The most practical tool for detecting hypocoagulable or hyper-
Peripheral edema and signs of specific vitamin deficiencies are coagulable states [see 1:4 Bleeding and Transfusion and 6:6 Venous
suggestive of severe malnutrition. A huge multicenter Veterans Thromboembolism] is a careful history. Risk factors for postopera-
Affairs hospital study found that hypoalbuminemia was consis- tive phlebothrombosis and possible pulmonary embolism include
tently the most reliable indicator of morbidity and mortality [see Virchow’s well-known triad: hypercoagulability (e.g., from anti-
Table 7].42 A decrease in serum albumin concentration from thrombin deficiency, oral contraceptives, or malignancy), stasis
greater than 4.6 g/dl to less than 2.1 g/dl was associated with an (e.g., from venous outflow obstruction, immobility, or CHF), and
increase in mortality from less than 1% to 29% and an increase endothelial injury (e.g., from trauma or operation). A thromboe-
in morbidity rate from 10% to 65%. Again, in these regression
models, albumin concentration was the strongest predictor of
mortality and morbidity after surgery.42 Table 7 Preoperative Predictors of Morbidity and
A global nutrition assessment has been shown to identify
patients who are increased risk as a result of nutritional deficien- Mortality in General Surgical Patients2,4
cies.43 Persons with macronutrient deficiencies may benefit from
preoperative nutritional supplementation44 [see 8:23 Nutritional Rank Predictor of Morbidity Predictor of Mortality
Support]; however, such supplementation should be employed
1 Albumin concentration Albumin concentration
selectively and tailored to the particular patient population
involved.45 A trial done by a study group from the VA determined 2 ASA class ASA class
that preoperative nutritional intervention was necessary only in 3 Complexity of operation Emergency operation
the most severely nutritionally depleted patients (i.e., those who
had lost more than 15% of their body weight).46 4 Emergency operation Disseminated cancer
5 Functional status Age

Endocrine Status
The endocrine-related conditions most relevant in the periop- 6 History of COPD DNR status
erative period are hypothyroidism, hyperthryroidism, diabetes 7 BUN > 40 mg/dl Platelet count < 150,000/mm3
mellitus, pheochromocytoma, and adrenal insufficiency (in par-
8 Dependency on ventilator Weight loss > 10%
ticular, iatrogenic adrenocortical insufficiency secondary to
steroid use within the preceding 6 months). All of these condi- 9 Age Complexity of operation
tions should be normalized to the extent possible before elective
10 WBC count > 11,000/mm3 BUN > 40 mg/dl
surgery, whether by hormone replacement, by adrenergic block-
lastogram is an effective screening tool in patients with suspected experience. Classic studies have shown that well-informed
abnormalities. Prothrombin time, partial thromboplastin time, and patients require less analgesia in the postoperative period and
platelet count constitute sufficient preoperative testing in a patient experience significantly less pain than less well informed
with a suspected bleeding problem. Antithrombin, protein C, pro- patients.59 Subsequent investigations have supported these con-
tein S, and factor V Leiden levels constitute sufficient preoperative clusions. Perioperative information facilitates coping, reduces pre-
screening in a patient with suspected hypercoagulable disease. operative anxiety, and may enhance postoperative recovery.60
Such information can be provided orally or in the form of book-
lets or videotapes.
Assessment of Physical and Mental Happiness
Calculation of the risks and benefits of surgical (or, indeed,
any) therapy has become a much more complex process than it Reduction of Perioperative Cardiac Risk
once was. Simple assessment of survival or basic quality of life is A number of trials have indicated that perioperative beta block-
no longer sufficient: more sophisticated measures are required. ade can reduce the risk of perioperative cardiac complications in
Generic instruments now exist that are aimed at evaluating a patients with known or suspected CAD who are undergoing major
patient’s level of productive assimilation into his or her environ- noncardiac procedures.61-63 One prospective study randomly
ment. The Short Form–36 (SF-36) is designed to assess physical assigned 200 noncardiac surgical patients to receive either atenolol
and mental happiness in eight domains of health: (1) physical or placebo.64 Atenolol was administered intravenously before and
function (10 items); (2) physical role limitations (4 items); (3) after surgery, then continued orally until hospital discharge. Of the
bodily pain (2 items); (4) vitality (4 items); (5) general health per- original 200 patients, 194 survived hospitalization, and 192 were
ceptions (5 items); (6) emotional role limitations (3 items); (7) followed for 2 years. Mortality, even after hospital discharge and
social function (2 items); and (8) mental health (5 items). The discontinuance of beta blockade, was significantly lower in
underlying assumption is that mental and physical functions are atenolol-treated patients than in control subjects both at 6 months
readily separable aspects of health, but of course, this is not real- and at 2 years. These findings, though somewhat puzzling, have
ly the case.52,53 Predictably, patients’ responses on the SF-36 tend sparked considerable enthusiasm for perioperative beta blockade.
to be strongly influenced by the type of operation they had. For Some clinicians, however, have expressed reservations.63
example, a patient who has undergone total hip arthroplasty will In 1999, a Dutch echocardiographic cardiac risk evaluation
feel better immediately; one who has undergone lung resection for study group published a prospective, randomized, multicenter
cancer may not feel particularly well immediately afterward but, study of perioperative beta blockade in extremely high risk vascu-
ideally, will be relieved of a cancer scare; and one who has under- lar surgical patients.61 Of the 1,351 patients screened, 846 exhib-
gone abdominal aneurysm repair will feel worse immediately, ited cardiac risk factors that would have made them moderate- or
though conscious of an improved life expectancy. Less pre- high-risk patients according to either Goldman’s or Lee’s classifi-
dictably, however, patients’ perceptions of their own surgical out- cation system. Of these 846 patients, 173 had positive results on
comes are equally strongly influenced by when in the postopera- dobutamine stress echocardiography, and 112 of the 173 agreed
tive period the questions are asked.54 The answers obtained 6 to undergo randomization. Of these 112 patients, 59 were ran-
months after operation will differ from those obtained at 1 month domly assigned to perioperative beta blockade with bisoprolol,
or 12 months. If the questions are asked several times, the answers and 53 served as control subjects. Of the patients undergoing beta
change; indeed, the mere asking of the question may change the blockade, 3.4% died of cardiac causes or experienced a nonfatal
answer.55 For an outcome measure to be effective by current stan- MI, compared with 34% of the control subjects. Admittedly, this
dards, it must be not only feasible, valid, and reliable but also sen- is a study of very high risk patients; nonetheless, the conclusions
sitive to change.56,57 are striking, and it is tempting to extrapolate them to lower-risk
An outcome tool that has been further refined to focus specifi- noncardiac surgical patients. In the human heart, alpha1-, beta1-,
cally on cardiovascular capacity and disease is the Specific Activ- and beta2-adrenergic receptors promote inotropy, chronotropy,
ity Scale (SAS). Unfortunately for assessment purposes, attempts myocyte apoptosis, and direct myocyte toxicity.63 Expanded use of
to use the SAS and the SF-36 simultaneously have yielded signif- beta-adrenergic receptor inhibition in the perioperative period has
icantly divergent results. Such results underscore the complexities been supported by several groups of investigators.65-68
of standardizing tests of ability, intelligence, and happiness.58 Prophylactic use of other agents (e.g., aspirin, alpha2-adrener-
Quality is subjective. Some patients are happy when they seem- gic agents, nitroglycerin, and calcium channel blockers) has been
ingly have every reason to be unhappy; others are unhappy when studied, but at present, the data are insufficient to support routine
they seemingly have every reason to be happy. Scientific tools for use of any of these.69,70 Risk reduction should focus on strategies
collectively examining psychosocial productivity in groups of for which there is good evidence (e.g., maintenance of normo-
patients may still be largely lacking, but this does not mean that thermia, avoidance of extreme anemia, control of postoperative
surgeons have no methods of evaluating and enhancing a given pain, and perioperative beta blockade). A stepwise approach to
patient’s prospects for comfort. Indeed, any surgeon whose con- preoperative assessment allows judicious use of both noninvasive
tribution to patient management stops with superb operative and invasive procedures while preserving a low rate of cardiac
technique, or even with exemplary perioperative care added to complications [see Figure 1].23
technique, is not making optimal use of his or her privileged posi-
tion. By incorporating a patient’s values into the anticipated out-
come, surgeons are uniquely positioned to achieve the best possi- Epidemiology of Surgical Risk
ble outcome-to-value ratios. In a 1999 prospective study, a team of VA investigators exam-
ined the outcomes of surgical procedures in an effort to identify
PATIENT EDUCATION
variables related to poor surgical results. Initial results were
Education of the patient about the postoperative care plan plays reported from 23,919 patients who underwent one of 11 noncar-
a major role in modifying his or her response to the operative diac operations performed by surgeons from five specialties (gen-
Patient is scheduled to undergo major noncardiac operation

and is older than 40 yr, if male, or 45 yr, if female
Procedure is semiemergency (e.g., Procedure is elective

bowel obstruction or threatened limb)
Obtain history and perform physical exam
to look for evidence of cardiovascular disease.
No cardiac risk factors noted Cardiac risk factors are noted

or cannot be excluded
Consider prophylactic beta
blockade (see below).
Patient is poor historian, is diabetic, Patient has classic

or has atypical presentation of CAD indicators of CAD
Perform exercise ECG or, if patient

cannot exercise, cardiac stress imaging.
Stress test is negative Stress test is positive
Perform cardiac catheterization.
Standard indications Standard indications for Evidence of severe

for coronary coronary revascularization uncorrectable CAD
revascularization are are present is seen
absent
Perform indicated Reconsider or cancel
revascularization procedure noncardiac surgery.
(PTCA or CABG).
Contraindications to beta blockade No contraindications to beta blockade are present

(e.g., COPD) are present
Initiate beta blockade (e.g., with short-acting agent such as metoprolol,
25–50 mg b.i.d.) to achieve resting HR ≤ 60 beats/min. Begin as soon
as possible and continue for ≥ 30 days postoperatively.
Proceed with noncardiac operation.
Figure 1 Algorithm depicts recommended approach to cardiac assessment before non-

cardiac surgery. (CAD—coronary artery disease; CABG—coronary artery bypass graft-
ing; PTCA—percutaneous transluminal coronary angioplasty)
eral surgery, urology, orthopedic surgery, vascular surgery, and gies in terms of cost in relation to each QALY saved.73 Although
neurosurgery).71 The authors concluded that prolonged hospital the question this study was designed to answer was slightly differ-
stay could be related to advanced age, diminished functional sta- ent from what surgeons typically address before noncardiac
tus, and higher ASA class. Other preoperative patient characteris- surgery, several instructive findings emerged:
tics were associated with increased morbidity and mortality [see
1. For a 55-year-old man with typical chest pain, the incremental
Table 7].72
cost-effectiveness ratio for routine coronary angiography versus
exercise echocardiography was $36,400/QALY saved.
Changing Paradigms of Cost-effectiveness 2. For a 55-year-old man with atypical chest pain, the incremen-
tal cost-effectiveness ratio for exercise electrocardiography ver-
It is now clear that postoperative survival, by itself, is no longer
sus no testing was $57,700/QALY saved.
an adequate assay of surgical success. Risk must be stratified
3. The incremental cost-effectiveness ratio for exercise echocardio-
before operation, and the degree of risk must be evaluated in the
graphy versus stress electrocardiography was $41,900/QALY
light of both the quantity and the quality of life to be expected
saved.
after operation. Cost must then be appropriately factored in: a
modern health care system will want to know the cost of a risk- The literature makes it very clear, however, that none of the
stratified, quality-adjusted postoperative year of life. A 1999 study available diagnostic strategies are more cost-effective than com-
assessed the cost-effectiveness of various cardiac diagnostic strate- munication with the patient.
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ELEMENTS OF CONTEMPORARY PRACTICE 5 OUTPATIENT SURGERY — 1
5 OUTPATIENT SURGERY
Richard B. Reiling, M.D., F.A.C.S., and Daniel P. McKellar, M.D., F.A.C.S.
A safe and cost-effective approach to elective surgery begins with setting was accompanied by a transfer of all the measures
a careful history, a thorough physical examination, well-chosen designed to ensure patient safety, including peer review. However,
laboratory tests, and consultation as appropriate and proceeds to this same transfer has not occurred in the office-based setting,
selection of the optimal procedure, assessment of patient suit- where at least 15% of outpatient surgical procedures are current-
ability, and choice of the most appropriate site in which to per- ly being performed.5 There is a growing concern that better reg-
form the procedure. In what follows, we address these issues ulation is needed for office-based surgical units. Surgery con-
specifically as they pertain to outpatient surgery: from selection of ducted in office settings has been found to pose about a 10-fold
suitable patients and procedures to determination of appropriate higher risk of adverse incidents and death than surgery conduct-
outpatient settings in which to perform the procedures, to peri- ed in ambulatory centers.6
operative management (e.g., premedication, anesthesia, monitor- Certain relative contraindications to outpatient surgical proce-
ing, and immediate postoperative care), to discharge and postop- dures have been identified, but these vary depending on the
erative pain control. patient, the physician, and the setting [see Table 1].The surgeon is
Accumulating evidence indicates that outpatient surgery can responsible for detecting undiagnosed and unsuspected acute
offer significant advantages over inpatient surgery. For example, and chronic conditions before operation. The anesthesiologist
patients who undergo breast surgery with same-day dismissal are shares the responsibility for uncovering potential preoperative
not at a disadvantage; on the contrary, they report faster recovery problems if the patient will require complex anesthesia that must
and better psychological adjustment.1 Moreover, the pronounced be given by an anesthesiologist; otherwise, the surgeon is also
shift toward outpatient surgery has been accompanied by an responsible for this aspect of care. In addition, the surgical unit
equally impressive technological revolution, which has led to the plays a role in determining which types of patients can be treat-
development of operative approaches that require less postopera- ed. Likewise, these determinations should be made in the office-
tive care. based practice before undertaking any surgical intervention.This
is best accomplished in a well-thought-out governance plan.
Hospital-affiliated units or units in immediate proximity to a full-
Selection of Patients for Inpatient and Outpatient service hospital that have an agreement for rapid transfer are bet-
Procedures ter able to accept patients with more serious concomitant illness-
Just as inpatient and outpatient procedures must be carefully es than facilities physically separated from the acute care hospital.
selected with an eye to difficulty and severity of illness, so too Surgeons also tend to select certain apparently higher-risk
should patients be carefully selected. The following six questions patients for treatment in hospital outpatient or ambulatory surgi-
should be asked: cal units rather than in freestanding day surgical units, as reflect-
ed in the higher rate of admission for hospital-based units [see
1. Is the facility adequately equipped and appropriate for the
Tables 2 through 4].7
intended procedure, and are quality standards maintained?
Some reimbursement plans, including the Center for Medicare
2. Can the procedure routinely be performed safely without
and Medicaid Services (CMS), possess a curious feature by
hospital admission?
which patients are considered outpatients if they are discharged
3. Is the patient at risk for major complications if the opera-
from the facility within 24 hours. Obviously, an outpatient who
tion is performed in the facility?
4. Do concomitant or comorbid conditions present unaccept-
able risks in the intended setting?
5. Will the patient require any special instructions or psycho- Table 1—Relative Contraindications to
logical counseling before the operation?
6. Do the patient and the family understand their own obli- Outpatient Surgery
gations regarding postoperative care in an outpatient setting?
Procedures with an anticipated significant blood loss
Surgeons and anesthesiologists have gained an immense Procedures associated with significant postoperative pain
amount of experience in outpatient management of many diffi- Procedures necessitating extended postoperative I.V. therapy
cult procedures that were once considered to be best suited for ASA class IV (or III if the systemic disease is not under control, as with
more controlled inpatient environments. Procedures that were unstable angina, asthma, diabetes mellitus, and morbid obesity)
regarded as unsafe in an outpatient setting as late as the mid- Known coagulation problems, including the use of anticoagulants
1990s are now being performed in ambulatory centers, and there
Inadequate abillity or understanding on the part of caretakers with
is evidence that this shift has not increased patient risk.2-4 respect to requirements for postoperative care
Ambulatory centers are integrated with or based in hospitals, and
the transfer of surgical care from the inpatient to the ambulatory
Table 2—Surgical Categories

Category 1 Postoperative monitored care setting (ICU, ACU), with no open
Generally noninvasive procedures with minimal blood loss and with exposure of abdomen, thorax, neck, cranium, or extremities other
minimal risk to the patient independent of anesthesia than wrist, hand, or digits
Anticipated blood loss less than 250 ml
Category 3
Limited procedure involving skin, subcutaneous, eye, or superficial
More invasive procedures and those involving moderate blood loss with
lymphoid tissue
moderate risk to the patient independent of anesthesia
Entry into body without surgical incision
Anticipated blood loss 500–1,500 ml
Excludes the following:
Open exposure of the abdomen
Open exposure of internal body organs, repair of vascular or
neurologic structures, or placement of prosthetic devices Reconstructive work on hip, shoulder, knees
Entry into abdomen, thorax, neck, cranium, or extremities other than Excludes the following:
wrist, hand, or digits
Open thoracic or intracranial procedure
Placement of prosthetic devices
Major vascular repair (e.g., aortofemoral bypass)
Postoperative monitored care setting (ICU, ACU)
Major orthopedic reconstruction (e.g., spinal fusion)
Category 2 Planned postoperative monitored care setting (ICU, ACU)
Procedures limited in their invasive nature, usually with minimal to mild
blood loss and only mild associated risk to the patient independent of Category 4
anesthesia Procedures posing significant risk to the patient independent of anesthesia
Anticipated blood loss less than 500 ml or in one or more of the following categories:
Limited entry into abdomen, thorax, neck, or extremities for diagnostic Procedure for which postoperative intensive care is planned
or minor therapy without removal or major alteration of major organs
Procedure with anticipated blood loss greater than 1,500 ml
Extensive superficial procedure
Cardiothoracic procedure
Excludes the following:
Intracranial procedure
Open exposure of internal body organs or repair of vascular or
neurologic structures Major procedure on the oropharynx
Placement of prosthetic devices Major vascular, skeletal, or neurologic repair
stays overnight is effectively an inpatient, even if the length of stay units according to level of service, in the same way as the
is less than 24 hours. Outpatient facilities exist that are physical- American College of Surgeons (ACS) has classified units accord-
ly separated from an inpatient hospital but that also can accept ing to type of surgery performed and level of anesthesia available,
patients for this 24-hour arrangement. Such freestanding facili- is a sensible one that is likely to be more fully developed and
ties must clearly ensure safety and quality in the unit to the same more widely applied in the coming years.
extent as facilities approved by the Joint Commission on Patient acceptance is critical in outpatient surgery for reasons
Accreditation of Healthcare Organizations (JCAHO). of safety and liability. If the patient or any responsible relative of
In addition, the concept of recovery care has been introduced the patient does not accept or is extremely critical of nonadmis-
for facilities that provide postoperative care. In this concept, facil- sion surgical care and cannot be easily assured of its advantages
ities are classified according to the defined length of stay (e.g., and safety, inpatient treatment is indicated, regardless of the pol-
extended recovery and 23-hour care).8 The idea of classifying icy of the third-party payor or other regulatory bodies. Certain
Table 3 American Society of Anesthesiologists’ Physical Status Classification
Classification Description Examples
Class I Normal, healthy patient An inguinal hernia in a fit patient or a fibroid uterus in a healthy woman
Patient with mild systemic disease—a mild to moderate

Moderate obesity, extremes of age, diet-controlled diabetes, mild hypertension,
Class II systemic disorder related to the condition to be
chronic obstructive pulmonary disease
treated or to some other, unrelated process
Morbid obesity, severely limiting heart disease, angina pectoris, healed myocardial
Patient with severe systemic disease that limits activity
Class III infarction, insulin-dependent diabetes, moderate to severe pulmonary
but is not incapacitating
insufficiency
Organic heart disease with signs of cardiac insufficiency; unstable angina;

Patient with incapacitating systemic disease that is
Class IV refractory arrhythmia; advanced pulmonary, renal, hepatic, or endocrine
life threatening
disease
Moribund patient not expected to survive 24 hr without Ruptured aortic aneurysm with profound shock, massive pulmonary embolus,
Class V
an operation major cerebral trauma with increasing intracranial pressure
Emergency surgery—the suffix “E” is added to denote the poorer status of any patient in one of these five categories who is operated on in
Emergency (E)
an emergency
Table 4—Guidelines for Selection of Outpatient versus Inpatient Surgery
Surgical Category
ASA
Class
1 2 3 4
Outpatient procedure with Outpatient procedure with general

I Inpatient procedure Inpatient procedure
local anesthesia or regional anesthesia
Outpatient procedure with Outpatient procedure with local,

II Inpatient procedure Inpatient procedure
local anesthesia* regional, or general anesthesia*
Inpatient procedure (unless operation

III Inpatient procedure Inpatient procedure Inpatient procedure
can be done with local anesthesia)*
Inpatient procedure (unless operation

IV Inpatient procedure Inpatient procedure Inpatient procedure
can be done with local anesthesia)*
*Patient must be watched carefully.

ASA—American Society of Anesthesiologists
complicating factors, such as substantial distance from the facili- sions are for problems related to the patient’s preoperative car-
ty, the lack of sufficient support at home, and the presence of sig- diovascular and respiratory status, but the major reason for
nificant comorbid illnesses, also call for inpatient treatment admission is still uncontrollable nausea and vomiting.4 Moreover,
regardless of the payor’s policy. It then becomes the responsibili- most complications are related to factors other than the setting of
ty of the surgeon to notify the third-party payor of these contin- the surgical procedure (outpatient or inpatient). Admission to the
gencies in a simple and nonconfrontational manner, as well as to hospital after ambulatory surgery because of urinary retention,
explain to the patient and family why it is necessary to deviate for example, is related to the use of general anesthesia, the age of
from the more usual outpatient approach for which the payor the patient, and the administration of more than 1,200 ml of I.V.
would more readily provide reimbursement. Efforts to coerce the fluids before, during, and after the operation.9
patient or the family to accept outpatient surgery not only engen- Patients in American Society of Anesthesiologists (ASA) class
der bad will between physician and patient but also tend to give III (or even class IV) [see Table 3] are appropriate candidates for
rise to more postoperative problems (either real or factitious). ambulatory surgery if their systemic diseases are medically stable
Third-party payors, for their part, must understand and accept and the intended procedure will be relatively short. A report on
that some patients, for whatever reason, will refuse nonadmission patient morbidity and mortality within 1 month after ambulatory
surgery. It is the responsibility of third-party payors and their cus- surgery showed only eight morbid events in over 10,500 ASA III
tomers (i.e., corporations or employers) to provide adequate patients and two deaths, both occurring in ASA II patients.2
information to those covered (i.e., employees and families) about
the advantages and safety of outpatient surgery. Such education Age
should be provided well before surgical intervention is sought or Extremes of age by themselves automatically increase the ASA
needed. Too often, the patient and the family are unaware of the classification from I to II. Even though age is not correlated with
payor’s guidelines. Finally, patients and their families must also hospital admission after ambulatory surgery, elderly patients often
realize the need for cost-effective care and be willing to play their have concomitant conditions that may have gone unrecognized but
part in achieving it. It is reassuring that patients and families are should have been brought to light before the operation.This is the
increasingly accepting the concept of same-day discharge, which obvious justification for the higher ASA classification—that is, to
is becoming more widely prevalent. make the surgical team aware of the potential increased risk. In ad-
dition, the family or social support networks available to elderly pa-
SPECIFIC PATIENT RISK FACTORS
tients are often of questionable value and may even pose their own
Careful monitoring and improvement of the patient’s physical risks after the operation. Most studies have failed to show age-relat-
status before operation reduce mortality and morbidity. ed increases in complications or recovery. Fine motor skills and cog-
Therefore, one should accept a patient with a poor preoperative nitive function diminish with age, however, so elderly patients re-
physical status for outpatient treatment only when it is clear that quire closer surveillance in the postanesthesia period.
concomitant disease is well controlled and that the patient will Young children, especially neonates, present separate problems
have adequate postoperative monitoring and treatment at home. that must be independently evaluated by the surgeon and the
In evaluating the risk factors for any surgical intervention, the fol- anesthesiologist.
lowing variables should be considered: (1) the patient’s age, (2) the
proposed anesthetic approach (type and duration), (3) the extent of Drug Therapy for Preexisting Disease
the surgical procedure (including the surgical site), (4) the patient’s Two questions must be answered about a patient taking med-
overall physiologic status, (5) the presence or absence of concomi- ication for preexisting disease. First, should the drug or drugs be
tant diseases, (6) baseline medications, and (7) the patient’s general discontinued or the dosage altered before operation [see Table 5]?
mental status. The aim is to return the patient to the preoperative Second, do the medications necessitate special laboratory evalua-
functional level with respect to respiration, cardiovascular stability, tions before operation (e.g., a prothrombin time and internation-
and mental status; no deviations should be acceptable. al normalized ratio [INR] for patients taking anticoagulants)?
Several studies aimed at determining reasons for admission Whereas dosages of some medications, such as adrenocorti-
after ambulatory surgical procedures indicate that many admis- costeroids, may have to be temporarily increased, certain oral
Abrupt withdrawal of clonidine, which is used to treat chronic

Table 5 Disposition of Current Medications essential hypertension, is particularly dangerous because it is
often associated with an increase in the plasma catecholamine
before Outpatient Surgery97 level. Accordingly, clonidine should be continued throughout the
perioperative period.
Continue Discontinue or withhold
Antihypertensives Diuretics Heart Disease and Congestive Heart Failure
Beta blockers Insulin Patients with serious heart disease or congestive heart failure
Calcium channel blockers Digitalis fall into ASA class III or IV and thus should not be considered for
ACE inhibitors Anticoagulants (may change outpatient surgery unless the procedure is a minor one necessi-
Vasodilators to short-acting agent such
as heparin) tating only local or regional anesthesia. Patients with less serious
Bronchodilators heart disease should take any prescribed cardiac glycosides, beta
Antiseizure medications blockers, or antiarrhythmics with a small amount of water when
Tricyclic antidepressants they awake on the day of the operation.
MAO inhibitors (controversial)
Corticosteroids Bronchopulmonary Disease
Thyroid preparations Patients with bronchopulmonary disease must be evaluated
Anxiolytics individually. The degree of impairment is determined by means
ACE—angiotensin-converting enzyme MAO—monoamine oxidase of a careful history and appropriate testing; a chest x-ray should
always be obtained.The history should also reveal factors that ini-
tiate attacks of asthma or bronchospasm, as well as identify the
medications being taken. Many patients with bronchopulmonary
agents may have to be replaced during the immediate periopera- disease need corticosteroids and antibiotics preoperatively.
tive period with agents that can be delivered intravenously. In par-
ticular, oral antiarrhythmic drugs (e.g., quinidine sulfate, pro- Diabetes Mellitus
cainamide, and disopyramide) should be discontinued 8 hours Patients whose diabetes is controlled with oral hypoglycemics or
before the operation.10 Patients taking aspirin should be instruct- with low dosages of insulin (i.e., < 25 U/day) can be adequately
ed to stop at least 1 week before elective operation because managed by withholding the medication on the day of the opera-
aspirin’s antiplatelet effect lingers for the life of the affected tion. In general, patients with more severe insulin-dependent dia-
platelets. Patients receiving warfarin require uninterrupted anti- betes mellitus should not undergo outpatient procedures. Those
coagulation; hence, the drug should be stopped only in the imme- who do undergo such procedures are best managed by the adminis-
diate preoperative period. Fresh frozen plasma may be required tration of a fraction of the insulin dose on the day of the operation in
intraoperatively if excessive bleeding occurs. If warfarin is to be conjunction with I.V. infusion of a dextrose solution (usually 5%),
discontinued for a longer period, I.V. or subcutaneous heparin beginning shortly after the patient’s arrival at the surgical facility.
can be given. Ideally, such administration should be scheduled as early in the day
In a study of nearly 18,000 ambulatory surgical patients in a maas possible. Patient status is monitored by measuring either the
jor surgical center, almost 2,000 patients had preexisting systemic blood glucose level or the urine glucose level, both of which can be
disease, and more than 900 of them were taking specific drugs for easily and rapidly determined at the bedside.
their disease.11 Nearly half of these patients were taking at least one
antihypertensive medication; a significant number were taking one Obesity
or more cardiovascular medications, including cardiac glycosides, In general, moderately to severely obese patients should not
beta blockers, diuretics, antiarrhythmics, vasodilators, and anticoag- undergo outpatient surgery. The hazards and risks of surgery in
ulants. Other drugs that were being used included insulin and asth- the obese are often unrecognized. Morbid obesity stresses the car-
ma medications. However, none of the complications recorded were diopulmonary system, and morbidly obese patients easily
related to preoperative drug use. become, or already are, hypoxemic. In addition, these patients
In any case, patients should bring all of their medications on usually have comorbid disorders such as diabetes, hypertension,
the day of the operation. This instruction includes transdermal liver disease, or cardiac failure. Moderate obesity increases the
patches and pills and both prescribed and self-administered med- ASA classification from I to II; morbid obesity increases it to III.
ications. Herbals and other over-the-counter medications are Careful consideration is essential before a morbidly obese patient
often overlooked and underreported by patients, yet some of is released from skilled observation after major anesthesia. Obese
these medications may well influence the procedure and subse- children often are not recognized as being at risk. There is some
quent recovery. controversy over whether the ability to swallow water in a recov-
ering obese pediatric patient is an acceptable condition for dis-
Hypertension charge. Minor procedures have ended in tragedy after a seeming-
In general, hypertension should be under control before the op- ly recovered obese patient was discharged.
eration. It is advisable to discontinue monoamine oxidase (MAO)
inhibitors, if possible, 2 weeks before operation because these agents Adrenocortical Steroid Therapy
have unpredictable cardiac effects and may lead to hypertension in Patients taking adrenocortical steroids for 6 to 12 months before
patients receiving meperidine or vasopressors; however, whether operation should usually receive supplemental steroids in the pre-
preoperative discontinuance of MAO inhibitors is absolutely neces- operative period. It should be remembered that many patients fail
sary remains somewhat controversial. All antihypertensive agents to inform the surgeon of transdermal corticosteroid use. Short-term
should be continued until the day before the operation; beta block- steroid overdosage has virtually no complications, but inadequate
ers can be taken on the day of the operation. adrenocortical support may have serious repercussions.
Alcohol and Drug Abuse

Alcohol and drug abusers (a category that may also include self-
Table 6—Core Principles of Patient Safety for
medicated patients and those who are taking a large number of
physician-directed medications) are also poor candidates for outpa- Office-Based Procedures12
tient surgery. Chronic alcoholism is associated with a number of se-
1. Guidelines or regulations should be developed by states for office-
rious metabolic disorders, and chronic drug abusers often have based surgery according to levels of anesthesia defined by the
many medical problems that are related to the habit (e.g., endo- American Society of Anesthesiologists' (ASA's) "Continuum of Depth
carditis, superficial infections, hepatitis, and thrombophlebitis). of Sedation" statement dated October 13, 1999, excluding local anes-
thesia or minimal sedation.
Psychotropic Drug Therapy 2. Physicians should select patients by criteria including the ASA pa-
tient selection Physical Status Classification System and so document.
Except for MAO inhibitors, most psychotropic drugs do not 3. Physicians who perform office-based surgery with moderate seda-
interact with anesthetics. Continuation of anxiolytics probably tion/analgesia, deep sedation/analgesia, or general anesthesia should
has a beneficial effect overall. have their facilities accredited by JCAHO, the American Association
for Accreditation of Ambulatory Surgery Facilities (AAAASF), AOA, or a
Psychiatric Illness state recognized entity, or are state licensed and/or Medicare certified.
4. Physicians performing office-based surgery with moderate seda-
Mental instability is a potential problem even in the best of cir- tion/analgesia, deep sedation/analgesia, or general anesthesia must
cumstances. A competent adult must be available to provide care have admitting privileges at a nearby hospital, or a transfer agreement
with another physician who has admitting privileges at a nearby hospi-
for a mentally unstable patient after operation. One benefit of tal, or maintain an emergency transfer agreement with a nearby hospital.
outpatient surgery for such patients, as for very young and very 5. States should follow the guidelines outlined by the Federation of
old patients, is that it allows them to return quickly to a familiar State Medical Boards (FSMB) regarding informed consent.
environment, which is desirable when safety can be ensured. If 6. For office surgery with moderate sedation/analgesia, deep seda-
safety cannot be ensured, admission is indicated. tion/analgesia, or general anesthesia, states should consider legally-
privileged adverse incident reporting requirements as recommended
by the FSMB and accompanied by periodic peer review and a pro-
gram of Continuous Quality Improvement.
Selection of Appropriate Site for Procedure 7. Physicians performing office-based surgery must be currently
The following are the four main types of facilities used in the board certified/qualified by one of the boards recognized by the
American Board of Medical Specialties, American Osteopathic
performance of outpatient surgical procedures: Association, or a board with equivalent standards approved by the
state medical board. The procedure must be one that is generally rec-
1. Office surgical facilities (OSFs). These include individual ognized by that certifying board as falling within the scope of training
surgeons’ offices and larger group-practice units. and practice of the physician providing the care.
2. Freestanding day surgical units. These are often used by 8. Physicians performing office-based surgery with moderate seda-
managed health care systems and independent contractors. tion/analgesia, deep sedation/analgesia, or general anesthesia may
show competency by maintaining core privileges at an accredited or
3. In-hospital day surgical units. These are often associated licensed hospital or ambulatory surgical center, for the procedures
with inpatient units. they perform in the office setting. Alternatively, the governing body of
4. In-hospital inpatient units. the office facility is responsible for a peer review process for privileging
physicians based on nationally-recognized credentialing standards.
At times, these facilities are collectively referred to as ambula- 9. For office-based surgery with moderate sedation/analgesia, deep
tory surgical centers (ASCs); however, the term ASC also has a sedation/analgesia, or general anesthesia, at least one physician who
is currently trained in advanced resuscitative techniques (ATLS, ACLS,
specific meaning to third-party payors (especially Medicare) for or PALS), must be present or immediately available with age and size-
billing purposes. appropriate resuscitative equipment until the patient has been dis-
The primary influences on the choice of setting are the type of charged from the facility. In addition, other medical personnel with
direct patient contact should at a minimum be trained in Basic Life
procedure to be performed and the condition of the patient. Support (BLS).
There is an increasingly recognized need to implement standards 10. Physicians administering or supervising moderate sedation/anal-
and guidelines for surgery performed in the office. Many states gesia, deep sedation/analgesia, or general anesthesia should have
have already enacted standards to regulate such surgical proce- appropriate education and training.
dures, especially in regard to the level of anesthesia administered.
The ACS, in cooperation with a coalition under the umbrella of
the American Medical Association, has issued 10 core principles
for patient safety in office-based surgery [see Table 6].12 American Association for Accreditation of Ambulatory Surgery
It is clear that many individually operated units are delivering Facilities (AAAASF) and the Accreditation Association for
cost-efficient, safe, and effective care. The imposition of costly Ambulatory Health Care (AAAHC). The CMS requires certifi-
regulations and accreditation processes on such units may be fis- cation by one of these bodies before a facility can be classified as
cally prohibitive. It is equally clear, however, that many such units an ASC for reimbursement purposes.Thus, if reimbursement for
may well be delivering substandard care, and at present, there is Medicare patients is a goal, appropriate certification should be a
no way of determining quality and safety in these units. Several priority. It is merely a matter of time before the lead taken by
institutions are currently involved in devising guidelines, stan- those states that already require accreditation of outpatient facil-
dards, and even regulations. Already, some payors, such as ities is followed by most, if not all, of the remaining states. It is
Medicare, do not provide reimbursement for care delivered in hoped and anticipated, however, that the states will be guided by
nonaccredited facilities. the ACS’s 10 core principles.
Accordingly, it is wise to have an outpatient surgical facility The ACS has developed guidelines for office-based surgery
accredited by JCAHO or another major outpatient surgical and continues to reevaluate these guidelines periodically.13 (The
accrediting organization. At present, besides JCAHO, the follow- third edition is currently available from the ACS.) In contrast to
ing accrediting organizations are approved by Medicare: the its accrediting activities in cancer and trauma, however, the ACS
does not certify outpatient surgery facilities.The goal of the ACS Table 7 Premedications
initiative is simply to present readily acceptable guidelines that
meet a minimum standard for surgical care without the necessity Recommended Dose
of a costly and time-consuming accreditation process.The guide- Drug (Trade Onset
Class and Route of
Name) (min)
lines are “intended to ensure and maintain superior quality of Administration
care for the surgical patient who undergoes an outpatient proce-
Midazolam* (Versed) Titrate in 0.5–1.0 mg aliquots I.V. 1–5
dure in an office-based or ambulatory surgical facility.”13 (total, ~ 2–3 mg)
The concept of governance in an ASC is key to quality. In 7.5–15 mg p.o. 15–30
Anxiolytics
effect, governance comprises the rules and regulations that deter- Diazepam (Valium) 4–10 mg (0.05–0.15 µg/kg) I.V. 1–5
mine how the facility does business. The ultimate authority and 5–10 mg p.o. 15–40
responsibility reside with the governing body. The processes out-
lined in the governance manual should include the following13: Fentanyl (Sublimaze) 0.5–1.0 µg/kg I.V. or I.M.
Narcotics† —
Sufentanil (Sufenta) 0.1–0.25 µg/kg
1. Specifying mission and goals, including the types of ser-
*Drug of choice. Oral administration allows children to be separated from parents as early
vices provided. as 15 min after ingestion, with no prolongation of recovery.
†Long-acting narcotics such as meperidine and morphine are usually not recommended for
2. Defining organizational structure. use in outpatient surgery.
3. Adopting policies and procedures for the orderly conduct
of the ASC.
4. Adopting a quality-assurance (QA) program. in physicians’ offices.14 The data were obtained from the 1989
5. Reviewing and taking appropriate action on all legal affairs Part B Medicare Annual Data and thus are somewhat dated;
of the unit and its staff. however, it is likely that the situation has not changed greatly over
6. Ensuring financial management and accountability. the succeeding years.The 1993 report contained disturbing find-
7. Establishing a policy on patients’ rights. ings: in 20% of the medical records, reasonable quality of care
8. Approving all arrangements for ancillary medical care was not documented; in 13%, an indication for surgery was not
delivered in the ASC, including laboratory, radiologic, documented; for a small number of operations, the physician’s
pathologic, and anesthesia services. office was not an appropriate setting; and in 16% of sample cases,
9. Conducting the operation of the unit without discrimina- procedure codes did not match the operations performed.
tion on any basis (including the presence of disabilities). Physicians performing surgery in the office-based setting need to
pay careful attention to compliance with documentation require-
Other regulatory agencies must also be taken into account in ments concerning safety. The headline in a surgical newspaper
the management of an ASC, especially if laboratory, x-ray, and article about the OIG report described office-based surgery as
pharmacy services are being offered. Examples include the “the Wild West of surgery”15—not the image that the surgical pro-
Clinical Laboratory Improvement Amendments (CLIA) of 1988 fession would like to project!
and the Occupational Safety and Health Administration (OSHA)
standards on hazard communication (29CFR1910.1200) and
blood-borne pathogens (29CFR1910.1030). In addition, compli- Performance of the Operation
ance with local and state fire and safety regulations and state
nuclear regulatory agencies is essential. PREOPERATIVE PATIENT EDUCATION
An important aspect of the ACS guidelines is that they take Time spent in preoperative preparation of the patient—
into account the differing capabilities of individual facilities. The whether by the surgeon, anesthesiologist, nurse, or other person-
ACS classifies ambulatory surgical facilities into three cate- nel—is time well spent. Surgical patients are especially suscepti-
gories—classes A, B, and C—on the basis of the level of anesthe- ble to preoperative anxiety and stress during the week before the
sia provided, the types of procedures performed, and the degree intended surgical procedure.This increased stress level continues
of sedation employed.13 The suggested guidelines for each class of into the postoperative period, until the patient is assured of an
unit differ; for example, less resuscitation equipment would be uneventful recovery.16 Well-informed patients have been demon-
required in a class A facility than in a class C facility. This differ- strated to have less stress perioperatively.17
entiation makes it easier for a small OSF to demonstrate compli- Preoperative education needs to cover topics of particular con-
ance with reasonable guidelines, in that the relevant requirements cern for patients, which include intraoperative awareness, awak-
are not as extensive as they would be for a more comprehensive ening after sedation, postoperative pain and nausea, and socio-
center.13 economic aspects such as return to work and loss of income.
Hospital-based ambulatory care units that are extensions of Education needs to take place sufficiently far in advance; rarely
inpatient facilities obviously have many advantages for the sur-
geon and the patient, but they are often less efficient and conve-
nient than other ambulatory facilities. On the other hand, it is eas- Table 8 Premedication and Recovery Time 19
ier to assess the safety and quality of hospital-based units, in that
the QA functions of the hospital must extend to such units. Type Number of Patients Recovery Time* (min)
JCAHO is now well established in the voluntary accreditation
process for ambulatory health care facilities, as well as for inpa- No premedication 1,015 179 ± 113
tient facilities. Even though accreditation is still voluntary, it is Diazepam 98 168 ± 104
clear that a mandate already exists for some sort of QA for ambu- Pentobarbital 25 231 ± 88
latory facilities. Narcotics (meperidine,
388 208 ± 101
morphine)
In 1993, the Office of the Inspector General (OIG) reported
Hydroxyzine 92 192 ± 120
on the appropriateness of the surgical setting, the medical neces-
sity of the surgical procedure, and the quality of care performed *Values are ± SD.
does discussion immediately before the procedure, such as in the pronounced. Newer short-acting narcotics are now available, but
preoperative area, lessen stress levels. they have side effects of their own.
Preoperative teaching for children is a special case. Such teach-
ing must be age appropriate, and it should address sources of par- Anxiolytics
ticular distress in children, especially separation from caregivers Most barbiturates are long-acting agents and thus are not indi-
and changes in dietary habits. cated for outpatient procedures. Very short acting barbiturates,
such as thiopental, are occasionally used during anesthesia.
ORAL-INTAKE GUIDELINES
Nonbarbiturate tranquilizers, such as midazolam or diazepam,
Prolonged fasting does not guarantee an empty stomach. In are being used more often, primarily because they do not cause
contrast, liquids pass through the stomach quite quickly; the half- much sleepiness and because they may reduce the amount of
time of clear liquids is 10 to 20 minutes. There is less content in anesthetic required. Midazolam has become the medication of
the stomach of patients 2 hours after consuming small amounts choice because of its ease of administration (it is nonirritating as
of clear liquids than in the fasting patient.18 The risk of dangerous a parenteral injection), rapid onset, and flexibility (an oral for-
hypoglycemia should be more of a concern than stomach volume. mulation is now available, and is especially useful for children). In
For that reason, patients should be permitted small quantities of addition, these benzodiazepines are useful in stopping convulsions.
clear liquids up to 2 hours before the procedure, and the old
standard of “NPO past midnight” should be abandoned. These Antinauseants
recommendations are especially applicable to infants and chil- Administration of antinauseants is often begun in the preoper-
dren, but they also apply to elderly patients and debilitated ative setting.21 Given that PONV is a common cause of prolonged
patients with diabetes or other metabolic diseases. recovery and of subsequent hospital admission, preventive mea-
sures aimed at high-risk patients are preferable to treatment.
PREMEDICATION
Premedication is an important adjunct to local and regional Antacids and Histamine Antagonists
general anesthesia [see Table 7].19 It can facilitate performance of Antacids and histamine antagonists are sometimes used in an ef-
the procedure by alleviating fear and anxiety, supplementing anal- fort to diminish the risk of gastric aspiration and the consequent
gesia, reducing gastric acidity and volume, reducing oral and air- deleterious effects of acidic gastric contents on the respiratory tract,
way secretions, decreasing histaminic effects in patients with mul- but they have not been proved to be beneficial in this respect. It is
tiple allergies, limiting postoperative nausea and vomiting important to remember that most of the commonly used antacid
(PONV), and controlling infection. preparations are composed of particulate matter, so aspiration of
On the other hand, premedication, especially with narcotics, the antacid can itself be a serious problem. Patients who are as-
can also delay recovery; in fact, patients may actually take longer sumed to be at high risk for aspiration (e.g., diabetic, obese, or preg-
to recover from premedication and local anesthesia than from nant patients or patients with gastroesophageal reflux disease
general anesthesia. Still, no patient should be denied premedica- [GERD], stroke, or swallowing difficulties) should be premedicated
tion out of fear that it might delay discharge. Some studies have with an H2 receptor antagonist on the evening before and the
shown that premedication with agents other than long-acting nar- morning of the operation. Alternatively, these high-risk patients may
cotics does not prolong recovery time [see Table 8].20 Narcotic pre- be premedicated with a nonparticulate (i.e., clear) antacid, such as
medications are the usual cause of PONV and one of the major sodium citrate; a 50 ml dose of sodium citrate 1 hour before the op-
reasons for admission of outpatients to the hospital. eration raises the pH to a safe level, albeit at the expense of a slight-
The five major categories of agents used for premedication are ly increased gastric residual volume.22 Rapid infusions of H2 in-
(1) anticholinergic drugs, (2) narcotics, (3) anxiolytics, (4) antinau- hibitors at the time of surgery are discouraged because of the
seants and antiemetics, and (5) antacids and histamine antagonists. possibility that bradycardia will result.
Anticholinergic Drugs ANESTHESIA
Atropine and scopolamine are not routinely indicated for out- It is beyond the scope of this chapter to address general anes-
patient premedication, because newer anesthetics are less irritat- thesia in depth. We merely note that one should be prepared to
ing than older ones and because use of anticholinergic agents may meet all of the contingencies that can accompany general anes-
increase the incidence of cardiac irregularities. If an anticholiner- thesia, especially when anesthesia is delivered by someone other
gic is needed, glycopyrrolate, 0.2 to 0.3 mg I.M. or I.V., is a bet- than an anesthesiologist and is not immediately supervised by an
ter alternative in that it does not cross the blood-brain barrier and anesthesiologist. The patient’s cardiac activity, blood pressure,
causes less tachycardia than atropine does. temperature, respiration, and neuromuscular activity should be
properly monitored. The incidence of postoperative complica-
Narcotics tions is related to the anesthetic technique23: one of 268 patients
The primary effect of narcotics is the relief of pain; however, who receive local anesthesia experience postoperative complica-
they also have significant side effects that limit their usefulness for tions, compared with one of 106 patients who undergo sedation.
outpatient procedures. Fentanyl is appropriate for outpatient Obviously, the anesthetic technique used reflects the invasiveness
surgery because of its short duration of action and its limited side of the surgical procedure.
effects; it should be given within 30 minutes of the actual induc-
tion of anesthesia. Long-acting narcotics, especially meperidine Local Anesthetics for Local and Regional Anesthesia
and morphine, are usually not indicated in the outpatient setting. As outpatient surgery has become more popular, so too has the
As outpatient surgical procedures become more lengthy and use of local anesthetics for local and regional control of pain [see
complex, larger doses of short-acting narcotics such as fentanyl 1:5 Postoperative Pain]. Local anesthetics are usually administered
are being used. As the doses are increased, however, the advan- by the surgeon. It is crucial that the patient accept this type of
tages of short-acting drugs over long-acting drugs become less anesthesia and be psychologically suited for it; obviously, local or
Table 9 Local Anesthetics for Infiltration
Epinephrine-Containing
Plain Solutions Solutions
Drug
Maximum Adult Duration Maximum Adult Duration
Dose (mg) (min) Dose (mg) (min)
Short-acting Procaine 1%–2% 800 15–30 1,000 30–90
Lidocaine 0.5%–2.0% 300 30–60 500 120–360

Intermediate-acting
Mepivacaine 1%–2% 300 45–90 500 120–360
Long-acting Bupivacaine* 0.25%–5.0% 175 180+ 225 240+
*Not recommended for children younger than 12 yr.
regional anesthesia can be very disturbing and disruptive when (e.g., the fingers, the toes, the nose, and the external ears). In
administered inadequately or when given to an emotionally unsta- addition, adrenergic agents should not be used in unstable cardiac
ble patient. During the preoperative conference or the patient patients unless absolutely necessary.
education session, the surgeon, the anesthesiologist, or both Administration of long-acting local anesthetics (e.g., 0.25%
should make a point of describing how the anesthetic will be bupivacaine, injected in the skin edges at the end of the proce-
administered and what sensations will ensue. dure) seems to limit postoperative pain and thus to encourage
Local anesthetics can be classified into three groups according early activity and ambulation. Often, this technique not only post-
to their potency and duration of action: (1) low potency and short pones pain but reduces it as well. Bupivacaine is not, however, rec-
duration (e.g., procaine and chloroprocaine), (2) moderate ommended for patients younger than 12 years.
potency and intermediate duration (e.g., lidocaine, mepivacaine,
and prilocaine), and (3) high potency and long duration (e.g., Adjunctive Use of Local Anesthetics to Prolong Anesthetic Effect
tetracaine, bupivacaine, and etidocaine) [see Table 9]. It is clear that even when regional anesthetics, general anes-
Most local anesthetics are administered by infiltration into the thetics, or both are employed, adjunctive use of local anesthetics
extravascular space. In some areas, especially the hands, intravas- at the end of the procedure prolongs the anesthetic effect. In addi-
cular (I.V. regional) infiltration has been used with considerable tion, once the patient realizes that ambulation is possible without
success; however, inadvertent intravascular administration of discomfort, he or she is more likely to leave the hospital sooner
epidural doses of the high-potency agents can lead to life-threat- and is less likely to need additional postoperative analgesia.
ening complications [see Toxicity and Allergy, below]. Although Several centers are currently experimenting with administering
such complications have not been reported in association with local anesthetics before operation; the hypothesis, which is still
inadvertent intravascular administration during infiltration for unproven, is that preoperative administration may result in less
local anesthesia, it is advisable to check carefully to be sure that use of postoperative analgesics and a longer anesthetic effect than
the injecting needle is not located in an intravascular site. administration at the end of the procedure.
Intravascular injection can usually be prevented by constantly Injection of joint capsules with long-acting anesthetics and nar-
aspirating during infiltration and by infiltrating only while with- cotics (e.g., morphine sulfate) relieves a great deal of postopera-
drawing the needle. tive pain. Bathing of wounds with bupivacaine is a safe and effec-
Mixing local anesthetics is an effective means of obtaining the ad- tive method of decreasing postoperative pain.26 The addition of
vantages of more than one drug at once. At the Lichtenstein Hernia epinephrine can extend the prolongation of analgesia to 12 hours
Institute, in Los Angeles,24 patients undergoing repair of inguinal after operation.
hernias receive a 50-50 mixture of 1% lidocaine and 0.5% bupiva-
caine.The maximum therapeutic dose of lidocaine is 300 mg alone Nonsteroidal Anti-inflammatory Drugs
and 500 mg with epinephrine; the maximum therapeutic dose of Some centers use nonsteroidal anti-inflammatory drugs
bupivacaine is 175 mg alone and 225 mg with epinephrine.The ad- (NSAIDs) to reduce inflammation and thus pain [see 1:5
dition of 1 mEq/10 ml of sodium bicarbonate to the solution short- Postoperative Pain]. In addition, it has been shown that NSAIDs sig-
ens the onset time25 and reduces discomfort by raising the pH.This nificantly reduce the need for opioid analgesics after abdominal
combination of drugs has several advantages: (1) lidocaine has a procedures. Administration of ketorolac over a short period (i.e., 5
rapid onset, whereas bupivacaine prolongs the duration of the effect; days or less), first at the time of operation (60 mg I.M. in the OR;
(2) the negative chronotropic and inotropic action of lidocaine may lower doses for patients weighing less than 50 kg, those older than
well counteract the cardiac excitability of bupivacaine; and (3) use of 65 years, and those with impaired renal function) and then every 6
multiple drugs makes it less likely that the maximum therapeutic hours thereafter (10 to 15 mg p.o.), has improved recovery after
dose of any single agent will be exceeded. many operations, especially perianal and inguinal procedures.
Regional anesthesia, usually in the form of a regional nerve (Ketorolac is, however, contraindicated as a preoperative prophy-
block, is generally administered by an anesthesiologist but can be lactic analgesic.) Other NSAIDs can be given in transdermal
adequately administered by a knowledgeable surgeon. patches (which are not recommended for children) or transnasally.
The use of epinephrine with local anesthetics prolongs the
duration of the anesthetic effect without delaying its onset; how- Toxicity and Allergy
ever, epinephrine should not be used with anesthetics at sites Whenever local anesthetics are used, especially when they are
where the vascular supply distal to the site of infusion is marginal administered regionally for major nerve blockade, the possibility
of systemic toxicity should be considered. Such toxicity often anesthetic of unrelated structure. An intradermal skin test, in
results from inadvertent intravascular injection of these agents, which 0.1 ml of the anesthetic drug is injected intradermally into
leading to a sudden increase in systemic concentration.20 The the volar aspect of the forearm, may be tried. A negative reaction
rate of injection is inversely related to the patient’s tolerance of indicates that the drug probably can be used safely; nevertheless,
the drug: the higher the injection rate, the lower the tolerance. In resources for handling major cardiopulmonary irregularities
general, arterial infusion is less likely to cause a toxic reaction should be available when anesthetics are used in previously sen-
than venous infusion because of the delay in circulation through sitized patients.30
the distal capillary network. Other factors that can lead to toxic
reactions are a diminished drug detoxification rate, systemic aci- Control of Nausea and Vomiting
dosis, and individual sensitivities, which are highly variable. Many predisposing factors play a role in causing PONV. Not
In the CNS, toxic reactions range from drowsiness to frank all of these factors can be managed. Nevertheless, it behooves the
convulsions. One study found that the incidence of mild toxic surgeon and the anesthesiologist to identify patients at risk so as
reactions to local and regional anesthetics was 0.38% and the to minimize the incidence of this debilitating syndrome, which is
incidence of convulsions was 0.12%.27 In the cardiovascular sys- responsible for a large number of hospital admissions after out-
tem, toxicity is initially manifested by elevated blood pressure; patient surgical procedures.
eventually, depression of systemic resistance and myocardial con- Some of the more common causes of nausea are often over-
tractility leads to cardiovascular collapse.The myocardial depres- looked. Pain is in itself capable of causing nausea and vomiting.
sion associated with intravascular injection of 0.75% bupivacaine Accordingly, adequate control of pain is essential, and the patient
for epidural anesthesia has been reported to be strongly resistant must not be deprived of analgesics under the false assumption
to treatment in pregnant women.28 Systemic toxicity is also man- that the medications are the only cause of the nausea. Changes in
ifested by alterations in the metabolic system, such as derange- body activity, especially assumption of the upright position by a
ment of acid-base balance. (Respiratory or metabolic acidosis patient with hypotension, can also cause nausea, as is experi-
leads to an increased sensitivity to local anesthetics.) All such enced before a vasovagal attack. In some patients who are prone
reactions are best managed by prevention. Constant vigilance is to motion sickness, the sensation of motion is aggravated by the
necessary to ensure that inadvertent intravascular injection does surgical procedure, the anesthetics, and pain. A preoperative his-
not occur at the time of infiltration. Any serious reactions (e.g., tory of frequent attacks of motion sickness is often a signal that
convulsions and cardiovascular collapse) that arise despite pre- the patient is prone to nausea and vomiting.
cautions are treated with standard measures. The use of narcotics in premedication, as well as in induction
Many patients claim to be allergic to anesthetics (which they and maintenance of anesthesia, is definitely a cause of increased
often refer to generically as Novocain), but true allergic reactions postoperative nausea and vomiting; however, some of the newer
are rare.29 A careful history of allergic drug reactions should be opioid analgesics (e.g., fentanyl, sufentanil, and alfentanil), when
taken, including reactions to concomitant medications such as given judiciously as premedications [see Table 7], appear to reduce
epinephrine. It is important to explain to a patient the nature of anxiety, decrease anesthetic requirements, and relieve pain in the
any reaction that occurs so that if the reaction is not in fact an early postoperative period.31 One should have a thorough under-
allergic one, he or she will not give a history of allergy to anes- standing of the proper use of these medications before employing
thetics in the future. them in the ambulatory setting.
Allergic reactions are mediated by the release of histamine. Benzquinamide, trimethobenzamide, promethazine, and
Previous exposure to the offending local anesthetic can lead to prochlorperazine have all been used in an effort to control PONV
the production of IgE antibodies, which initiate anaphylaxis on but with only limited success.32 Droperidol had been popular for
subsequent exposure; however, anesthetics can also initiate com- this purpose, but in December 2001, the Food and Drug
plement-mediated release of histamine without previous expo- Administration added a so-called black-box warning to the drug’s
sure. Histamine release leads to characteristic symptoms: skin labeling because of the potential for fatal cardiac arrhythmias;
erythema, followed by erythema in various regions of the body consequently, droperidol is now rarely used.33 Metoclopramide
and edema of the upper airway. Abdominal cramps and cardiac acts specifically on the upper GI tract and is a useful premedica-
instability may also be present. tion because it also encourages gastric emptying and prevents
If an allergic reaction occurs, administration of the drug aspiration; however, it is a short-acting agent and thus may have
should be stopped immediately. Epinephrine, 0.3 to 0.5 ml of a to be given again after a long procedure.The usual dose of meto-
1:1,000 dilution, should immediately be given either locally (I.M. clopramide for the average adult patient is 10 to 20 mg.34,35
or subcutaneously) or, if the reaction is severe, systemically.30 Given that a history of motion sickness is a good predictor of
Diphenhydramine, 0.5 to 1.0 mg/kg, should also be given sys- increased risk for nausea and vomiting, it is not surprising that
temically. If bronchospasm occurs, aminophylline, 3 to 5 mg/kg
I.V., should be administered. Corticosteroids have been used in
this setting, but there is little evidence that such therapy is help- Table 10 Treatment of Allergic
ful [see Table 10].
Reactions to Local Anesthetics
One common cause of allergic reactions is sensitivity to
paraben derivatives, which are preservatives used in local anes-
thetics. Paraben preservatives resemble para-aminobenzoic acid Agent Route of Administration Recommended Dose
(PABA), a metabolic-breakdown product of ester-type anesthet- Epinephrine I.M. or subcutaneously 0.3–0.5 ml of
ics (e.g., procaine, benzocaine, and tetracaine). PABA is a mem- 1:1,000 dilution
ber of a class of compounds that are highly allergenic. Patients Diphenhydramine Systemically 0.5–1.0 mg/kg
sensitive to sunscreens containing PABA often show cross-sensi- Aminophylline I.V. 3–5 mg/kg
tivity to ester-type local anesthetics. Patients who are allergic to a Corticosteroids I.V. 1g
local anesthetic usually can be safely given a preservative-free
dimenhydrinate is effective in many cases. Indeed, in some cases, Table 11 Modified Aldrete Phase I Postanesthetic
it is significantly more effective than droperidol.36 Recovery Score42,43
Postoperative Care Patient Sign Criterion Score
The cornerstone of postoperative care in outpatient surgery is Able to move 4 extremities* 2

a well-instructed and well-informed patient. Many postoperative Activity Able to move 2 extemities* 1
problems can be avoided if patients fully understand the nature Able to move 0 extremities* 0
of the proposed procedure, the potential side effects of the oper-
Able to breathe deeply and cough 2
ation, and the role they must play in their own postoperative care.
Respiration Dyspnea or limited breathing 1
Facilitating such understanding not only helps prevent potential
Apneic, obstructed airway 0
problems but also increases patients’ overall satisfaction with the
process of outpatient surgery. BP ± 20% of preanesthetic value 2
Circulation BP ± 20%–49% of preanesthetic value 1
RECOVERY
BP ± 50% of preanesthetic value 0
The process of postoperative recovery may be divided into
Fully awake 2
three phases as follows.37,38
Consciousness Arousable (by name) 1
Phase I Nonresponsive 0
Phase I, or early recovery, includes the patient’s return to con- SpO2 > 92% on room air 2
sciousness and recovery of vital reflexes. Generally, phase I takes Oxygen saturation
Requires supplemental O2 to maintain 1
place in the postanesthesia care unit (PACU). Currently, howev- SpO2 > 90%
er, as a result of increasing use of short-acting anesthetics39 and SpO2 < 90% even with O2 supplement 0
conscious sedation, this phase sometimes occurs in the OR, thus *Either spontaneously or on command.
eliminating the need for recovery in the PACU. This fast-track SpO2—pulse oximetry
approach is being adopted more frequently in ASCs, where

patients typically undergo shorter, less invasive procedures.40 It is this period. It is in phase III that patients may experience various
attractive because if patients can recover in the ASCs and avoid postoperative problems [see Postoperative Problems, below] that
the PACU, they can be discharged sooner, and costs can thereby
require specific management. Patients should also be informed
be reduced. On the other hand, more rapid recovery and dis-
about warning signs and symptoms. Patients should be provided
charge can mask some minor adverse symptoms, which may lead
with contact numbers to call if these symptoms occur and with
to patient dissatisfaction with ambulatory surgery.41
instructions on returning to a health care facility if necessary.
Several significant problems (e.g., PONV, pain, hypotension,
and respiratory depression) may arise during phase I. DISCHARGE INSTRUCTIONS
Accordingly, the patient’s vital signs, including oxygen saturation,
Ideally, ambulatory surgery patients should be given their dis-
must be closely monitored. Frequent reassessment in the PACU
charge instructions during the preoperative conference in the
is indicated. A useful way of determining whether the patient is
office. A variety of patient education tools (e.g., pamphlets,
ready for discharge to phase II is to employ a scoring system such
as the modified Aldrete system, which assigns scores from 0 to 2 detailed written instructions, and videos) may be used to help
in each of five categories (activity, respiration, circulation, con- educate patients about their operations and subsequent postop-
sciousness, and oxygen saturation) [see Table 11].42,43 erative care.38 Verbal reinforcement of written instructions by the
surgeon is an important component of patient education.
Phase II Communications from the surgeon should be consistent with the
Phase II, or intermediate recovery, is the period between imme- other materials (e.g., pamphlets, brochures, and preprinted
diate clinical recovery and the time when the patient is ready to be instruction sheets) provided to the patient. The instructions the
discharged.This phase usually takes place in the ASC or the step- patient is given before leaving the ASC must also be consistent
down unit. Patients still need periodic monitoring during this peri- with what the patient or family has previously been told, whether
od because they often have not yet fully recovered from the effects orally or in writing, by the surgeon. Providing careful periopera-
of the anesthetic or the surgical procedure. As in phase I, patients tive instructions can yield several significant benefits, including
must be thoroughly assessed according to predetermined criteria to increased patient satisfaction, improved outcomes, decreased
determine whether they are ready to be discharged to the next patient anxiety, improved compliance, and even reduced costs.45
phase of recovery.44 Before discharge to phase III, patients should In a multicenter British study, up to 25% of patients did not
be provided with both verbal and written discharge instructions. A comply with postoperative instructions.46 There are several barri-
responsible adult must be present to accompany the patient home ers to comprehension of or adherence to instructions that the sur-
and assist in the final phase of recovery; often, the absence of such a geon must take into account.47 The most obvious barrier is that
person delays completion of phase II. patients simply may not understand or remember the instruc-
tions given. It has been shown that patients’ ability to understand
Phase III written instructions may be a few grades lower than their actual
Phase III, or late recovery, takes place outside the health care education level48; accordingly, instructions should be written in
facility, usually at home. Because the anesthetic may still be such a way as to be easily understood by patients. In addition,
affecting patients 24 to 48 hours after the procedure (and some- patients may not be able to remember long, detailed verbal
times considerably longer), they should be cautioned not to drive, instructions well, even if they understood them on first hearing;
operate heavy machinery, or make important decisions during thus, supplemental written instructions should be provided.
structions regarding medications if the surgical procedure may

Table 12 Issues to Address in interfere with their usual diet.
As part of the postoperative instructions, patients or caretakers
Postoperative Instructions should be given a list of items that require them to notify the
physician [see Table 13]. Access to postoperative care in the event
Activity Possible complications or side effects
(of procedure, anesthesia, or medications) of an emergency is mandatory. Whether such access is available
Medication
Follow-up testing or treatments in a given instance often plays a role in determining whether
Diet
ambulatory surgery is appropriate for that patient. The patient
Wound care Emergency contacts, including surgeon
and acute care facility
should be given the telephone number of the surgeon and the
Pain relief ASC, as well as the location and telephone number of the appro-
priate emergency care facility.37 Providing careful and thorough
postoperative instructions, however, should help minimize
unnecessary telephone calls to the surgeon and inappropriate vis-
its to an emergency facility.50
Table 13 Reasons for Notification of Surgeon37 POSTOPERATIVE PROBLEMS
Persistent nausea and vomiting Persistent uncontrolled pain

Delayed Discharge or Unexpected Hospital Admission
Bleeding Excessive redness or drainage
Fever (usually > 101° F [38.3° C])
from incision The overall rate of unanticipated hospital admission after
Urinary retention ambulatory surgery ranges from 0.15% to 2.5%4,51-55 The rate
may vary considerably, depending on what types of procedures
are performed at the facility, how patients are selected for outpa-
Another barrier to comprehension and compliance is that tient surgery, patient characteristics such as age, and whether the
patients’ perception of when postoperative recovery is complete facility is hospital-based or independent. Many ASCs use unex-
may be inaccurate. Many patients, mistakenly believing that they pected hospital admission after ambulatory surgery as a quality
are fully recovered, resume driving, working, or other strenuous indicator. Analysis of such admissions may be useful in helping a
activities prematurely. Surgeons must therefore stress the neces- facility develop appropriate patient and procedure selection cri-
sity of following discharge instructions exactly, even if patients teria.53 It may also be helpful for developing discharge criteria
feel that they are completely recovered. and identifying patients who will require additional monitoring
Postoperative instructions should include several specific cate- before discharge.
gories of information [see Table 12], preferably in writing. In addi- Factors leading to hospital admission from an ASC may be
tion, a follow-up appointment should be made, and patients classified into four general categories: procedure-related factors,
should be given clear directions regarding access to postoperative anesthetic-related factors, patient-related factors, and system-
care in the event of an emergency.37,49 As a rule, it is best to pre- related factors.
sent these instructions at the time of the preoperative evaluation,
but it is probably advisable to present them again at the time of Procedure-related factors Length of operation has been
discharge from the ASC. shown to be an independent predictor of increased admission
Activity instructions should address exercise or activity level, rates after ambulatory surgery.45,46 Other procedure-related fac-
driving or operating machinery, return to work, and showering or tors associated with increased admission rates include a proce-
bathing. The importance of following postoperative instructions, dure that is more extensive than planned, inappropriate booking
especially regarding activities such as driving, must be made clear of the case, the need for a subsequent procedure, and intraoper-
to the patient. Patients often feel that these instructions are over- ative adverse events (e.g., bleeding or bowel perforation during
ly cautious, and therefore, many patients are noncompliant with laparoscopy). Uncontrolled pain related to the procedure is a sig-
activity instructions.46 If patients are likely to need someone to nificant cause of unanticipated admission from an ASC.52 Accord-
assist them in their routine daily activities, they should be ingly, measures to prevent and control excessive pain should be
informed well in advance, so that suitable arrangements can be taken [see Pain, below].
made preoperatively.
Detailed wound care instructions, including directions for Anesthetic-related factors One of the most common of the
removing or changing dressings, applying ice or heat, and elevat- anesthetic-related factors necessitating hospital admission is
ing the affected area, are essential. In addition, patients should be PONV [see Nausea and Vomiting, below]. Other adverse reactions
told what to do when they see signs of wound problems, such as to anesthesia that call for admission or observation include
redness, drainage, or bleeding. Patients should also be taught delayed emergence from the anesthetic, excessive drowsiness,
drain or catheter care, if pertinent, before the operation. If the and delayed resolution of a regional block; more serious reactions
outputs of these devices must be measured and recorded, include pulmonary aspiration of gastric contents and malignant
patients or caretakers should be taught how to do this as well. hyperthermia.
It is vital that patients and caretakers be advised regarding
resumption of preoperative medications. In addition, patients Patient-related factors Patient-related factors leading to
should be provided with specific information about pain medica- hospital admission after ambulatory surgery may be further
tions, including drug names, dosages, potential side effects, and divided into two subcategories: medical factors and social factors.
drug interactions. If patients are taking analgesic preparations Many of the medical factors are related to preexisting condi-
that contain acetaminophen, they must be cautioned not to take tions56; for example, it has been shown that patients with preex-
other acetaminophen-containing medications, because of the isting congestive heart failure stay longer in the ASC.57 Such
potential for hepatotoxicity. Diabetic patients need special in- findings underscore the need for appropriate selection of patients
for ambulatory surgery and the importance of optimizing treat- from an ambulatory surgical facility had a higher incidence of
ment of any preexisting medical conditions. PONV.68 A similar study of adult patients, however, did not docu-
Social factors account for as many as 41% of delays in dis- ment increased risk of PONV in patients required to drink fluids
charge from the ASC.The most common social reason for delayed before discharge, nor did it document decreased risk in patients
discharge is the lack of an adult escort to accompany the patient who were not so required.69 Given these findings, we believe that
home.58,59 To prevent this occurrence, patients should be coun- patients should be allowed to choose whether they want to drink
seled preoperatively in the office on the need for someone to ac- fluids before discharge; oral fluid intake should not be a mandatory
company them home from the ASC, and the availability of the discharge criterion.
escort should be verified when the patient presents to the ASC Several categories of antiemetic agents are available for preven-
before the scheduled procedure. tion and treatment of PONV, the most common of which are the
antihistamines, the antidopaminergics, and the antiserotoninergics.60
System-related factors Many system-related factors may The antihistamines have long been used to treat motion sick-
delay discharge or increase the postoperative admission rate from ness and other disturbances of the vestibular pathway. They may
the ASC. These include patient prescriptions that are not ready, be more effective than other antiemetics after middle-ear proce-
nurses who are too busy to instruct and discharge patients, dures. Common side effects include dry mouth and sedation.
uncompleted paperwork, or physicians who have not discharged One of the most commonly used antidopaminergic antiemetics is
the patient.59 Because the PACU may close before the patient is promethazine. This agent possesses both antihistaminic and anti-
fully recovered, some patients need to remain in the ASC until cholinergic properties and is therefore useful for treating motion
their recovery is complete.53 For an ASC to be efficient and prof- sickness.60 Droperidol has also been widely used for prevention of
itable, as well as to promote patient satisfaction, these types of PONV. However, because of its association with fatal cardiac ar-
unnecessary delays should be anticipated and avoided. rhythmias, which prompted the December 2001 black-box warning
from the FDA—the most serious warning an FDA-approved drug
Nausea and Vomiting can carry—and because of studies documenting slower recovery
PONV is distressing to patients and is a common source of from anesthesia with droperidol than with other agents, the current
patient dissatisfaction with ambulatory surgery and anesthesia.60-64 consensus is that the use of droperidol should be limited.70 Side ef-
In addition, PONV often causes delayed discharge from the fects of antidopaminergic agents include anxiety, dizziness, drowsi-
ASC or unplanned hospital admission, thereby inconveniencing ness, extrapyramidal effects, and hypotension.These effects are dose
patients and increasing the cost to the ASC.37,57 Patients who related and may continue after discharge.60,70
experience PONV report more difficulty in resuming normal The selective serotonin receptor antagonist ondansetron is very
activities and may require a longer recovery period.65 PONV may effective in preventing and treating PONV.71 The optimal prophy-
also lead to a variety of postoperative problems, including aspira- lactic dose for adults is 4 mg.72 The side effects commonly seen with
tion pneumonitis, dehydration, esophageal rupture, and wound antihistamines (e.g., blurred vision, dry mouth, and diplopia) are
dehiscence.66 rare with ondansetron.70,72
The etiology of PONV is complex and includes factors related Metoclopramide reduces PONV by increasing lower esoph-
to the procedure, the anesthetic, and the patient. Certain opera- ageal sphincter pressure and increasing gastric emptying. This
tions, including ophthalmic procedures, orchiectomy, and middle- agent may be useful in counteracting the effects of narcotics on
ear procedures, are associated with a high incidence of PONV. gastric motility. Because it does not affect the vestibular system,
Certain anesthetics (e.g., narcotics, etomidate, and ketamine) have metoclopramide is usually employed as an adjunct to other
been shown to carry a greater risk of PONV than other agents do.60 agents in the treatment of PONV. However, its use is somewhat
Use of propofol as an induction agent has been shown to decrease controversial.60,66
the incidence of PONV.67 Other anesthetic-related causes include The synthetic glucocorticoid dexamethasone is also a safe and
gastric distention during mask ventilation, hypotension related to effective agent in preventing PONV.73,74 The delayed onset of
regional anesthesia, and vagal stimulation. Of the patient-related action and prolonged effectiveness of dexamethasone make it
causes, younger age, anxiety, pain, underlying medical conditions ideal for use in conjunction with other agents in patients who are
such as gastroparesis, and a previous history of PONV are also at particularly high risk for PONV.73 Dexamethasone has few side
known to be associated with a higher incidence of PONV. effects and is more cost-effective than other agents.75
Prevention of PONV depends on a clear understanding of the In summary, the management of PONV requires a systematic
etiology and on an accurate assessment of the patient’s level of approach. Identifying patients who are at high risk and providing
risk for this complication. Given the cost and side effects of the multimodal treatment can often prevent PONV.76
medications required, prophylaxis for all patients undergoing
ambulatory surgery is not advisable60; however, prophylaxis for Pain
patients known to be at high risk for PONV may result in Effective pain management after ambulatory surgery depends
decreased cost to the patient and facility, greater patient satisfac- on a clear understanding of the mechanisms of pain, a careful
tion, and fewer associated complications. assessment of the type and degree of pain, and appropriate selec-
PONV prophylaxis should include both pharmacologic and non- tion of pain-control methods so as to optimize patient comfort
pharmacologic interventions. Preoperative sedation to alleviate anx- while minimizing side effects. Incomplete pain control is associ-
iety may facilitate control of PONV, as may adequate management ated with several significant complications, such as PONV,
of postoperative pain [see Pain, below]. Judicious selection of anes- reduced mobility, and inability to cough and breathe deeply. In
thetic agents also helps reduce the incidence of PONV. Limiting pa- addition, pain is associated with delayed discharge from phase II
tient motion after certain operations (e.g., ophthalmic procedures) of recovery, more frequent return visits by the patient to a health
may be beneficial. A more flexible approach to postoperative fluid care facility, and higher rates of unplanned hospital admis-
intake may be helpful as well. One pediatric study found that pa- sion.77,78 Postoperative pain also can be physiologically harmful,
tients who were required to drink liquids before being discharged causing increased release of catecholamines with resultant eleva-
tion of blood pressure and pulse rate. Inadequate postoperative Overall, opioids are the most commonly used pain medica-
pain control is a significant source of patient dissatisfaction with tions after ambulatory surgery. They can be delivered via many
ambulatory surgery.55 By limiting mobility, postoperative pain different routes, including oral, I.V., I.M., transcutaneous,
may hamper patient recovery. Moreover, inability to manage pain intranasal, oral transmucosal, and subcutaneous. The main con-
adequately after certain procedures makes it difficult (or even cerns with respect to opioid use are the side effects and the
impossible) for surgeons to perform these procedures in an potential for abuse. Common side effects include respiratory
ambulatory setting.79 depression, sedation, reduction of rapid-eye-movement sleep,
Assessment of postoperative pain requires good communication impaired GI motility, urinary retention, PONV, and allergic reac-
between the surgeon and the patient. Patients have varying sensi- tions. PONV is a particular problem; however, if other agents
tivity to pain and respond differently to pain medication. Use of a (e.g., NSAIDs and adjuvants) are being used as well, the opioid
measurement tool such as the verbal analogue scale can facilitate dosage can be reduced and the incidence of PONV thereby low-
assessment of postoperative pain. A 1998 study found that 40% of ered.83 Because of the many side effects of opioid analgesics, the
patients reported moderate to severe pain in the first 24 hours after preoperative teaching should include instructions to patients
ambulatory surgery and that the best predictor of severe pain at regarding the management of these side effects. The patient
home was inadequate pain control during the first few hours after should also be instructed on avoiding driving and use of heavy
the operation.79 It is therefore crucial to assess patients’ pain and machinery while taking these medications.
treat it aggressively before discharging them from the ASC. Adjuvant methods of controlling pain include infiltration of local
A key component of pain control after ambulatory surgery is anesthetics (e.g., bupivacaine) into the surgical site, continuous or
education of patients regarding the degree of postoperative pain patient-controlled regional anesthesia (PCRA) systems, local nerve
they may experience. It is not uncommon for patients to com- blocks, and transcutaneous electrical nerve stimulation (TENS).
plain that they were given no information about how much pain Often, these measures add substantially to control of pain after am-
to expect and how to manage it. During the preoperative visit, bulatory surgery. In particular, PCRA is very effective in certain
patients should be informed about various nonpharmacologic procedures.83 In this approach, a catheter is placed in the surgical
methods of alleviating pain. Depending on the procedure to be site or near local peripheral nerves and attached to an elastometric
performed, appropriate methods may include application of ice, (balloon) pump containing bupivacaine; the patient can then con-
elevation of an affected extremity, wearing of loose-fitting cloth- trol administration of the local anesthetic.
ing, sitz baths, or modified sleeping positions.80 During the same
visit, patients should also be informed about the medications Infection
they will be given for pain control—specifically, names, dosages, The incidence of postoperative infection in ambulatory
potential side effects, drug interactions, and precautions. Finally, surgery patients varies, depending on the procedure performed
patients should be told how to notify their physician if they con- and the risk factors for infection present. Overall, however, infec-
tinue to experience excessive pain. tion rates after ambulatory surgery tend to be substantially lower
The best pharmacologic strategy for controlling postoperative than those after inpatient surgery.84,85 Actual infection rates can
pain is to employ regimens comprising multiple analgesics that be difficult to quantify in ambulatory surgery patients but should
work synergistically.78 So-called balanced analgesia involves giv- nonetheless be measured both as an indicator of quality and as
ing medications from three different analgesic groups: nonopi- an aid to reducing the incidence of infection.86
oids, opioids, and adjuvants.81 Patients should be given a list of potential signs of infection
The nonopioid agents most commonly used after outpatient sur- (i.e., redness, drainage, excessive pain around the incision, and
gery are the NSAIDs and acetaminophen. NSAIDs act peripherally fever) and instructed to call the physician if these appear. The
and have anti-inflammatory, analgesic, and antipyretic effects.They presence of any of these signs is an indication for examination by
are very effective against mild to moderate pain. Side effects include a physician. Most of the postoperative surgical site infections that
gastric mucosal irritation and inhibition of platelet aggregation; occur in ambulatory surgery patients can be treated in the office
however, newer NSAIDs that selectively inhibit the cyclooxyge- with local wound care.
nase-2 (COX-2) enzyme exhibit these effects to a much lesser de- Many other types of infection may occur in ambulatory surgery
gree.82 One of the most commonly used NSAIDs in ambulatory patients, of which pneumonia, urinary tract infections, and pros-
surgery patients is ketorolac, which may be administered either I.V. thetic-device infections are the most common. Generally, these in-
or I.M. Its onset of action occurs approximately 30 minutes after fections develop several days after the procedure; thus, it is impor-
administration, with peak effect coming at about 75 minutes.81 This tant to schedule a postoperative visit around this time.
agent causes reversible inhibition of platelet aggregation, which re-
solves 24 to 48 hours after the drug is stopped; it also has an ad- Urinary Retention
verse affect on renal function. Accordingly, ketorolac should be Postoperative urinary retention occurs in 0.5% to 5% of
used with caution in elderly patients and in patients with altered re- ambulatory surgery patients.87,88 Patients at high risk for this
nal function.83 complication are those who have previously experienced urinary
Acetaminophen acts to alleviate pain by a central mechanism. retention and those who are undergoing particular types of pro-
It lacks the antiplatelet effects of NSAIDs and has few side cedures (e.g., herniorrhaphy and anal procedures). Other predis-
effects. Acetaminophen should not be given to patients with liver posing factors are advanced age,88 spinal anesthesia,87 use of anti-
disease or chronic alcoholism.The maximum daily dose of aceta- cholinergics, bladder overdistention, use of analgesics, unrelieved
minophen in adults is 4,000 mg; thus, as noted [see Discharge pain, preoperative use of beta blockers,89 and a history of preop-
Instructions, above], patients must be cautioned not to take any erative catheterization.
other acetaminophen-containing medications.This is a matter of Surgeons often require ambulatory surgery patients to void
particular concern because many of the commonly used oral nar- before discharge; however, this practice unnecessarily delays dis-
cotic pain preparations already include a significant amount of charge of low-risk ambulatory surgery patients. A 1999 study
acetaminophen, which patients may not realize.81 showed that low-risk patients could be safely discharged without
voiding and did not benefit from being required to void sponta- Table 14 Predisposing Factors to Complications
neously before discharge.87 The incidence of postoperative urinary during and after Outpatient Anesthesia23
retention in these patients was 0%. In low-risk patients who were
discharged without voiding, the mean time to voiding after dis- Predisposing Factor Incidence of Complications
charge was 75 minutes, indicating that discharge had been expe-
dited by at least that length of time. In high-risk patients, howev- Preexisting disease
er, catheterization before discharge should be considered if they None (ASA I) 1/156
are unable to void. In addition, once discharged, high-risk patients Diabetes mellitus 1/149
should have ready access to a medical facility and should be Asthma 1/139
instructed to return if they are still unable to void 8 to 12 hours Chronic pulmonary disease 1/112
Hypertension (diuretic therapy) 1/87 (1/64)*
after discharge.
Heart disease 1/74*
The presence or absence of symptoms is not a reliable indica-
Type of anesthesia
tor of urinary retention: many patients are asymptomatic even
Local only 1/268
with bladder volumes greater than 600 ml.87,90 Alternative meth- Regional only 1/277
ods of diagnosing urinary retention, such as ultrasonography or Local/regional with sedation 1/106*
catheterization of patients known to be at high risk for urinary General (combination of techniques) 1/120*
retention and unable to void before discharge, are more reliable. Duration of anesthesia
Bladder overdistention is a significant cause of postoperative < 1 hr 1/155
urinary retention.9,87 Judicious use of fluids helps minimize post- 1–2 hr 1/84
operative urinary retention in patients at high risk.Those who are 2–3 hr 1/54*
at high risk for retention and are receiving substantial amounts of > 3 hr 1/35*
I.V. fluids should be considered for early catheterization to help Significantly different from initial value for the group; P < 0.05.
prevent excessive distention of the bladder with resultant reten-
tion and bladder atony.
Patients who require catheterization more than once postoper- disturbances, and PONV may be noted as well. How PDPH is
atively may be safely discharged home after placement of an treated depends on the severity of the symptoms. For mild symp-
indwelling catheter. The catheter should be left in place for 24 to toms, the patient should be instructed to take appropriate amounts
72 hours, after which time it can be removed in the physician’s of fluids, remain recumbent, decrease environmental stimuli (e.g.,
office. In the absence of any complicating circumstances, there is lights and noise), and take analgesics; caffeine may be a helpful ad-
generally no need to admit patients to a hospital simply because juvant.37 For severe, persistent symptoms, the patient may have to
of urinary retention. undergo a blood-patch procedure, in which a small amount of his
or her blood is injected epidurally to patch the dural leak.93
Other Postoperative Problems A small amount of incisional bleeding after ambulatory surgery
Other common postoperative problems that may develop in is common. Patients must be carefully taught how to monitor for
ambulatory surgery patients are headache, insomnia, constipa- excessive bleeding and how to perform initial management of inci-
tion, bleeding, and pharyngitis. Many of these problems can be sional bleeding with direct pressure and dressing changes. They
handled by providing reassurance and carrying out simple inter- must also be instructed to call the physician if bleeding persists.
ventions; however, some problems (e.g., headache and bleeding)
DOCUMENTATION OF OUTCOMES
may necessitate direct physician intervention to ensure that they
do not worsen. Evidence-based medicine is becoming the basis for accredita-
Headache occurs in 10% to 38% of patients in the first 24 hours tion, reimbursement, and public acceptance of the care-delivery
after the operation.37 It may be related to caffeine withdrawal, in system. Outpatient surgery is no exception to this trend.Therefore,
which case it is easily treated with caffeine-containing beverages, of- clear documentation and follow-up are important.The Federated
ten before discharge. Spinal headache, or postdural puncture head- Ambulatory Surgery Association (FASA) has published a list of
ache (PDPH), however, may be much more difficult to treat.This predisposing factors for complications during and after surgery
condition results from leakage of CSF from a tear in the dura dur- [see Table 14].23 It is imperative that the staff of any surgical unit
ing spinal anesthesia; thanks to advances in spinal-needle design, it be just as diligent in documenting outcomes as it is in docu-
is now less common than it once was.91,92 PDPH is most common- menting other parameters in preparation for surgery. National
ly a frontal or occipital headache that worsens with sitting or stand- benchmarks, such as those developed by the FASA, should be
ing and lessens with recumbency. Photophobia, diplopia, auditory used as guidelines for measuring the safety of any unit.
Discussion
Growth of Outpatient Surgery
delivery of surgical health care. Just a few years ago, it was esti-
The recent evolution of health care in response primarily to mated that more than 40% of all operative procedures would be
socioeconomic factors has been spectacular, and the process is by performed in the outpatient setting. By 2000, however, 70% of
no means complete.The most striking result to date is the emer- operative procedures were already being performed on an outpa-
gence of ambulatory surgery as the predominant mode for the tient basis. In 1996, an estimated 31.5 million procedures were
performed during 20.8 million ambulatory surgical visits.94 The Economic benefits aside, the major issue in the movement of
majority (84%) of these visits still took place in hospitals, howev- surgical activities out of the hospital and into a more convenient
er, with the remainder in freestanding units.94 Although proce- and economical environment is how best to ensure that patients
dures such as endoscopies and lens extraction and insertion were continue to receive safe, high-quality care. This consideration
predominant at this time, there were also many breast biopsies, must in all circumstances be the primary issue underlying the
herniorrhaphies, and orthopedic procedures. planning of elective surgery. More and more, third-party payors
The explosive growth of ambulatory surgery was initiated by expect surgical care to be provided to their clients (patients, to us)
economic factors, but it has had some positive effects on patient in a cost-effective environment. On the whole, this is not a bad
care, for the following reasons: thing. If, however, they also expect that surgical care can be pro-
vided just as cost-effectively to diabetic patients, morbidly obese
1. Development of new technology. Newer techniques, such as
patients, and patients with serious cardiac or respiratory disease,
laparoscopic surgery, minimize the need for hospitalization
there is a real danger that patients’ welfare could be compro-
and decrease the pain and suffering that patients must endure.
mised. Accordingly, it is crucial that all third parties who are not
It is not yet clear, however, whether such developments will
inevitably lead to a reduction in total health care costs. One directly involved in the care of the patient permit the surgeon and
study reported that the cholecystectomy rate increased from the anesthesiologist to exercise sound medical judgment in regard
1.35 per 1,000 enrollees in an HMO in 1988 to 2.15 per 1,000 to what type of care is needed and where such care can best be
in 1990 and that the total cost for cholecystectomies rose by delivered. Surgeons must not delegate their responsibility for
11.4% despite a unit cost savings of 25.1%.95 The authors sug- safeguarding their patients’ well-being.
gested that these results might be attributable to changing The ACS has issued several statements on ambulatory
indications for gallbladder operations; however, it is much surgery.96 In their 1983 statement, the ACS approved “the con-
more likely that a significant number of patients suffering from cept that certain procedures may be performed in an ambulatory
gallbladder dysfunction who were reluctant to undergo an surgical facility” but emphasized that “a prime concern about
open procedure are now willing to accept the lesser discomfort ambulatory surgery is assurance of quality” and that “a discussion
and inconvenience characteristic of a laparoscopic procedure. between patient and surgeon about performance of the procedure
What the appropriate cholecystectomy rate may be is a ques- on an ambulatory basis should result in a mutually agreeable
tion for the future to answer; in the meantime, many patients decision.”96 More than two decades later, this is still the position
are living more comfortably, having had the dysfunctional of the ACS. The College is continually evaluating evolving med-
organ removed. The situation is similar in the treatment of ical technology, both inpatient and outpatient.
GERD. Repairs to the esophagogastric junction can now be Outpatient surgery would seem to have an obvious advantage
done without a long and difficult postoperative course. In over inpatient surgery with respect to cost savings, especially if the
addition, there have been major advances in anesthetic tech- main focus of the comparison is the high charges for 1 or more
niques and postoperative management of pain and PONV. days of inpatient care. Such a comparison may be misleading
2. Cost savings achieved by Medicare and other payors. In insofar as it suggests that the entire cost of inpatient care can be
1987, Medicare approved over 200 procedures as suitable for saved when the procedure is done on an outpatient basis. The
ASCs. Currently, more than 1,200 procedures are so desig- hospital inpatient charge reflects the costs of a number of func-
nated, with more procedures being approved every year. The tions associated with early convalescence in the hospital, includ-
endorsement of cost-efficient delivery systems by employers ing nursing, diet, and housekeeping; some of these costs are also
and the reduction of employee benefits by insurers are associated with immediate postoperative care in the outpatient
encouraging employees (as both consumers and patients) to recovery area and consequently will be reflected in the outpatient
be more cost-conscious. When patients are involved in the facility’s bill as well.The comparison may also be misleading inso-
actual cost of medical care, they tend to accept more efficient far as it ignores the inherent costs of outpatient surgery. In some
modes of delivery.This is even more likely to be the case when cases, medical personnel perform functions that do not appear on
they are at risk for the cost of care. the bill, such as follow-up care, care by phone, and home visits to
3. Physician concern.The emergence of the concept of managed evaluate recovery, as well as dressing changes and other services
care has exerted a strong influence on physician involvement similar to those provided by family members or friends.The costs
in ambulatory surgery. Concerns over the safety of major sur- associated with buying or renting durable medical equipment
gical procedures being performed in the outpatient setting (e.g., beds and commodes), preparing meals, and various other
have largely been removed, and surgeons are becoming more activities must also be taken into account. Clearly, there are
aggressive. Clearly, surgeons have benefited from the ease and avenues for development in the postoperative setting that might
convenience of outpatient surgery, especially with respect to raise expenses for outpatient surgery, but certainly not to the level
scheduling and protection from cancellations due to emer- of an inpatient stay.
gencies. Equally clearly, however, they will now have to be It is to be hoped that new Medicare and state regulations man-
more vigilant, given that outpatient surgical facilities tend to dating evaluation of quality of care in outpatient surgical facilities
be less well monitored and supervised. will provide definitive statistics for determining actual cost sav-
4. Patient awareness of quality assurance. Today’s patients (or ings. Cost data must be analyzed thoroughly if we are to assess
consumers) are more medically knowledgeable than ever the true contribution of outpatient surgery to cost containment.
before and more concerned with actively seeking out institu- As medicine advances into the 21st century, the changes in
tions that deliver high-quality and cost-efficient care. patient care have been and will continue to be nothing but spec-
Consumers are highly sensitive to the issue of quality, but their tacular, and one can only speculate what is to come. If this cen-
definitions of this attribute are not always based on the same tury brings about the same level of innovation that was experi-
criteria that surgeons use.To patients, quality is a combination enced in the 20th century, the future for surgery and the surgical
of effectiveness, safety, cost, convenience, and comfort. patient is bright, exciting, and to be greatly anticipated.
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ambulatory surgery. Surg Clin North Am tient surgery. Anesthesiology 91:42, 1999
96. Ambulatory surgery. ACS Reports. American
79:401, 1999 88. Tammela T: Postoperative urinary retention— College of Surgeons, Chicago, 1983
79. Beauregard L, Pomp A, Choiniere M: Severity why the patient cannot void. Scand J Urol 97. Green CR, Pandit SK: Preoperative preparation.
and impact of pain after day-surgery. Can J Nephrol 175:75, 1995 The Ambulatory Anesthesia Handbook. Twersky
Anaesth 45:304, 1998 89. Boulis NM, Mian FS, Rodriguez D, et al: RS, Ed. CV Mosby, St Louis, 1995, p 180
ELEMENTS OF CONTEMPORARY PRACTICE 6 Fast Track Surgery — 1
6 FAST TRACK SURGERY

Henrik Kehlet, M.D., Ph.D., F.A.C.S. (Hon.), and Douglas W.Wilmore, M.D., F.A.C.S.
Over the past several decades, surgery has undergone revolution- surgery must be based on a process of multidisciplinary collabo-
ary changes that are leading to improved treatments (involving ration that embraces not only the surgeon, the anesthesiologist,
lower risk and better outcome) for an increasing number of dis- the physiotherapist, and the surgical nurse but also the patient.
eases. These salutary developments are the result of more ad- More specifically, fast track surgery depends on the inclusion and
vanced anesthetic techniques, new methods of reducing the peri- integration of a number of key constituent elements (see below).
operative stress response, wider application of minimally invasive
techniques, improved understanding of perioperative pathophysi-
ology, and more sophisticated approaches to the prevention of Constituent Elements
postoperative organ dysfunction. Currently, many operations that
EDUCATION OF THE PATIENT
once necessitated hospitalization can readily be performed in the
outpatient setting; in addition, many major procedures are now To obtain the full advantages of a fast track surgical program,
associated with a significantly reduced duration of hospitalization it is essential to provide patients with information about their peri-
and a shorter convalescence. operative care in advance of the procedure. Such educational
Although these anesthetic and surgical developments are the efforts often serve to reduce patients’ level of anxiety and need for
result of basic scientific and clinical research, they have also been pain relief, thereby providing a rational basis for collaboration
influenced by governmental and managed care policies aimed at with health care personnel, a process that is crucial for enhancing
encouraging more cost-effective treatments. Such extraclinical postoperative rehabilitation.1-3 Patients can supplement the infor-
influences, coupled with new clinical developments, have resulted mation they receive directly from health care providers by access-
in novel approaches designed to enhance the cost-effectiveness of ing reference sources such as www.facs.org/public_info/operation/
health care, such as so-called fast track surgery, critical pathways, aboutbroch.html, a collection of electronic brochures on specific
and various types of clinical guidelines. To understand the true clinical procedures that is provided by the American College of
potential value of such approaches, it is essential to recognize that Surgeons.
their aim is not merely to ensure that fewer health care dollars are
OPTIMIZATION OF ANESTHESIA
spent but, more important, to ensure that better and more effi-
cient health care is delivered. Although these novel approaches The introduction of rapid-onset, short-acting volatile anesthet-
may reduce cost, their primary purpose is to improve surgical ics (e.g., desflurane and sevoflurane), opioids (e.g., remifentanil),
management by reducing complications and providing better out- and muscle relaxants has enabled earlier recovery from anesthesia
comes. In what follows, we outline the basic concept, primary and thereby facilitated ambulatory and fast track surgery.4 Al-
components, and current results of fast track surgery, which is a though use of these newer general anesthetic agents has resulted
comprehensive approach to the elective surgical patient that is in quicker recovery of vital organ function after minor surgical
designed to accelerate recovery, reduce morbidity, and shorten procedures, it has not been shown to decrease stress responses or
convalescence. mitigate organ dysfunction after major procedures.
Regional anesthetic techniques (e.g., peripheral nerve blocks
and spinal or epidural analgesia), on the other hand, have several
Basic Concept advantages in addition to providing anesthesia. Such advantages
Fast track surgery involves a coordinated effort to combine (1) include improved pulmonary function, decreased cardiovascular
preoperative patient education; (2) newer anesthetic, analgesic, demands, reduced ileus, and more effective pain relief. Neural
and surgical techniques whose aim is to reduce surgical stress blockade is the most effective technique for providing postopera-
responses, pain, and discomfort; and (3) aggressive postoperative tive pain relief, and it has been shown to reduce endocrine and
rehabilitation, including early enteral nutrition and ambulation. It metabolic responses to surgery [see 1:5 Postoperative Pain]. For a
also includes an up-to-date approach to general principles of pronounced reduction in perioperative stress after a major opera-
postoperative care (e.g., use of tubes, drains, and catheters; mon- tion, continuous epidural analgesia for 24 to 72 hours is neces-
itoring; and general rehabilitation) that takes into account the sary.5,6 A meta-analysis of randomized trials evaluating regional
revisions to traditional practice mandated by current scientific anesthesia (primarily involving patients undergoing operations on
findings. It is believed that by these means, fast track surgery can the lower body) found that morbidity was 30% lower with region-
shorten the time required for full recovery, reduce the need for al anesthesia than with general anesthesia.7 However, the effect of
hospitalization and convalescence, and lower the incidence of continuous epidural analgesia on outcome after major abdominal
generalized morbidity related to pulmonary, cardiac, thromboem- or thoracic procedures has been questioned in the past several
bolic, and infectious complications.1-3 years. In three large randomized trials,8-10 no beneficial effect on
For an accelerated recovery program of this type to succeed, overall morbidity could be demonstrated, except for a slight
proper organization is essential. In general terms, fast track improvement in pulmonary outcome, and the duration of hospi-
talization was not reduced. It should be remembered, however, tions for hip fracture received either low-dose GH (20 mg/kg/day)
that in these studies, either an epidural opioid regimen or a pre- or placebo.28 Overall, those in the GH group were able to return
dominantly epidural opioid regimen was employed and that the to their prefracture living situation earlier than those in the place-
perioperative care regimens either were not described or were not bo group. A 1999 study reported increased mortality when GH
revised according to current scientific data regarding the use of was administered to ICU patients,29 but a 2001 meta-analysis
nasogastric tubes, early oral feeding, mobilization, and other care failed to confirm this observation.30 More work is necessary
parameters.3 We believe, therefore, that for further assessment of before definitive conclusions can be formed in this regard.
the role of continuous epidural local analgesic regimens that Postoperative insulin resistance is an important metabolic fac-
include local anesthetics in improving outcome, an integrated tor for catabolism. There is evidence to suggest that preoperative
approach within the context of fast track surgery is required.6 oral or intravenous carbohydrate feeding may reduce postopera-
Perioperative measures should also be taken to preserve intra- tive insulin resistance.31 Whether this approach yields clinical
operative normothermia. Hypothermia may lead to an augment- benefits in terms of improved recovery remains to be deter-
ed stress response during rewarming, impaired coagulation and mined,31,32 but its simplicity, its clear pathophysiologic rationale,
leukocyte function, and increased cardiovascular demands. and its low cost make it a potentially attractive option.
Preservation of intraoperative and early postoperative normother-
CONTROL OF NAUSEA, VOMITING, AND ILEUS
mia has been shown to decrease surgical site infection, intraoper-
ative blood loss, postoperative cardiac morbidity, and overall The ability to resume a normal diet after a surgical procedure
catabolism.11 (whether minor or major) is essential to the success of fast track
surgery. To this end, postoperative nausea, vomiting, and ileus
REDUCTION OF SURGICAL STRESS
must be controlled. Principles for rational prophylaxis of nausea
The neuroendocrine and inflammatory stress responses to and vomiting have been developed on the basis of systematic
surgery increase demands on various organs, and this increased reviews33: for example, 5-HT3 receptor antagonists, droperidol,
demand is thought to contribute to the development of postop- and dexamethasone have been shown to be effective in this
erative organ system complications. At present, the most impor- regard, whereas metoclopramide is ineffective.There is some rea-
tant of the techniques used to reduce the surgical stress response son to think that multimodal antiemetic combinations may be
are regional anesthesia, minimally invasive surgery, and pharma- superior to single antiemetic agents; unfortunately, the data cur-
cologic intervention (e.g., with steroids, beta blockers, or anabol- rently available on combination regimens are relatively sparse. In
ic agents).12 addition, analgesic regimens in which opioids are cut back or
Neural blockade with local anesthetics reduces endocrine and eliminated have been shown to decrease postoperative nausea
metabolic (specifically, catabolic) activation and sympathetic stim- and vomiting.
ulation, thereby decreasing the demands placed on organs and Paralytic ileus remains a significant cause of delayed recovery
reducing loss of muscle tissue; however, regional anesthetic tech- from surgery and contributes substantially to postoperative dis-
niques have no relevant effect on inflammatory responses.5,6 comfort and pain. Of the various techniques available for manag-
Minimally invasive surgical techniques clearly decrease pain ing ileus,34,35 continuous epidural analgesia with local anesthetics
and lessen inflammatory responses,13-15 but they appear to have is the most effective, besides providing excellent pain relief. Now
relatively little, if any, effect on endocrine and metabolic responses. that cisapride has been taken off the market, no effective anti-
Pharmacologic intervention with a single dose of a glucocorti- ileus drugs are available. In a 2001 study, however, a peripheral-
coid (usually dexamethasone, 8 mg) given before a minor proce- ly acting mu opioid receptor antagonist significantly reduced
dure has led to reduced nausea, vomiting, and pain, as well as to nausea, vomiting, and ileus after abdominal procedures, without
decreased inflammatory responses (interleukin-6), with no ob- reducing analgesia.36 If further studies confirm these findings, use
served side effects.16,17 This intervention may facilitate recovery of peripherally acting opioid antagonists may become a popular
from minor (i.e., ambulatory) procedures18; however, the data and effective way of improving postoperative recovery; this treat-
from major procedures are inconclusive.The use of perioperative ment is simple and apparently has no major side effects.
beta blockade to reduce sympathetic stimulation and thereby
ADEQUATE TREATMENT OF POSTOPERATIVE PAIN
attenuate cardiovascular demands has been shown to reduce car-
diac morbidity,19 as well as to reduce catabolism in burn patients Despite ongoing development and documentation of effective
[see Elements of Contemporary Practice:2 Risk Stratification, Pre- postoperative analgesic regimens—such as continuous epidural
operative Testing, and Operative Planning].20,21 Perioperative beta analgesia in major operations, patient-controlled analgesia
blockade may therefore become an important component of efforts (PCA), and multimodal (balanced) analgesia that includes non-
to facilitate recovery in fast track surgical programs. steroidal anti-inflammatory drugs as well as stronger agents37-39
For patients whose nutritional status is normal, oral feeding ad [see 1:5 Postoperative Pain]—postoperative pain still is too often
libitum is appropriate in the postoperative period. For patients inadequately treated. Improved pain relief, facilitated by an acute
who are elderly or nutritionally depleted, nutritional supplementa- pain service,40 is a central component of any fast track surgery
tion, administration of an anabolic agent (e.g., oxandrolone or an- program and is a prerequisite for optimal mobilization and oral
other anabolic steroid,22-24 insulin,25 or growth hormone [GH]26,27) nutrition, as well as a valuable aid in reducing surgical stress
to enhance deposition of lean tissue, or both may be beneficial. responses.37
Most of the studies addressing the use of anabolic agents have
APPROPRIATE USE OF TUBES, DRAINS, AND CATHETERS
focused on critically ill catabolic patients, in whom both indirect
effects (e.g., improved nitrogen balance26) and direct effects (e.g., There is substantial support in the literature for the idea that
improved wound healing and decreased length of stay with GH in nasogastric tubes should not be used routinely in patients undergo-
burned children27 and decreased mortality with insulin in critical- ing elective abdominal surgery.1,2 Randomized trials indicated that
ly ill patients25) on outcome have been demonstrated. In a study drains offered little benefit after cholecystectomy, joint replace-
published in 2000, a group of elderly patients undergoing opera- ments, colon resection, thyroidectomy, radical hysterectomy, or
pancreatic resection1,3,41 but that they might limit seroma forma- or a slightly modified fast track care program. On the whole, the
tion after mastectomy.1,3 Such postmastectomy drainage does not preliminary results from these studies are very positive: fast track
necessarily impede hospital discharge, and the patient generally surgery is associated with shorter hospital stays, reduced or at
may be treated on an outpatient basis. Urinary catheterization has least comparable morbidities, and low readmission rates, with no
been routinely performed after many operations, but scientific doc- apparent decrease in safety.
umentation of the requirement for this measure is often lacking. In Studies of fast track surgery in which organ function was
general, catheterization beyond 24 hours is not recommended with assessed postoperatively and compared with organ function after
colorectal procedures, except with the lowest rectal procedures, for traditional care found fast track surgery to be associated with ear-
which 3 to 4 days of catheterization may be indicated.3 lier ambulation,43,44 superior postoperative muscle function,44
Although tubes, drains, and catheters may lead to morbidity improved oral nutritional intake,45 better preservation of lean body
only when used for extended periods, they do tend to hinder mass,43,45 reduced postoperative impairment of pulmonary func-
mobilization, and they can raise a psychological barrier to the pation,43 earlier recovery of GI motility,46 and mitigation of the de-
tient’s active participation in postoperative rehabilitation. There- crease in exercise capacity and impairment of cardiovascular
fore, such devices should be used not routinely but selectively, in response to exercise that are usually expected after an operation.43
accordance with the available scientific documentation. The few randomized trials performed to date (mostly involving
patients undergoing cholecystectomy, colonic resection, or mastec-
NURSING CARE, NUTRITION, AND MOBILIZATION
tomy) reported that fast track programs increased or at least main-
Postoperative nursing care should include psychological sup- tained patient satisfaction while achieving major cost reductions.
port for early rehabilitation, with a particular focus on encourag-
ing the patient to resume a normal diet and become ambulatory
as soon as possible. Early resumption of an oral diet is essential for Future Developments
self-care; furthermore, according to a 2001 meta-analysis of con- The initial promising results from the fast track surgical pro-
trolled trials, it may reduce infectious complications and shorten grams studied suggest that such programs can achieve major care
hospital stay after abdominal procedures, without increasing the improvements in terms of reducing postoperative stay. At present,
risk of anastomotic dehiscence.42 In addition, early resumption of however, sufficient scientific documentation is lacking for many
enteral feeding may reduce catabolism and may be facilitated by commonly performed major operations. Thus, there is a need for
the methods used to reduce postoperative nausea, vomiting, and additional data—in particular, data on the potential positive
ileus (see above). effects of fast track surgery on postoperative morbidity. The nec-
Postoperative bed rest is undesirable because it increases mus- essary data would probably be best obtained through multicenter
cle loss, decreases strength, impairs pulmonary function and tis- trials using identical protocols. Randomized trials within the same
sue oxygenation, and predisposes to venous stasis and throm- unit that allocate some patients to suboptimal care recommenda-
boembolism.3 Accordingly, every effort should be made to enforce tions for pain relief, mobilization, and nutrition would be difficult
postoperative mobilization; adequate pain relief is a key adjuvant to perform, if not unethical, though a few such reports have been
measure in this regard. published on colon surgery patients.44,47
Organization is essential for good postoperative nursing care: a As yet, it has not been conclusively demonstrated that reducing
prescheduled care map should be drawn up, with goals for reha- the duration of hospitalization necessarily reduces morbidity,48
bilitation listed for each day. though data from studies addressing colonic and vascular proce-
dures suggest that nonsurgical (i.e., cardiopulmonary and throm-
DISCHARGE PLANNING
boembolic) morbidity may be reduced and overall postoperative
Given that a primary result of fast track surgery is reduced recovery (assessed in terms of exercise performance and muscle
length of hospitalization, discharge planning must be a major con- power) enhanced. More study is required in this area. Future tri-
sideration in the preoperative patient information program, as als should also focus on identifying any factors that might be lim-
well as during hospitalization. Careful, detailed discharge plan- iting even more aggressive early recovery efforts, so that more
ning is essential for reducing readmissions and increasing patient effective fast track programs can be designed. Finally, studies are
safety and satisfaction. The discharge plan should include (1) needed to identify potential high-risk patient groups for whom fast
detailed information on the expected time course of recovery, (2) track surgery may not be appropriate or who may need to be hos-
recommendations for convalescence, and (3) encouragement of pitalized for slightly longer periods to optimize organ function.47
enteral intake and mobilization. For patients with a significant There has been considerable interest in whether the use of crit-
degree of postoperative disability, various acute care facilities are ical pathways improves postoperative care. Preliminary studies
available after hospital discharge. It should be kept in mind, how- involving coronary artery bypass grafting, total knee replacement,
ever, that the integrated care approach fundamental to fast track colectomy, thoracic procedures, and hysterectomy suggested that
surgery is specifically intended as a way of limiting or preventing critical pathways may reduce length of hospital stay, but the
such disability, thereby reducing patients’ need for and depen- reduction is no greater than can be observed in neighboring hos-
dence on postdischarge care facilities. pitals that do not use critical pathways.49 Thus, the initial enthusi-
asm for critical pathways notwithstanding, conclusive evidence
that they have a beneficial effect on postoperative care is still lack-
Reported Results ing.The continuously decreasing length of stay noted in hospitals
Ongoing efforts to formulate multimodal strategies aimed at without fast track programs may be partly attributable to the
improving postoperative outcome have led to the development of intense competition within the health care system, which can lead
a variety of fast track surgical programs [see Table 1]. Most of the to changes in care principles even without the formal adoption of
studies published to date have been descriptive ones reporting critical pathways or similar systems.49
consecutive patient series from single centers, the findings from All of the studies on the economic implications of fast track sur-
which have often been confirmed by other groups using the same gical programs and critical pathways have documented substantial
Table 1 Results from Selected Fast Track Surgical Programs
Type of Operation Postoperative Hospital Stay Comments and Other Findings
Abdominal procedures
Inguinal hernia repair59-61 1.5–6 hr Large consecutive series using local infiltration anesthesia in > 95%, with one
series59 using unmonitored anesthesia; documented low morbidity, with no urinary
retention; patient satisfaction ~90%, cost reduction > $250 with local anesthesia
Cholecystectomy (laparoscopic,62-67 > 80% discharge on same day Large consecutive series, with documented safety and patient satisfaction > 80%;
mini-incision68) cost reduction of $750/patient in randomized study64; recovery of organ functions
within 2–3 days, with <1 wk convalescence67; similar results with mini-incision in
consecutive series68
Fundoplication69,70 > 90% < 23 hr Large consecutive series with documented safety70
Open43,44,46,47,56,71-76 and laparo- 2–4 days Consecutive series including high-risk patients; reduced cardiopulmonary morbidity,
scopic72,77-79 colorectal procedures readmission rates 0%–15%; no documented advantages of laparoscopy-assisted
colonic resection, though costs may be reduced72; ileus reduced to < 48 hr in
> 90% of patients,46,56 with improved muscle and pulmonary function in fast track
patients and better preservation of postoperative body composition43; one random-
ized study showed similar morbidity, readmissions, and satisfaction with fast track
versus traditional care47
Complex pelvic-colorectal 3–6 days Short stay80 (~4–6 days) even with additional stoma; low readmission rate (7%)
procedures80,81
Rectal prolapse82 80% < 24 hr Consecutive series (N = 63) with Altemeier repair; 5% readmission rate (nonserious
indications)
Pancreaticoduodenectomy,83,84 — Hospital stay decreased by implementation of clinical pathway
complex biliary tract procedures85
Mastectomy86-90 90% < 1 day Large cumulative series; documented safety and major cost reduction with high
patient satisfaction; no increased morbidity with fast track, but less wound pain and
improved arm movement and no increase in risk of psychosocial complications
Vascular procedures
Carotid endarterectomy91-94 90% < 1 day Surgery done with local anesthesia; specialized nurses and wards
Lower-extremity arterial bypass95 2–3 days Large series (N = 130); documented safety
Abdominal aortic aneurysmectomy96,97 ~3 days Preliminary studies (N = 5096 and N = 7797); documented early recovery and safety;
one study with epidural analgesia,97 one without96
Urologic procedures
Radical prostatectomy98 ~75% 1 day Large consecutive series (N = 252); documented safety and patient satisfaction
Laparoscopic adrenalectomy99-101 < 1 day Small series; safety and low morbidity suggested
Cystectomy102,103 7 days Improved mobilization, bowel function, and sleep recovery with fast track surgery102;
low mortality; ileus a problem102,103
Laparoscopic donor nephrectomy104 < 1 day Preliminary study (N = 41); low readmission rate (2%)
Open donor nephrectomy105 2 days —
Pulmonary procedures106-110 ~1 day in some series,106,107 Shortest stay with fast track protocol including revision of drainage principles106,107;
~4–5 days in others safety with very early discharge suggested
Other procedures
Craniotomy111 ~40% < 24 hr Large consecutive series (N = 241) including tumor surgery; local anesthesia used;
low readmission rate; safety suggested
Parathyroid procedures112 ~90% ambulatory Selected consecutive series (N = 100); regional anesthesia and intraoperative
adenoma localization employed; documented safety
Vaginal procedures113 ~1 day Consecutive series (N = 108); surgery done with local anesthesia
cost savings. It should, however, be borne in mind that the last thereby achieving additional cost savings. As noted, the large-scale
portion of a hospital stay is much less expensive than the initial data with detailed patient description and stratification that are
portion; thus, the cost savings in this area may turn out to be needed to clarify the improvements achieved by fast track surgery
smaller than they would at first appear.50-52 This cavil should not are, unfortunately, lacking at present, but so far, all indications are
hinder further development and documentation of fast track that postoperative morbidity is comparable or reduced.
surgery, because inherent in the concept is the idea that revision A commonly expressed concern is that fast track surgery might
and optimization of perioperative care may also reduce morbidity, increase the burden on general practitioners and other parts of the
nonhospital care system. The evidence currently available clearly addressed patient functional status after fast track colonic surgery
indicates that increased use of ambulatory surgery is safe and is suggested that muscle function, exercise capacity, and body compo-
associated with a very low readmission rate.53,54 After major proce- sition are better preserved with this approach than with traditional
dures such as colorectal surgery, however, readmissions are often care, in which surgical stress, insufficient nutrition, and prolonged
unpredictable, and the readmission rate is not significantly reduced immobilization typically lead to significant deterioration of organ
by keeping patients in the hospital for an additional 2 to 3 days.55,56 function. Accordingly, an optimal fast track surgery regimen should
Moreover, in some studies of patients who have undergone coro- aim at early recovery of organ function, not just early discharge.
nary bypass57 and hip replacement,58 earlier discharge and hospital In summary, the basic concept of fast track surgery, which
cost savings have been offset by increased use of postacute rehabil- could be expressed as multimodal control of perioperative patho-
itation services. Thus, any assessment of the costs associated with physiology, seems to be a highly promising approach to improving
fast track surgery should include the total period during which care surgical outcome. We believe that the principles and techniques
(including both hospital care and rehabilitation care) is delivered. embodied in this approach will eventually be integrated into the
Again, however, it should be emphasized that the basic concept care of all surgical patients. To this end, resources should be allo-
of fast track surgery implies control of perioperative pathophysiolo- cated for evaluation and documentation of the effects of fast track
gy with the aim of enhancing recovery and thereby reducing the surgery and related systems on cost, postoperative morbidity, safe-
need for postdischarge care.The relatively few published studies that ty, and overall patient well-being.
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ELEMENTS OF CONTEMPORARY PRACTICE 7 INFECTION CONTROL IN SURGICAL PRACTICE — 1
7 INFECTION CONTROL IN
SURGICAL PRACTICE
Vivian G. Loo, M.D., M.Sc., and A. Peter McLean, M.D., F.A.C.S.
Surgical procedures, by their very nature, interfere with the nor- example, the emergence of drug-resistant microorganisms, such as
mal protective skin barrier and expose the patient to microorgan- methicillin-resistant Staphylococcus aureus (MRSA), glycopeptide-
isms from both endogenous and exogenous sources. Infections intermediate S. aureus (GISA), multidrug-resistant Mycobacterium
resulting from this exposure may not be limited to the surgical site tuberculosis, and multidrug-resistant Enterococcus strains.13-16 Such
but may produce widespread systemic effects. Prevention of surgi- complications reemphasize the need to focus on infection control
cal site infections (SSIs) is therefore of primary concern to sur- as an essential component of preventive medicine.
geons and must be addressed in the planning of any operation. Besides the impact of morbidity and mortality on patients, there
Standards of control have been developed for every step of a sur- is the cost of treating nosocomial infections, which is a matter of
gical procedure to help reduce the impact of exposure to microor- concern for surgeons, hospital administrators, insurance compa-
ganisms.1-3 Traditional control measures include sterilization of nies, and government planners alike. Efforts to reduce the occur-
surgical equipment, disinfection of the skin, use of prophylactic rence of nosocomial infections are now a part of hospital cost-con-
antibiotics, and expeditious operation. trol management programs.17,18 The challenge to clinicians is how
The Study on the Efficacy of Nosocomial Infection Control to reduce cost while maintaining control over, and preventing
(SENIC), conducted in United States hospitals between 1976 and spread of, infection.
1986, showed that surgical patients were at increased risk for all
types of infection.The nosocomial, or hospital-acquired, infection
rate at that time was estimated to be 5.7 cases out of every 100 The Surgical Wound and Infection Control
hospital admissions.4 These infections included SSIs as well as Nosocomial infections are defined as infections acquired in the
bloodstream, urinary, and respiratory infections. Today, the hospital.There must be no evidence that the infection was present
increased use of minimally invasive surgical procedures and early or incubating at the time of hospital admission. Usually, an infec-
discharge from the hospital necessitates postdischarge surveil- tion that manifests 48 to 72 hours after admission is considered to
lance5 in addition to in-hospital surveillance for the tracking of be nosocomially acquired. An infection that is apparent on the day
nosocomial infections. With the reorganization of health care of admission is usually considered to be community acquired,
delivery programs, nosocomial infections will appear more fre- unless it is epidemiologically linked to a previous admission or to
quently in the community and should therefore be considered a an operative procedure at the time of admission.
part of any patient care assessment plan.
IDENTIFICATION OF RISK FACTORS
Care assessment programs designed to help minimize the risk
of nosocomial infections were first introduced in 1951 by the Joint The risk of development of an SSI depends on host factors,
Commission on Accreditation of Healthcare Organizations perioperative wound hygiene, and the duration of the surgical pro-
(JCAHO). Since then, as medical technology has changed, cedure. The risk of development of other nosocomial infections
JCAHO has redesigned the survey process. In its plan for infection depends on these and other factors, including length of the hospi-
control programs, JCAHO strongly recommends that the survey, tal stay and appropriate management of the hospital environment
documentation, and reporting of infections be made mandatory [see Activities of an Infection Control Program, below]. Identifi-
for the purpose of hospital accreditation.6 cation of host and operative risk factors can help determine the
Effective infection control and prevention requires an orga- potential for infection and point toward measures that might be
nized, hospital-wide program aimed at achieving specific objec- necessary for prevention and control.
tives. The program’s purpose should be to obtain relevant infor-
mation on the occurrence of nosocomial infections both in Host Risk Factors
patients and in employees. The data should be documented, ana- Host susceptibility to infection can be estimated according to the
lyzed, and communicated with a plan for corrective measures. following variables: older age, severity of disease, physical-status
Such surveillance activities, combined with education, form the classification (see below), prolonged preoperative hospitalization,
basis of an infection control program. morbid obesity, malnutrition, immunosuppressive therapy, smok-
Data relating to host factors are an integral part of infection ing, preoperative colonization with S. aureus, and coexistent infec-
data analysis. Documentation of host factors has made for a bet- tion at a remote body site.19
ter appreciation of the associated risks and has allowed compara- A scale dividing patients into five classes according to their
tive evaluation of infection rates. Development of new surgical physical status was introduced by the American Society of
equipment and technological advances have influenced the impact Anesthesiologists (ASA) in 1974 and tested for precision in
of certain risk factors, such as lengthy operation and prolonged 1978.20 The test results showed that the ASA scale is a workable
hospital stay. Clinical investigations have helped improve the system, although it lacks scientific definition [see Table 1].
understanding of host factors and have influenced other aspects of Significant differences in infection rates have been shown in
surgical practice.7-12 Excessive use of and reliance on antibiotics patients with different illnesses. In one prospective study, the
have led to problems not previously encountered in practice—for severity of underlying disease (rated as fatal, ultimately fatal, or
Table 1 American Society of Anesthesiologists and an operation lasting over T hours (where T represents the
Physical-Status Scale 75th percentile of distribution of the duration of the operative
procedure being performed, rounded to the nearest whole num-
Class 1 A normally healthy individual ber of hours).
Class 2 A patient with mild systemic disease
Class 3 A patient with severe systemic disease that is not Modified NNIS basic risk index for procedures using
incapacitating laparoscopes For cholecystectomy and colon surgery proce-
Class 4 A patient with incapacitating systemic disease that is a dures, the use of a laparoscope lowered the risk of SSI within each
constant threat to life
NNIS risk index category.27 Hence, for these procedures, when
Class 5 A moribund patient who is not expected to survive 24 hr
with or without operation the procedure is performed laparoscopically, the risk index should
be modified by subtracting 1 from the basic NNIS risk index
E Added for emergency procedures score. With this modification, the risk index has values of M (or
–1), 0, 1, 2, or 3. For appendectomy and gastric surgery, use of a
laparoscope affected SSI rates only when the NNIS basic risk
nonfatal) was shown to have predictive value for endemic noso- index was 0, thereby yielding five risk categories: 0–Yes, 0–No, 1,
comial infections: the nosocomial infection rate in patients with 2, and 3, whereYes or No refers to whether the procedure was per-
fatal diseases was 23.6%, compared with 2.1% in patients with formed with a laparoscope.27
nonfatal diseases.21
Operation-specific risk factors It is likely that operation-
Operative Risk Factors specific logistic regression models will increasingly be used to cal-
Several factors related to the operative procedure may be asso- culate risk. For example, in spinal fusion surgery, Richards and
ciated with the risk of development of an SSI [see 1:2 Prevention of colleagues identified diabetes mellitus, ASA score greater than 3,
Postoperative Infection].These include method of hair removal (and operation duration longer than 4 hours, and posterior surgical
likelihood of consequent skin injury), inappropriate use of antimi- approach as significant independent predictors of SSI.28 Other
crobial prophylaxis, duration of the operation, and wound classi- logistic regression models have been developed for craniotomy
fication. The influence of hair removal methods on SSI has been and cesarean section.29,30 These models should permit more pre-
examined by many investigators. Lower infection rates were cise risk adjustment.
reported with the use of depilatory agents and electric clippers
PREVENTIVE MEASURES
than with razors.7,8 Antimicrobial prophylaxis is used for all oper-
ations that involve entry into a hollow viscus. Antimicrobial pro- In any surgical practice, policies and procedures should be in
phylaxis is also indicated for clean operations in which an intra- place pertaining to the making of a surgical incision and the pre-
articular or intravascular prosthetic device will be inserted and for vention of infection.These policies and procedures should govern
any operation in which an SSI would have a high morbidity.19 A the following: (1) skin disinfection and hand-washing practices of
comprehensive study determined that there is considerable varia- the operating team, (2) preoperative preparation of the patient’s
tion in the timing of administration of prophylactic antibiotics, but skin (e.g., hair removal and use of antiseptics), (3) the use of pro-
that the administration within 2 hours before surgery reduces the phylactic antibiotics, (4) techniques for preparation of the opera-
risk of SSI.9 tive site, (5) management of the postoperative site if drains, dress-
Operative wounds are susceptible to varying levels of bacterial ings, or both are in place, (6) standards of behavior and practice
contamination, by which they are classified as clean, clean-contami- for the operating team (e.g., the use of gown, mask, and gloves),
nated, contaminated, or dirty.22 In most institutions, the responsibil- (7) special training of the operating team, and (8) sterilization and
ity for classifying the incision site is assigned to the operating room disinfection of instruments.
circulating nurse; one assessment suggests that the accuracy of deci-
sions made by this group is as high as 88%.23 Hand Hygiene
Although hand washing is considered the single most important
Composite Risk Indices measure for preventing nosocomial infections, poor compliance is
The Centers for Disease Control and Prevention (CDC) estab- frequent.31 Role modeling is important in positively influencing this
lished the National Nosocomial Infections Surveillance (NNIS) behavior. One study showed that a hand-washing educational pro-
system in 1970 to create a national database of nosocomial infec- gram contributed to a reduction in the rate of nosocomial infec-
tions.24 The NNIS system has been used to develop indices for tions.32 Good hand-washing habits can be encouraged by making
predicting the risk of nosocomial infection in a given patient. facilities (with sink, soap, and towel) visible and easily accessible in
patient care areas [see 1:2 Prevention of Postoperative Infection].
NNIS basic risk index NNIS developed a composite risk Cleansers used for hand hygiene include plain nonantimicro-
index composed of the following criteria: ASA score, wound class, bial soap, antimicrobial soaps, and waterless alcohol-based hand
and duration of surgery. Reporting on data collected from 44 antiseptics. Plain soaps have very little antimicrobial activity; they
United States hospitals between 1987 and 1990, NNIS demon- mainly remove dirt and transient flora.33 Compared with plain
strated that this risk index is a significantly better predictor for soaps, antimicrobial soaps achieve a greater log reduction in elim-
development of SSI than the traditional wound classification sys- inating transient flora and have the additional advantage of sus-
tem alone.25,26 The NNIS risk index is a useful method of risk tained activity against resident hand flora.33 Alcohol-based hand
adjustment for a wide variety of procedures. antiseptics have an excellent spectrum of antimicrobial activity
The NNIS risk index is scored as 0, 1, 2, or 3. A patient’s and rapid onset of action, dry rapidly, and do not require the use
score is determined by counting the number of risk factors pres- of water or towels.34 Therefore, they are recommended for routine
ent from among the following: an ASA score of 3, 4, or 5; a sur- decontamination of hands during patient care except when hands
gical wound that is classified as contaminated or dirty/infected; are visibly soiled. Emollients are often added to alcohol-based
Operating Room Environment

waterless hand antiseptics because of these antiseptics’ tendency
to cause drying of the skin.34 Environmental controls in the OR have been used to reduce the
risk of SSI [see 1:1 Preparation of the Operating Room]. The OR
Sterilization and Disinfection
should be maintained under positive pressure of at least 2.5 Pa in
Spaulding proposed in 1972 that the level of disinfection and relation to corridors and adjacent areas. In addition, there should
sterilization for surgical and other instruments be determined by be at least 15 air changes per hour, of which three should involve
classifying the instruments into three categories—critical, semi- fresh air.42
critical, and noncritical—according to the degree of infection risk
involved in their use.35 HEALTH STATUS OF THE HEALTH CARE TEAM
Critical items include objects or instruments that enter directly The health care team has a primary role in the prevention of
into the vascular system or sterile areas of the body. These items infection. Continued education and reindoctrination of policies
should be sterilized by steam under pressure, dry heat, ethylene are essential: the team must be kept well informed and up to date
oxide, or other approved methods. Flash sterilization is the process on concepts of infection control. Inadvertently, team members
by which surgical instruments are sterilized for immediate use may also be the source of, or the vector in, transmission of infec-
should an emergency situation arise (e.g., to sterilize an instru- tion. Nosocomial infection outbreaks with MRSA have been
ment that was accidentally dropped). This is usually achieved by traced to MRSA carriers among health care workers.43
leaving instruments unwrapped in a container and using a rapid Screening of personnel to identify carriers is undertaken only
steam cycle.36 Instruments must still be manually cleaned, decon- when an outbreak of nosocomial infection occurs that cannot
taminated, inspected, and properly arranged in the container be contained despite implementation of effective control mea-
before sterilization. Implantables should not be flash sterilized. sures and when a health care worker is epidemiologically linked
Flash sterilization is not intended to replace conventional steam to cases.
sterilization of surgical instruments or to reduce the need for ade- Protecting the health care team from infection is a constant
quate instrument inventory.36 concern. Preventive measures, such as immunizations and pre-
Semicritical items are those that come into contact with mucous employment medical examinations, should be undertaken at an
membranes or skin that is not intact (e.g., bronchoscopes and gas- employee health care center staffed by knowledgeable person-
troscopes). Scopes have the potential to cause infection if they are nel.44 Preventable infectious diseases, such as chickenpox and
improperly cleaned and disinfected. Transmission of infection has rubella, should be tightly controlled in hospitals that serve
been documented after endoscopic investigations, including infec- immunocompromised and obstetric patients. It is highly recom-
tion with Salmonella typhi37 and Helicobacter pylori.38 Such incidents mended that a record be maintained of an employee’s immu-
emphasize the need for sterilization of the endoscopic biopsy forceps. nizations. Knowledge of the employee’s health status on entry to
Semicritical items generally require high-level disinfection that kills the hospital helps ensure appropriate placement and good pre-
all microorganisms except bacterial spores.39 ventive care.
Glutaraldehyde 2% is a high-level disinfectant that has been When exposure to contagious infections is unavoidable, suscep-
used extensively in flexible endoscopy. Before disinfection, scopes tible personnel should be located, screened, and given prophylac-
should receive a thorough manual cleaning to eliminate gross tic treatment if necessary. Infection control personnel should
debris. To achieve high-level disinfection, the internal and external define the problem, establish a definition of contact, and take mea-
surfaces and channels should come into contact with the disinfect- sures to help reduce panic.
ing agent for a minimum of 20 minutes.39 Glutaraldehyde has cer-
tain disadvantages. In particular, it requires activation before use; Isolation Precautions
moreover, it is irritating to the skin, eyes, and nasal mucosa, and CDC guidelines have been developed to prevent the transmis-
thus, its use requires special ventilation or a ducted fume hood.39 sion of infections.45 These isolation guidelines promote two levels
An alternative to glutaraldehyde is orthophthaldehyde (OPA), a of isolation precautions: standard precautions and transmission-
newer agent approved by the Food and Drug Administration based precautions.
(FDA) for high-level disinfection. OPA is odorless and nonirritat-
ing and does not require activation before use.40 Standard precautions The standard precautions guide-
Noncritical items are those that come in contact with intact skin lines—which incorporate the main features of the older universal
(e.g., blood pressure cuffs). They require only washing or scrub- precautions and body substance isolation guidelines—were devel-
bing with a detergent and warm water or disinfection with an oped to reduce the risk of transmission of microorganisms for all
intermediate-level or low-level germicide for 10 minutes. patients regardless of their diagnosis.45-47 Standard precautions
The reuse of single-use medical devices has become a topic of apply to blood, all body fluids, secretions and excretions, and
interest because of the implied cost saving. The central concerns mucous membranes.
are the effectiveness of sterilization or disinfection according to
category of use, as well as maintenance of the essential mechani- Transmission-based precautions Transmission-based
cal features and the functional integrity of the item to be reused. precautions were developed for certain epidemiologically impor-
The FDA has issued regulations governing third-party and hospi- tant pathogens or clinical presentations. These precautions com-
tal reprocessors engaged in reprocessing single-use devices for prise three categories, based on the mode of transmission: air-
reuse.41 These regulations are available on the FDA’s web site borne precautions, droplet precautions, and contact precautions.45
(www.fda.gov/cdrh/comp/guidance/1168.pdf). Precautions may be combined for certain microorganisms or clin-
ical presentations (e.g., both contact and airborne precautions are
Hair Removal indicated for a patient with varicella).
An infection control program should have a hair-removal poli- Airborne precautions are designed to reduce transmission of
cy for preoperative skin preparation [see 1:2 Prevention of Post- microorganisms spread via droplets that have nuclei 5 µm in size
operative Infection]. or smaller, remain suspended in air for prolonged periods of time,
and have the capability of being dispersed widely.45 Airborne pre-

cautions include wearing an N95 respirator, placing the patient in Table 2—CDC Recommendations for
a single room that is under negative pressure of 2.5 Pa in relation Prevention of HIV and HBV Transmission
to adjacent areas, keeping the door closed, providing a minimum during Invasive Procedures48
of 6 to 12 air changes per hour, and exhausting room air outside
the building and away from intake ducts or through a high-effi- Health care workers with exudative lesions or weeping dermatitis
should cover any unprotected skin, or they should not provide
ciency particulate air (HEPA) filter if recirculated.45,48 Airborne patient care until the damaged skin has healed.
precautions are indicated for patients with suspected or confirmed Hands should be washed after every patient contact.
infectious pulmonary or laryngeal tuberculosis; measles; varicella; Health care workers should wear gloves when contact with blood
disseminated zoster; and Lassa, Ebola, Marburg, and other hem- or body substances is anticipated; double gloves should be
orrhagic fevers with pneumonia. Varicella, disseminated herpes used during operative procedures; hands should be washed
after gloves are removed.
zoster, and hemorrhagic fevers with pneumonia also call for con- Gowns, plastic aprons, or both should be worn when soiling of
tact precautions (see below). clothing is anticipated.
Droplet precautions are designed to reduce the risk of trans- Mask and protective eyewear or face shield should be worn if
mission of microorganisms spread via large-particle droplets that aerosolization or splattering of blood or body substances is
expected.
are greater than 5 µm in size, do not remain suspended in the air
Resuscitation devices should be used to minimize the need for
for prolonged periods, and usually travel 1 m or less.45 No spe- mouth-to-mouth resuscitation.
cial ventilation requirements are required to prevent droplet Disposable containers should be used to dispose of needles and
transmission. A single room is preferable, and the door may sharp Instruments.
remain open. Examples of patients for whom droplet precau- Avoid accidents and self-wounding with sharp instruments by fol-
lowing these measures:
tions are indicated are those with influenza, rubella, mumps, and • Do not recap needles.
meningitis caused by Haemophilus influenzae and Neisseria • Use needleless systems when possible.
meningitidis. • Use cautery and stapling devices when possible.
• Pass sharp instruments in metal tray during operative
Contact precautions are designed to reduce the risk of trans- procedures.
mission of microorganisms by direct or indirect contact. Direct In the case of an accidental spill of blood or body substance on
contact involves skin-to-skin contact resulting in physical transfer skin or mucous membranes, do the following:
• Rinse the site immediately and thoroughly under water.
of microorganisms.45 Indirect contact involves contact with a con- • Wash the site with soap and water.
taminated inanimate object that acts as an intermediary. Contact • Document the incident (i.e., report to Occupational Safety and
precautions are indicated for patients colonized or infected with Health Administration or to the Infection Control Service).
multidrug-resistant bacteria that the infection control program Blood specimens from all patients should be considered haz-
ardous at all times.
judges to be of special clinical and epidemiologic significance on
Prompt attention should be given to spills of blood or body
the basis of recommendations in the literature.45 substances, which should be cleaned with an appropriate
disinfectant.
Exposure to Bloodborne Pathogens
The risk of transmission of HIV and hepatitis B virus (HBV)
from patient to surgeon or from surgeon to patient has resulted in Hepatitis B virus For active surgeons and other members of
a series of recommendations governing contact with blood and the health care team, HBV infection continues to pose a major
body fluids.48 The risk of acquiring a bloodborne infection—such risk. Hepatitis B vaccination has proved safe and protective and is
as with HBV, hepatitis C virus (HCV), or HIV—depends on three highly recommended for all high-risk employees; it should be
factors: type of exposure to the bloodborne pathogen, prevalence made available through the employee health care center.
of infection in the population, and the rate of infection after expo- Despite the efficacy of the vaccine, many surgeons and other
sure to the bloodborne pathogen.49 Postexposure management personnel remain unimmunized and are at high risk for HBV
has been discussed in CDC guidelines (www.cdc.gov/mmwr/pdf/ infection.48 HBV is far more easily transmitted than HIV and
rr/rr5011.pdf).50 continues to have a greater impact on the morbidity and mor-
Protection of the face and hands during operation has become tality of health care personnel. An estimated 8,700 new cases of
important. A study of 8,502 operations found that the rate of hepatitis B are acquired occupationally by health care workers
direct blood exposure was 12.4%, whereas the rate of parenteral each year; 200 to 250 of these cases result in death.54 The risk
exposure via puncture wounds and cuts was 2.2%. Parenteral of seroconversion is at least 30% after a percutaneous exposure
blood contacts were twice as likely to occur among surgeons as to blood from a hepatitis B e antigen–seropositive source.50
among other OR personnel.51 These findings support the need for Given that a patient’s serostatus may be unknown, it is impor-
OR practice policies and the choice of appropriate protective gar- tant that health care workers follow standard precautions for all
ments for the OR staff. OR practice policy should give particular patients.
attention to methods of using sharp instruments and to ways of With HBV infection, as with HIV (see below), the approach to
reducing the frequency of percutaneous injuries: sharp instru- prevention and control is a two-way street—that is, protection
ments should be passed in a metal dish, cautery should be used, should be afforded to patients as well as health care personnel. In
and great care should be taken in wound closures. It is important addition to standard precautions, the CDC has developed recom-
that masks protect the operating team from aerosolized fluids. mendations for health care workers that are designed to prevent
Researchers have shown that for ideal protection, a mask should transmission of HBV and HIV from health care worker to patient
be fluid-capture efficient and air resistant.52 or from patient to health care worker during exposure-prone inva-
For invasive surgical procedures, double gloving has become sive procedures [see Table 2]. Cognizant of the CDC recommen-
routine. However, there are recognized differences among the dations, the American College of Surgeons has issued additional
gloves available. Latex allergy is an important issue; nonlatex alter- recommendations regarding the surgeon’s role in the prevention of
natives are available for those who are allergic.53 hepatitis transmission [see Table 3].54
Hepatitis C virus The average incidence of seroconversion (www.cdc.gov/mmwr/pdf/rr/rr4313.pdf). The following measures
after percutaneous exposure from an HCV-positive source is 1.8% should be considered:
(range, 0% to 7%).55-57 Mucous membrane exposure to blood
1. The use of risk assessments and development of a written
rarely results in transmission, and no transmission has been docu-
tuberculosis control protocol.
mented from exposure of intact or nonintact skin to blood.50,58
There is no recommended postexposure prophylaxis regimen for 2. Early identification and treatment of persons who have
HCV. The use of immunoglobulin has not been demonstrated to tuberculosis.
be protective.50 There are no antiviral medications recommended 3. Tuberculosis screening programs for health care workers.
for postexposure prophylaxis.50 4. Training and education.
5. Evaluation of tuberculosis infection control programs.61
Human immunodeficiency virus Exposure to blood and
body substances of patients who have AIDS or who are seroposi- Activities of an Infection Control Program
tive for HIV constitutes a health hazard to hospital employees.The
magnitude of the risk depends on the degree and method of expo- SURVEILLANCE
sure [see 8:21 Acquired Immunodeficiency Syndrome].
The presence of HIV infection in a patient is not always known. The cornerstone of an infection control program is surveillance.
Because the prevalence of HIV in the North American patient pop- This process depends on the verification, classification, analysis,
ulation is less than 1% (range, 0.09% to 0.89%), and because a care- reporting, and investigation of infection occurrences, with the
giver’s risk of seroconversion after needlestick injury is likewise less intent of generating or correcting policies and procedures. Five
than 1%, the CDC recommends taking standard precautions [see surveillance methods can be applied62,63:
8:20 Viral Infection] and following in all patients the same guidelines 1. Total, or hospital-wide, surveillance-collection of compre-
for invasive procedures that one would use in cases of known HBV- hensive data on all infections in the facility, with the aim of
infected patients [see Table 2].48 Infection control personnel have in- correcting problems as they arise. This is labor intensive.
troduced realistic control measures and educational programs to 2. Surveillance by objective, or targeted surveillance, in which
help alleviate fears that health care workers might have about com- a specific goal is set for reducing certain types of infection.
ing in contact with patients infected with HIV. This concept is priority-directed and can be further subdi-
Exposure to Tuberculosis vided into two distinct activities:
a. The setting of outcome objectives, in which the objectives
In studies of health care workers, positive results on tuberculin for the month or year are established and all efforts
skin testing have ranged from 0.11% to 10%.59,60 Health care applied to achieve a desired rate of infection. As with the
workers who are immunocompromised are at high risk for devel- hospital-wide approach, a short-term plan would be made
opment of disease postexposure.59 to monitor, record, and measure results and provide feed-
The CDC recommendation for tuberculosis prevention places back on the data.
emphasis on a hierarchy of control measures, including adminis- b. The setting of process objectives, which incorporates the
trative engineering controls and personal respiratory protection patient care practices of doctors and nurses as they relate to
outcome (e.g., wound infections and their control).
3. Periodic surveillance—intensive surveillance of infections
Table 3 ACS Recommendations for and patient-care practices by unit or by service at different
times of the year.
Preventing Transmission of Hepatitis54 4. Prevalence survey—the counting and analysis of all active
Surgeons should continue to utilize the highest standards of infec- infections during a specified time period.This permits iden-
tion control, involving the most effective known sterile barriers, uni- tification of nosocomial infection trends and problem areas.
versal precautions, and scientifically accepted measures to pre-
vent blood exposure during every operation. This practice should 5. Outbreak surveillance—the identification and control of out-
extend to all sites where surgical care is rendered and should breaks of infection. Identification can be made on the basis
include safe handling practices for needles and sharp instru- of outbreak thresholds if baseline bacterial isolate rates are
ments.
available and outbreak thresholds can be developed. Prob-
Surgeons have the same ethical obligations to render care to
patients with hepatitis as they have to render care to other lems are evaluated only when the number of isolates of a par-
patients. ticular bacterial species exceeds outbreak thresholds.
Surgeons with natural or acquired antibodies to HBV are protected
from acquiring HBV from patients and cannot transmit the disease Surveillance techniques include the practice of direct patient
to patients. All surgeons and other members of the health care observation7 and indirect observation by review of microbiology
team should know their HBV immune status and become immu-
nized as early as possible in their medical career. reports, nursing Kardex, or the medical record to obtain data on
Surgeons without evidence of immunity to HBV who perform proce- nosocomial infections. The sensitivity of case finding by microbi-
dures should know their HBsAg status and, if this is positive, ology reports was found to be 33% to 65%; by Kardex, 85%; and
should also know their HBeAg status. In both instances, expert
medical advice should be obtained and all appropriate measures
by total chart review, 90%.62 These methods may be used either
taken to prevent disease transmission to patients. Medical advice separately or in combination to obtain data on clinical outcomes.
should be rendered by an expert panel composed and convened One use of surveillance data is to generate information for indi-
to fully protect practitioner confidentiality. The HBeAg-positive sur-
geon and the panel should discuss and agree on a strategy for vidual surgeons, service chiefs, and nursing personnel as a
protecting patients at risk for disease transmission. reminder of their progress in keeping infections and diseases
On the basis of current information, surgeons infected with HCV under control.This technique was used by Cruse in 1980 to show
have no reason to alter their practice but should seek expert
medical advice and appropriate treatment to prevent chronic liver
a progressive decrease in infection rates of clean surgical wounds
disease. to less than 1% over 10 years.8 In other settings, endemic rates of
bloodstream, respiratory, and urinary tract infections were cor-
rected and reduced by routine monitoring and reporting to med-

ical and nursing staff.21
Table 4 Surgical Site Infections (SSIs)65
The increasing practice of same-day or short-stay surgical pro-
cedures has led to the need for postdischarge surveillance. This Superficial SSIs
may be done by direct observation in a follow-up clinic, by survey- Skin
ing patients through the mail or over the telephone, by reviewing Deep incisional SSIs
medical records, or by mailing questionnaires directly to surgeons. Fascia
Muscle layers
The original CDC recommendation of 30 days for follow-up was
Organ or space SSIs
used by one hospital to randomly screen post–joint arthroplasty
Body organs
patients by telephone.This screening identified an infection rate of Body spaces
7.5%, compared with 2% for hospitalized orthopedic patients.64
Results from another medical center suggested that 90% of cases
would be captured in a 21-day postoperative follow-up program.5 Data Interpretation
Infections that occur after discharge are more likely with clean oper-
The predictive value of data is deemed more useful when it is ap-
ations, operations of short duration, and operations in obese pa-
plied to specific situations. According to CDC experts, the scoring for
tients and in nonalcoholic patients. The use of prosthetic materi-
infections depends on specified, related denominators to interpret
als for implants requires extending the follow-up period to 1 year.
the data, especially when there is to be interhospital comparison.67
Definition of Surgical Site Infections
Data Analysis
The CDC defines an incisional SSI as an infection that occurs The original practice of presenting overall hospital-wide crude
at the incision site within 30 days after surgery or within 1 year if rates provided little means for adjustment of variables (e.g., risk
a prosthetic implant is in place. Infection is characterized by red- related to the patient or to the operation).The following three for-
ness, swelling, or heat with tenderness, pain, or dehiscence at the mulas, however, are said to offer more precision than traditional
incision site and by purulent drainage. Other indicators of infec- methods67:
tion include fever, deliberate opening of the wound, culture-posi-
tive drainage, and a physician’s diagnosis of infection with pre- (Number of nosocomial infections/Service operations) × 100
scription of antibiotics. To encourage a uniform approach among [Number of site-specific nosocomial infections/Specific
data collectors, the CDC has suggested three categories of SSIs, operations (e.g., number of inguinal hernias)] × 100
with definitions for each category [see Table 4].65 The category of
organ or space SSI was included to cover any part of the anatomy [Number of nosocomial infections/Hospital admissions
(i.e., organs or spaces) other than the incision that might have (patient-days)] × 1,000
been opened or manipulated during the operative procedure.This Data on infections of the urinary tract, respiratory system, and
category would include, for example, arterial and venous infec- circulatory system resulting from exposure to devices such as
tions, endometritis, disk space infections, and mediastinitis.65 Foley catheters, ventilators, and intravascular lines can be illus-
There should be collaboration between the physician or nurse trated as device-associated risks according to site, as follows:
and the infection control practitioner to establish the presence of
(Number of device-associated infections of a site/
an SSI. The practitioner should complete the surveillance with a Number of device days) × 1,000
chart review and document the incident in a computer database
program for later analysis.The data must be systematically record- Reporting
ed; many commercial computer programs are available for this Infection notification to surgeons has been shown by Cruse and
purpose. One group reported that their experience with the Foord to have a positive influence on clean-wound infection rates.7,8
Health Evaluation through Logical Processing system was useful In a medical setting, Britt and colleagues also reported a reduction
for identifying patients at high risk for nosocomial infections.66 in endemic nosocomial infection rates for urinary tract infections,
from 3.7% to 1.3%, and for respiratory tract infections, from 4.0%
Verification of Infection
to 1.6%, simply by keeping medical personnel aware of the rates.21
A complete assessment should include clinical evaluation of
commonly recognized sites (e.g., wound, respiratory system, uri- Outbreak Investigation
nary tract, and intravenous access sites) for evidence of infection, There are 10 essential components to an outbreak investigation:
especially when no obvious infection is seen at the surgical
1. Verify the diagnosis and confirm that an outbreak exists. This
site. Microbiologic evaluation should identify the microorgan-
is an important step, because other factors may account for an
ism. Such evaluation, however, depends on an adequate speci- apparent increase in infections. These factors may include a
men for a Gram stain and culture. For epidemiologic reasons, reporting artifact resulting from a change in surveillance
DNA fingerprinting may be required, especially for outbreak methodology, a laboratory error or change in laboratory meth-
investigation. odology, or an increase in the denominator of the formula
A system of internal auditing should alert the infection control used for data analysis (if this increase is proportionate to the
service to multiresistant microorganisms—for example, to the rise in the numerator, the infection rate has not changed).
presence of MRSA or vancomycin-resistant Enterococcus (VRE) in 2. Formulate a case definition to guide the search for potential
a patient. Differentiation between infection and colonization is patients with disease.
important for the decision of how to treat. Regardless of whether 3. Draw an epidemic curve that plots cases of the disease against
infection or colonization is identified, verification of MRSA or time of onset of illness. This curve compares the number of
VRE should generate a discussion on control measures. cases during the epidemic period with the baseline. In addi-
tion, the epidemic curve helps to determine the probable incu- acquisition include length of hospital stay, liver transplantation,
bation period and how the disease is being transmitted (i.e., a presence of feeding tubes, dialysis, and exposure to cephalo-
common source versus person to person). sporins.78 Contact precautions are indicated for patients infected
4. Review the charts of case patients to determine demographics or colonized with VRE.79
and exposures to staff, medications, therapeutic modalities, Strategies to prevent and control the emergence and spread of
and other variables of importance. antimicrobial-resistant microorganisms have been developed.
5. Perform a line listing of case patients to determine whether These include optimal use of antimicrobial prophylaxis for surgi-
there is any common exposure. cal procedures; optimizing choice and duration of empirical ther-
6. Calculate the infection rate. The numerator is the number of apy; improving antimicrobial prescribing patterns by physicians;
infected patients and the denominator is the number of pa- monitoring and providing feedback regarding antibiotic resis-
tients at risk. tance; formulating and using practice guidelines for antibiotic
7. Formulate a tentative hypothesis to explain the reservoir and usage; developing a system to detect and report trends in antimi-
the mode of transmission. A review of the literature on similar crobial resistance; ensuring that caregivers respond rapidly to the
outbreaks may be necessary. detection of antimicrobial resistance in individual patients; incor-
8. Test the hypothesis, using a case-control study, cohort study, porating the importance of controlling antimicrobial resistance
prospective intervention study, or microbiologic study. A case- into the institutional mission and climate; increasing compliance
control study is usually used, because it is less labor intensive. with basic infection control policies and procedures; and develop-
For a case-control study, control subjects should be selected ing a plan for identifying, transferring, discharging, and readmit-
from an uninfected surgical population of patients who were ting patients colonized or infected with specific antimicrobial-
hospitalized at the same time as those identified during the epi- resistant microorganisms.80
demic period and matched for age, gender, service operation,
operation date, and health status (ASA score). Two or three Severe Acute Respiratory Syndrome
control patients are usually selected for every case patient.The The severe acute respiratory syndrome (SARS) first emerged in
cases and controls are then compared with respect to possible Guangdong Province, China, in November 2002. SARS is caused
exposures that may increase the risk of disease. Patient, per- by a novel coronavirus (SARS-CoV) that may have originated from
sonnel, and environmental microbiologic isolates (if any) an animal reservoir.81 It is characterized by fever, chills, cough, dys-
should be kept for fingerprinting (e.g., pulsed-field gel electro- pnea, and diarrhea and radiologic findings suggestive of atypical
pheresis, random amplified polymorphic DNA polymerase pneumonia.82 As of August 7, 2003, a total of 8,422 probable cases,
chain reaction). with 916 deaths (11%), had been reported from 29 countries.83
9. Institute infection control measures. This may be done at any The incubation period is estimated to be 10 days, and patients
time during the investigation.The control measures should be appear to be most infectious during the second week of illness.83
reviewed after institution to determine their efficacy and the Available evidence suggests that SARS-CoV is spread through con-
possible need for changing them. tact, in droplets, and possibly by airborne transmission.83 Accord-
10. Report the incident to the infection control committee and, at ingly, health care workers must adhere to contact, droplet, and air-
the completion of the investigation, submit a report. The borne precautions when caring for SARS patients. Included in such
administrators, physicians, and nurses involved should be precautions are the use of gloves, gowns, eye protection, and the
informed and updated as events change.68 N95 respirator.83 A comprehensive review of SARS is available at
the WHO web site (www.who.int/csr/sars/en/WHOconsensus.pdf).
ANTIMICROBIAL-RESISTANT MICROORGANISMS
ENVIRONMENTAL CONTROL
Hospitals and communities worldwide are facing the challenge
posed by the spread of antimicrobial-resistant microorganisms. Strains Control of the microbial reservoir of the patient’s immediate
of MRSA are increasing in hospitals and are an important cause of environment in the hospital is the goal of an infection control pro-
nosocomial infections; in the United States in the year 2002, the program. Environmental control begins with design of the hospital’s
portion of S.aureus isolates resistant to methicillin or oxacillin was more physical plant.The design must meet the functional standards for
than 55%.69 MRSA strains do not merely replace methicillin-sus- patient care and must be integrated into the architecture to pro-
ceptible strains as a cause of hospital-acquired infections but actually vide traffic accessibility and control. Since the 1960s, the practice
increase the burden of nosocomial infections.70 Moreover, there are of centralizing seriously ill patients in intensive care, dialysis, and
reports that MRSA may be becoming a community-acquired transplant units has accentuated the need for more careful analy-
pathogen.71,72 A proactive approach for controlling MRSA at all lev- sis and planning of space.The primary standards for these special
els of health care can result in decreased MRSA infection rates.73,74 care units and ORs require planning of floor space, physical sur-
Strains of GISA, an emerging pathogen, exhibit reduced sus- faces, lighting, ventilation, water, and sanitation to accommodate
ceptibility to vancomycin and teicoplanin. The first GISA strain easy cleaning and disinfecting of surfaces, sterilization of instru-
was isolated in 1996 in Japan.75 DNA fingerprinting suggests that ments, proper food handling, and garbage disposal. These activi-
these GISA strains evolved from preexisting MRSA strains that ties should then be governed by workable policies that are under-
infected patients in the months before the GISA infection. standable to the staff. Preventive maintenance should be a basic
Contact precautions are indicated for patients infected or colo- and integral activity of the physical plant department.
nized with GISA; infection control guidelines to prevent the Surveillance of the environment by routine culturing of operat-
spread of GISA are available.76 ing room floors and walls was discontinued in the late 1970s.
VRE accounts for 31% of all enterococci in the NNIS system.70 Autoclaves and sterilization systems should, however, be continu-
Transmission usually occurs through contact with the contami- ously monitored with routine testing for efficiency and perfor-
nated hands of a health care worker.The environment is an impor- mance.The results should be documented and records maintained.
tant reservoir for VRE, but it is not clear whether the environment Investigations of the physical plant should be reserved for spe-
plays a significant role in transmission.77 Risk factors for VRE cific outbreaks, depending on the organism and its potential for
causing infection.This was demonstrated by the incident of a clus- Benefits of an Infection Control Program
ter outbreak of sternal wound Legionella infections in post–cardio- The establishment of an infection control program can greatly
vascular surgery patients after they were exposed to tap water dur- benefit a hospital. An infection control program supports patient
ing bathing.84 Because outbreaks of nosocomial respiratory infec- care activities and is a means for continuous quality improvement
tions caused by L. pneumophila continue to be a problem,85 the in the care that is given, in addition to being an accreditation
CDC includes precautionary measures for this disease in its pneu- requirement. In Canada and the United States, the need for infec-
monia prevention guidelines.86 In addition, several water-treat- tion control programs is supported by all governing agents, includ-
ment measures are available to help eradicate or clear the water of ing the Canadian Council on Hospital Accreditation, JCAHO, the
these bacteria.87 American Hospital Association (AHA), the Canadian Hospital
Hospital-acquired aspergillosis is caused by another ubiquitous
Association, the Association for Practitioners in Infection Control
type of microorganism that is often a contaminant of ambient air
(APIC), the Society of Hospital Epidemiologists of America (SHEA)
during construction.The patients most at risk are usually immuno-
Joint Commission Task Force, and the Community and Hospital
suppressed (i.e., neutropenic). It is recommended that preventive
Infection Control Association–Canada (CHICA-Canada).
measures be organized for these patients when construction is
An infection control program requires a multidisciplinary com-
being planned.88 The provision of clean (i.e., HEPA-filtered) air in
mittee that includes an infection control practitioner, who may be
positive pressure-ventilated rooms, with up to 12 air exchanges an
a nurse or a technician. In the original concept, Infection Control
hour, is the basic requirement for these patients.42
Officer was the title given to the person in charge of the program.
A comprehensive review of environmental infection control in
As the practice has expanded into research and more sophisticat-
health care facilities is available at the CDC Web site (www.cdc.gov/
ed data analysis, physicians and nurses have had to update their
mmwr/pdf/rr/rr5210.pdf).This review contains recommendations
epidemiologic skills, and some hospitals have acquired the services
for preventing nosocomial infections associated with construction,
of an epidemiologist.The historical development of infection con-
demolition, and renovation.
trol programs in hospitals dates to the late 1970s.The SENIC pro-
EDUCATION ject endorsed the use of nurses89 because of their patient care
A strategy for routine training of the health care team is neces- expertise; the literature contains many examples of collaboration
sary at every professional level. The process may vary from insti- between infection control officers and nurse practitioners.
tution to institution, but some form of communication should be Controlling and preventing the spread of infections in health
established for the transmittal of information about the following: care facilities has taken many forms:
1. Endemic infection rates. 1. Prevention of cross-infection between patients.

2. Endemic bacterial trends. 2. Monitoring environmental systems (e.g., plumbing and
3. Updates on infection prevention measures (especially during ventilation).
and after an outbreak). 3. Procedures for sterilization of equipment and instruments.
4. Updates on preventive policies pertaining to intravenous line 4. Policies and procedures for the implementation of sterile
management, hand washing, isolation precautions, and other technique for surgical and other invasive procedures.
areas of concern. 5. Procedures for nursing care activities for the postoperative
patient.
Although members of the infection control team are the respon- 6. Policies and procedures for dietary, housekeeping, and
sible resource persons in the hospital system, each member of the other ancillary services.
health care team also has a responsibility to help prevent infection 7. Policies for the control of antibiotics.
in hospitalized patients. Under the JCAHO guidelines,6 education 8. Policies and procedures for occupational health prevention.
of patients and their families should become a part of teaching 9. Educational strategies for the implementation of isolation
plans, as well. precautions.
RESEARCH At present, infection control practices have developed into a
Infection control policies are constantly being evaluated and sophisticated network that does not allow for hospital-wide sur-
remodeled because most traditional preventive measures are not veillance as it was once practiced. However, the use of surveillance
scientifically proved but are based on clinical experience. Although by objective and the use of indicators to monitor select groups of
infection data are useful, research in infection control requires patients or select situations provide information that will benefit
microbiologic support to conduct realistic studies. Very few infec- the entire hospital. For example, monitoring bloodborne infec-
tion control programs have the personnel and resources for these tions in an intensive care setting will provide data to support an
activities. intravenous care plan for general use. Accomplishing a high-qual-
ity infection control program requires organization and the dedi-
PUBLIC HEALTH AND COMMUNITY HEALTH SERVICE cated service of all health care employees.
According to existing public health acts, certain infectious dis-
eases must be reported by law. Differences exist between the
Organization of an Infection Control Program
reporting systems of one country and those of another, but on the
whole, diseases such as tuberculosis and meningococcal meningi-
INFECTION CONTROL COMMITTEE
tis are reported for community follow-up.
Open communication with community hospitals and other The chair of the infection control committee should have an on-
health care facilities provides for better management of patients going interest in the prevention and control of infection. Members
with infections, allowing for notification and planning for addi- should represent microbiology, nursing, the OR, central supply, medi-
tional hospitalization or convalescence as the patient moves to and cine, surgery, pharmacy, and housekeeping. This multidisciplinary
from the community and hospital. group becomes the advocate for the entire hospital. The members
work with the infection control service to make decisions in the fol- grams are available to assist with professional and organizational de-
lowing areas: (1) assessing the effectiveness and pertinence of infec- velopment (see below), and the APIC certification program supports
tion control policies and protocols in their areas and (2) raising infec- continuous professional improvement. A viable and useful program
tion control–related concerns. for surveillance and collection of data requires a computer database
program networked to microbiology, the OR, and nursing units.
INFECTION CONTROL SERVICE
Methods for collecting, editing, storing, and sharing data should be
Collecting surveillance data on nosocomial infections and taking based on the CDC’s NNIS system,26 which promotes the use of
actions to decrease nosocomial infections are the benchmarks of the high-quality indicators for future monitoring and comparison
infection control service. In the traditional sense, the service provides among health care institutions.
information on all types of endemic infections (e.g., wound, urinary Training programs for infection control practitioners are avail-
tract, and bloodstream) to the benefit of the health care system.The able through the following organizations:
cost-effectiveness of data collection was demonstrated by the SENIC
study.90 Since then, other studies have shown that there are benefits Society of Hospital Epidemiologists of America (SHEA)
in reducing nosocomial infection.17,18,50 Cruse and Foord presented 19 Mantua Road, Mt. Royal, NJ 08061
data to show that clean-wound infection rates could be brought be- Telephone: 856-423-7222; Fax: 856-423-3420
low 0.8%.8 Such reductions bring multiple benefits because nosoco- E-mail: sheamtg@talley.com
mial infections have a substantial impact on morbidity, mortality, Web site: www.shea-online.org
length of stay, and cost90; for example, the extra costs of treating Association for Professionals in Infection Control (APIC)
bloodstream infections in an intensive care setting were recently esti- 1275 K Street NW, Suite 1000
mated to be $40,000 per survivor.91 Washington, DC 20005-4006
INFECTION CONTROL PRACTITIONERS Telephone: 202-789-1890; Fax: 202-789-1899
E-mail: APICinfo@apic.org
The reshaping of hospitals because of cost constraints will have an Web site: www.apic.org
effect on the work of infection control practitioners. Already, some
institutions have regrouped responsibilities and changed the role of Community and Hospital Infection Control Association–Canada
these professionals. Given the accreditation mandate, the need to (CHICA-Canada)
continue an active program may be reviewed. Many training pro- Web site: www.chica.org
References
1. Preparation of the operating team and support- otics and the risk of surgical-wound infection. N fections: methods for estimating economic burden
ing personnel. Manual on Control of Infection in Engl J Med 326:281, 1992 on the hospital. Am J Med 91(suppl 3B):32S,
Surgical Patients, 2nd ed. Altemeier WA, Burke 10. Clarke JS, Condon RE, Bartlett JG, et al: Pre- 1991
JF, Pruitt BA, et al, Eds. JB Lippincott Co, operative oral antibiotics reduce septic complica- 19. Hospital Infection Control Practices Advisory Com-
Philadelphia, 1986, p 91
tions of colon operations. Ann Surg 186:251, mittee Guideline for the prevention of surgical
2. LaForce FM: The control of infections in hospi- 1977 site infection, 1999. Infect Control Hosp Epi-
tals, 1750 to 1950. Prevention and Control of demiol 20:247, 1999
11. Farnell MB, Worthington-Self S, Mucha P, et al:
Nosocomial Infections, 2nd ed. Wenzel RP, Ed.
Closure of abdominal incisions with subcuta- 20. Owens WD, Felts JA, Spitznagel EL: ASA physi-
Williams & Wilkins, Baltimore, 1993, p 1
neous catheters: a prospective randomized trial. cal status classifications: a study of consistency of
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ELEMENTS OF CONTEMPORARY PRACTICE 8 MINIMIZING THE RISK OF MALPRACTICE CLAIMS — 1
8 MINIMIZING THE RISK

OF MALPRACTICE CLAIMS
Grant H. Fleming, Esq., and Wiley W. Souba, M.D., Sc.D., F.A.C.S.
Of all the challenges that surgeons face, perhaps none can be so when they are accompanied with a claim for punitive damages.
threatening and draining—on an emotional, personal, and pro- Such claims, announced in the formal complaint, are then typi-
fessional level—as being a defendant in a medical malpractice cally followed promptly with a grim letter to the defendant physi-
claim. This is especially true when the individual initiating the cian from the insurers involved, reminding the physician that
claim is the very patient the defendant physician was earnestly there is no coverage for punitive damages awarded. The allega-
trying to help.The purpose of this chapter is to provide the prac- tions in the plaintiff’s complaint necessary to support a claim for
ticing surgeon with practical information about the genesis and punitive damages are hurtful and sometimes outrageous; the
mechanics of malpractice suits. Application of this knowledge physician is accused of willful, reckless, and wanton behavior bor-
may decrease the likelihood of being named in a malpractice suit dering on intent to injure the plaintiff.The awards sought in such
or having to endure the ordeal of a jury trial. cases reach far beyond fair compensation for the injured plaintiff.
Rather, punitive damages are calculated to punish the defendant
physician—the perceived wrongdoer—and to serve as public
The Malpractice Climate sanctions. The physician against whom punitive damages are
Record verdicts are now commonplace. Our state, Pennsylva- sought then undergoes pretrial discovery, sometimes shortly after
nia, has contributed its share: the year 2001 saw a $100 million suit is filed. This process involves requests (interrogatories) for
malpractice award in Philadelphia—the third highest ever in the detailed accounting of personal assets that might be available to
United States. Just 1 month before that award came two others: be attached in the event of a judgment in the plaintiff’s favor.
one for $55 million and another for $49.6 million. In 1998, Phil- Whether or not punitive damages are sought, it is difficult for
adelphia paid out more malpractice case settlement awards and most physicians to regard being harpooned by a medical mal-
jury verdicts than the entire state of California. In 1999, there were practice claim as merely a cost of doing business, and for many,
33 medical malpractice verdicts in Philadelphia that exceeded $1 the arduous and seemingly never-ending nature of the claim is
million, compared with 19 the previous year. Statewide, by the end distracting and potentially debilitating.
of 2001, settlements in Pennsylvania had risen 15% to 20%.
The adverse malpractice environment has taken its toll on
insurers, and a number of them have gone into bankruptcy.1 St. Who Brings Medical Malpractice Claims?
Paul Companies, for years a mainstay for physicians’ profession- Despite the self-aggrandizing proclamations of trial lawyer
al liability coverage, has announced its intention to drop its med- associations, professional negligence has little to do with whether
ical malpractice business nationwide. Despite some effort at tort claims are brought for patient injuries. Nor has any research
reform on the state level, physicians are leaving Pennsylvania and established that a higher incidence of medical malpractice litiga-
other states because the practice of medicine has found itself tion has brought about a better quality of medical care delivery.
embroiled in a war with patients, the court system, and political Brennan and colleagues have shown that there is no relationship
lobby interests influenced by trial lawyers who have built power- between the occurrence of adverse events and the assertion of
ful law firms by profiting from the system. claims, nor is there any association between adverse events and
negligent or substandard care.2 These authors did, however, find
a relationship between the degree of disability and the payment of
Personal Issues for the Defendant Physician claims.
How physicians cope personally with being a defendant in a Only a small fraction of patients who are injured through sub-
medical malpractice suit varies, but a number of factors come to standard care or treatment actually bring claims or suits.3 Localio
bear on the amount of stress that litigation inflicts. These factors and colleagues concluded that although 1% of hospitalized
include the physician’s previous exposure to litigation claims, patients suffer a significant injury as a result of negligence, fewer
degree of familiarity with the legal system and the litigation than 2% of these patients initiate a malpractice claim.4 Other
process, and previous experience testifying in the courtroom or in authors have found that only 2% to 4% of patients injured
depositions; the size of the claim as measured by the seriousness through negligence file claims, yet five to six times as many
of the alleged injury; and the presence or absence of a claim for patients who suffered injuries that are not legally compensable
punitive damages—which, of course, are not insured by profes- also file malpractice claims.5
sional liability policies. Some physicians experience a sense of
profound isolation when they are first named in a suit, particu-
larly when service of suit papers is accompanied by the standard Who Are the Defendants in Medical Malpractice Cases?
instruction from their risk management office or legal counsel not The experience one of us (G.H.F.) has acquired in defending
to discuss the case with anyone. malpractice claims for over 25 years at the same teaching hospi-
Allegations of negligence or substandard care, in and of them- tal vouches for the contention that those targeted in medical mal-
selves, are bitter pills to swallow, but they are all the more painful practice suits are not the incompetent, the unskilled, or the care-
less. Entman and colleagues studied the quality of care rendered rather than the adverse outcome, determined the decision to
to 446 obstetric patients and performed a blinded comparison of bring the claim.They found that 71% of the depositions revealed
adverse outcomes, with physicians grouped according to fre- problems with physician-patient communication in four major
quency of medical malpractice claims against them.6 The authors categories: (1) perceived unavailability (“you never knew where
found no relationship between the number of adverse outcomes the doctor was,” “you asked for a doctor and no one came,” “no
and the frequency of claims experienced. In addition, other one returned our calls”); (2) devaluing of the patient’s or the
research has shown that no relationship exists between the pres- family’s views (e.g., perceived insensitivity to cultural or socio-
ence or absence of claims history and traditional indicators of economic differences); (3) poor delivery of medical information
physician ability, such as board certification, status, prestige of (e.g., lack of informed consent, failure to keep patients informed
medical school attended, country of medical school, medical during care, or failure to explain why a complication occurred);
school ranking, or solo practice.7,8 An examination of the files of and (4) failure to understand the patient’s perspective.
the National Practitioners Data Base, which lists those on whose Levinson and colleagues studied specific communication
behalf either jury awards or monetary settlements were paid, behaviors associated with malpractice history.10 Although they
would reveal the names of some of the most highly regarded did not discover a relationship between those two factors in the
physicians in the United States. surgeons they studied, they found that primary care physicians
who had no claims filed against them used more statements of
orientation (i.e., they educated patients about what to expect),
Reducing Malpractice Claims used humor more with their patients, and employed communi-
Clearly, some suits cannot be prevented. When catastrophic cation techniques designed to solicit their patients’ level of under-
injuries follow surgery or treatment, the emotional impact of the standing and opinions (i.e., they encouraged patients to provide
tragedy, coupled with overwhelming economic pressures, can verbal feedback).
create an environment in which a claim is assured. On the other Hickson and colleagues studied specific factors that led
hand, not all adverse outcomes from treatment result in claims. patients to file malpractice claims after perinatal injuries by sur-
Why is it that some patients and families sue for adverse out- veying patients whose claims had been closed after litigation.11
comes and some do not? Why do some patients sue for adverse Dissatisfaction with physician-patient communication was a sig-
outcomes that are expected and that occur in the context of high- nificant factor: 13% of the sample believed that their physicians
quality care? The answers to those questions typically have to do would not listen, 32% felt that their physicians did not talk open-
with physician-patient relationships rather than with professional ly, 48% believed that their physicians had deliberately misled
skill. them, and 70% indicated that their physicians had not warned
It has become increasingly clear that surgeons can reduce the them about long-term developmental problems.
likelihood of litigation by adopting a few key habits and practices In our own experience with defending malpractice suits, we
with their patients and their patients’ families. These include have seen instances in which attending physicians who had devel-
building trust through open communication, making effective oped a positive rapport with their patients were not named in a
use of informed consent, keeping accurate and complete medical suit, whereas other physicians involved in the patient’s care were
records, and educating office staff. named. In suits that progressed through pretrial discovery, we
have observed instances in which patients were willing to drop
COMMUNICATION AND INTERPERSONAL SKILLS IN THE
from the suit physicians with whom they had a good rapport,
PHYSICIAN-PATIENT RELATIONSHIP
leaving in the suit others with whom they had a less positive rela-
Although advancing medical technology has elevated patients’ tionship—or with whom they had had no communication.
level of expectation regarding treatment outcome, easy public Patients apparently made these decisions without regard to the
access to medical information on the Internet has encouraged extent of each defendant’s factual involvement in the case.
patients to become partners with their physicians in their own A component of the motivation to sue may be simply an unsat-
care. Experience with juries over the past few decades continues isfactory or incomplete explanation of how and why an adverse
to support the belief that in general, laypersons have a high outcome occurred. Patients who remain uninformed often
regard for physicians and a deep respect for their superior level of assume the worst—that their physician is uncomfortable talking
knowledge and training. At the same time, patients expect and about the complication because he or she made a mistake, was
deserve to receive intelligible and thorough explanations from careless, or is hiding something. In our experience, malpractice
their physicians regarding their diagnosis, their treatment plan, plaintiffs have sometimes claimed that when they sat through the
and the risks and benefits of their treatment. Even when the dis- process of jury education during the trial, it was the first time
ease process is beyond the physician’s control, the physician can they received any explanation of the complication for which they
still create an environment for effective communication with the had brought suit.
patient. Years of listening to patients and their family members When children suffer injuries, parents often seek desperately to
tell about their experiences at depositions and trials has con- avoid blaming themselves and so may attempt to transfer the
firmed for us that the quality of communication and trust responsibility to the health care providers. It is therefore critical
between physician and patient is the most important contribut- that after a complication or adverse event arises in a pediatric
ing factor in the patient’s decision to prosecute a medical mal- case, whenever possible the physician should speak openly with
practice suit. the parents about inappropriate feelings of guilt. The discussion
Several researchers have analyzed physician-patient communi- should cover possible or known causes or mechanisms of the
cation and its relationship to claims for damages for alleged pro- injury or death that are independent of any care rendered by the
fessional negligence. Beckman and colleagues studied 45 deposi- parents, including prenatal care or home care of a chronically ill
tion transcripts of plaintiffs in settled malpractice suits, focusing child. Similarly, the physician should make a point of explaining
on the question of why these plaintiffs decided to bring malprac- to adult patients and their families how and why adverse condi-
tice actions.9 These authors concluded that the process of care, tions arose, independent of any possible deficiencies in the qual-
ity of care received at home or in patient compliance. Patients and Informed consent is merely an extension of good communication
their families are keenly sensitive to unintended inferences that practices, albeit one that is mandated by law.The tort of informed
blame for the bad outcome rests with them. consent is derived from the concept of battery—for example,
The principles of good communication are the same, whether unauthorized touching. Patients are deemed not to have consent-
an adverse event has occurred or not.They include the following: ed to a procedure unless they have been advised of all the risks
involved in it and all the alternatives to it. In most jurisdictions,
1. Content. Convey medical information in descriptive terms
the standard is objective rather than subjective. In other words,
that patients can understand, using illustrations, sketches, and
the risks and alternatives that must be disclosed are those that a
diagrams. Ask about the response to the therapeutic regimen.
“reasonable patient, in similar circumstances”—not necessarily
Provide counseling and instruction if no improvement is
the plaintiff—would regard as material to the decision whether to
observed. Inform the patient about specific steps in the exam-
undergo the surgery in question. With procedures for which the
ination or treatment plan.
statistical incidence of risks has been published or is known, the
2. Process. Ask patients whether they understand what they have
physician has a duty to quantify for the patient the likelihood of
been told; check the understanding by listening to the patient
the risk being realized. If the patient’s particular condition or sit-
after providing an explanation. Demonstrate respect for any
uation is such that the likelihood of the risk occurring is higher
cultural or socioeconomic differences that may be impeding
than average, the physician has the duty to so inform the patient.
the patient’s understanding.
Many physicians ignore another critical element in the
3. Emotional affect. Demonstrate concern and understanding of
required informed consent discussions: describing the range of
the patient’s complaints. Express empathy; use humor where
reasonable alternative procedures or modalities other than the
appropriate. Demonstrate awareness of the patient’s occupa-
procedure in question that are available to the patient. The haz-
tion, social circumstances, hobbies, or interests.
ard that such omissions entail is illustrated by a case in which the
4. Follow-up. Return telephone calls. Explain the protocol for
physician performed a transesophageal balloon dilatation of the
substitute or resident coverage, and introduce patients to
esophagus to address achalasia that had not responded to con-
other personnel who may be following their care. During
servative medical therapy. The risk of esophageal perforation was
longer hospitalizations, keep the patient and the family
disclosed as part of informed consent, and the procedure was per-
informed of the patient’s progress or treatment plan. Keep the
formed totally within the standard of care, but the patient suf-
referring physician promptly informed by providing treat-
fered perforation of the esophagus with serious permanent and
ment or discharge summaries. In the event of a patient’s
long-term disability. Although an alternative approach, via thora-
death, meet with the family to review and explain autopsy
cotomy, was known to be followed at other institutions, it was not
findings.
used at the defendant hospital, and the informed consent discus-
Further guidelines apply when an adverse outcome occurs. In the sion therefore did not include the surgical alternative as a dis-
hospital setting, prompt disclosure of an untoward or unexpect- closed option. The defendants were forced to settle the case for a
ed event that causes injury or harm is mandated by the Joint significant amount of money, even though there had been no neg-
Commission on the Accreditation of Healthcare Organizations ligence and the patient acknowledged that the risk of esophageal
(JCAHO). JCAHO standards require disclosure of unanticipated perforation had been thoroughly disclosed. A breach of informed
outcomes “whenever those outcomes differ significantly from the consent was easily established because one of the reasonable
anticipated outcome.” The responsibility to communicate lies alternatives was not disclosed to the patient.The argument that a
with both the attending physician and, in the case of a complica- reasonable person would probably have rejected the surgical
tion incident to surgery, the person accountable for securing con- alternative had it been disclosed was not a valid defense; nondis-
sent for the procedure. closure of a reasonable alternative, in and of itself, created strict
When possible, it may be advisable to invite other responsible liability.
caregivers to take part in the discussion of the adverse event with Some surgeons regard the informed consent discussion as an
the patient and the family. Consideration should also be given to inconvenient imposition on their time. However, the few minutes
inviting other persons who may be sources of support for the needed for this discussion pales in comparison with the time
patient and could benefit from the disclosure. During the discus- needed to defend a lawsuit involving a breach of informed con-
sion, express regret for the occurrence, without ascribing blame, sent, either as the central or an ancillary claim. In addition, given
fault, or neglect to oneself or any other caregiver. Describe the that the surgeon’s personal interaction with a patient may be sig-
decisions that led to the adverse event, including those in which nificantly limited in comparison with that of the primary care
the patient participated. Explain and outline the course of events, physician, obstetrician, gynecologist, or medical specialist, the
using factual, nonspeculative, nontechnical language, without informed consent discussion presents an important opportunity
admitting fault or liability or ascribing blame to anyone else. State for the surgeon to develop rapport and a positive relationship with
the nature of the mistake or error if one was made, and highlight the patient. Such rapport can be invaluable in the event of a later
the expected consequences and prognosis, if known. Outline the complication or adverse outcome. An effective informed consent
plan of corrective action with respect to the patient. In the event discussion may decrease the likelihood of a claim for a particular
that certain information is unknown at the time of the discussion adverse outcome if the patient remembers that the risk of its
(e.g., the etiology of the condition, suspected equipment mal- occurrence was disclosed and discussed.
function in the absence of controlled testing, or pending labora- Informed consent is not the consent form. The form is merely
tory test results), tell the patient and family that such information a piece of evidence documenting that informed consent occurred;
is currently unknown and offer to share the information with the critical factor is the content of the discussion. For the form to
them when it becomes available. be effective, it must cogently summarize the disclosures in a man-
ner that makes it difficult for the patient to later refute, in a “he
INFORMED CONSENT
said, she said” controversy, the version of the discussion that the
Effective informed consent can reduce the risk of litigation. physician may be rendering in the courtroom under oath.
An effective informed-consent discussion based on custom scans are of relevance, be sure the printed copy is stapled and
and habit is essential because of the slow pace of the legal system. placed into the progress notes of the patient’s chart. A surgeon
In most jurisdictions, the statute of limitations for bringing claims who has provided the patient with a sketch to help explain an
involving adult patients is 2 years. By the time the defendant operative procedure should place the sketch in the patient’s chart
physician’s pretrial deposition is taken, another 1 to 3 years may and write the date on it. In one case involving an informed con-
have elapsed, and after that, even more time passes before the sent issue, the defense was able to produce a sketch of the opera-
conversation will have to be relayed under oath if the claim goes tion that the surgeon had made on the reverse side of a lab report
to trial. It is exceedingly rare that physicians can actually recall the in the patient’s chart, refuting the patient’s contention that no
informed consent discussion in question at the time of suit. explanation of the procedure had ever been given. If equipment
However, the content of the communication can be proved more malfunction is involved in an adverse outcome, such as a death in
reliably by means of custom and habit than by direct recollection, which a postmortem examination was conducted, insist that the
particularly when the elements of the discussion are corroborat- risk management office provide a secure place to store the speci-
ed with a comprehensive but clear form signed by the patient. men or equipment in question for later testing or use as a trial
In some cases, physicians encourage the showing of a patient exhibit. If an anomalous condition has contributed to an adverse
education video that explains the intended procedure. Such videos outcome in a death case, make sure the pathologist at autopsy at
should also communicate the risks of the procedure. The use of least photographs the abnormality if the specimen is not going to
such videos can provide additional evidence to support the be preserved for later use.
defense that the patient gave informed consent. Each version of If an untoward outcome or event occurs, document the event
the video should be labeled with the dates when it was routinely in the chart purely with facts. Avoid expressions of opinion or
used, and it should not be discarded when it is replaced with suggestions of blame of other health care providers. In the event
updated versions. The patient’s chart should reflect that the pa- relevant information becomes available at a later point, it can be
tient watched the video and had no questions after a review of its helpful to make a late entry in the chart, documenting the time of
contents. the entry.
The physician who will perform the procedure, not the nurse If one realizes that an error in documentation has been made
or resident who will assist at it, has the duty to secure the patient’s in the patient’s chart (e.g., inaccurate information recorded), do
consent. Information provided by other health care providers can not remove the page and start over and do not scratch out or
be used by the defense as evidence, however. “white out” the mistake.The appropriate way of handling such an
error is to draw a single line through the inaccurate information,
DOCUMENTATION
record the correct information, and initial and date the amend-
Along with effective communication techniques and informed ment. Clearly, a medical record should never be altered in an
consent protocols, good documentation practices can minimize a attempt to cover something up. In the event of a suit, this act
surgeon’s risk of becoming a defendant in a medical malpractice could lead to the loss of an otherwise defensible case.
suit, or at least provide a more effective defense if litigation is
EDUCATING AND INFORMING OFFICE STAFF
commenced. Although the purpose of keeping medical records is
to provide subsequent caregivers with important information rel- More than ever before, every practicing surgeon must recog-
evant to the patient’s condition and treatment, in the context of nize that his or her office staff must also be well informed and well
litigation, medical records are used to demonstrate what care was educated about malpractice issues. The Health Insurance
or was not rendered. A standard question that plaintiffs’ attorneys Portability and Accountability Act (HIPAA) of 1996, which
ask defendants at pretrial depositions is whether the defendant began taking effect in 2003, regulates the use of an individual’s
agrees with the adage, “If it is not documented, it wasn’t done.” protected health information and, for the first time, authorizes
Time and time again, otherwise defensible cases are compro- specific federal penalties if a patient’s right is violated. All practice
mised because of inadequate documentation, such as failure to employees must be trained in compliance with the law and must
document an order, the time an order was given, a critical tele- know how to deal with privacy requirements stated in the law.
phone call from the patient or patient’s family, a critical informal In-service training of office staff is pivotal to reducing the risk
consultation, or critical symptoms reported by a patient during of being sued. All office personnel should be well informed and
the course of an examination or clinic visit. educated on issues of confidentiality, including how to answer the
A current trend in tort reform legislation, designed to discour- phone, what kinds of conversations are inappropriate, and the
age frivolous suits, is to require that any claim being brought must giving out of medical information. Good patient relations is also
be accompanied by a certification of merit, which establishes that critical; many avoidable lawsuits have arisen simply because a
a qualified expert has reviewed the records and is supportive of member of the physician’s office staff was rude to a patient on the
the claim. If the chart is well documented in defensible cases, phone, or the patient waited too long to see the doctor without an
many reputable experts will be loath to give an opinion that sub- explanation. In the event that patients or family members call or
standard care was provided. On the other hand, absence of ade- write to express displeasure with service they received—whether
quate documentation sometimes prejudices expert case reviewers that service was provided by the surgeon, the resident, the clinic
in favor of the plaintiff, even though subsequent deposition testi- staff, or the nursing team—courtesy and common sense decree
mony may provide a cogent and defensible explanation for how that the dissatisfied customers be contacted and allowed to vocal-
and why the adverse event or complication occurred. ize their complaints, by telephone or in person.Willingness to lis-
Ensure that telephone conversations are documented. Cases ten to these persons indicates a genuine interest in improving the
have been saved in the courtroom simply because a resident who delivery of patient care and may well prevent some claims.
received a call jotted a short note of the patient’s complaint and
ADDITIONAL POINTERS
the advice given and pasted it in the patient’s chart. Keep log-
books of appointments, cancellations of appointments, and rea- Be vigilant for litigious patients; such individuals exist. They
sons for cancellations. If printed images of bedside ultrasound should receive the same high-quality medical care as any other
patient, but extra attention should go into documentation and at the time of pretrial depositions. Review the available records
informed consent. Avoid becoming paranoid, but inform the staff and prepare a confidential summary of the case; address this
of any concerns. Such patients may feel short-changed by the summary only to legal counsel, with no copies to anyone. If the
medical system, or they may be looking for any derogatory state- media is involved at the outset of the suit, under no circumstances
ments about another physician’s advice or treatment. Steer clear should the defendants attempt to be spokespersons on their own
of criticizing another physician. behalf; they should leave this task to others who are equipped to
With the enormous pressure on minimizing health care expen- determine how much information to provide to the media about
ditures, virtually all surgeons feel pressure to reduce length of stay the controversy.
and decrease the use of diagnostic tests and medications. These Defendants should find out the name of the lawyer who will be
constrictions should never influence patient care decisions. Cut- assigned to represent them and arrange an initial meeting to
ting corners may result in litigation. In dealing with health care familiarize the lawyer with the medical issues in the case. Defend-
plan denials, it can often be helpful to talk directly with the med- ants who conduct any medical research to assist themselves and
ical director. their counsel with the issues should do so with the understanding
that the research is in the context of communication with coun-
sel. Independent research conducted for the defendant’s own edi-
What Can Surgeons Do to Assist in Their Defense if They fication, not for communication with counsel, is discoverable by
Are Sued? the plaintiff. Defendants should take the time necessary to edu-
First, one should assemble all of the relevant records, phone cate their attorney on the medical issues involved so that the attor-
logs and messages, and e-mail correspondence or other notes and ney can gather more information effectively. Defendants can rec-
should cooperate fully with the claims representative of the insur- ommend and discuss with counsel certain fact-gathering tasks to
er and the representative of the hospital risk management team if be done by counsel on the defendants’ behalf. Both can begin
the hospital is involved in the case. Under no circumstances thinking about whom to engage as an outside expert to assist in
should one alter, amend, or discard records when a suit is initiat- identifying weak points or issues in the case before the defendant
ed. Do not discuss the facts of the case with any colleagues until submits to a deposition by the plaintiff’s lawyer. However, after
legal counsel is involved, because anyone involved in those dis- defendant and counsel have agreed on an expert, only counsel
cussions may be asked to repeat the substance of the conversation should approach or contact the expert.
References
1. Mello MM, Studdert DM, Brennan TA:The new Harvard Medical Practice Study III. N Engl J acteristics of physicians with obstetric malpractice
medical malpractice crisis. N Engl J Med 348: Med 325:245, 1991 claims experience. Obstet Gynecol 78:1050, 1991
2281, 2003 5. Hickson GB, Pichert JW, Federspiel CF, et al: 9. Beckman HB, Markakis KM, Suchman AL, et al:
2. Brennan TA, Sox CM, Burstin HR: Relation Development of an early identification and The doctor-patient relationship and malpractice.
between negligent adverse events and the out- response model of malpractice prevention. Law Arch Intern Med 154:1365, 1994
comes of medical malpractice litigation. N Engl J and Contemporary Problems 60:7, 1997
10. Levinson W, Roter DL, Mullooly JP, et al:
Med 335:1963, 1996 6. Entman SS, Glass CA, Hickson GB, et al: The Physician-patient communication: the relation-
3. Brennan TA, Leape LL, Laird NM, et al: relationship between malpractice claims history ship with malpractice claims among primary
Incidence of adverse events and negligence in and subsequent obstetric care. JAMA 272:1588, care physicians and surgeons. JAMA 277:553,
hospitalized patients. N Engl J Med 324:370, 1994 1997
1991 7. Sloan FA, Mergenhagen PM, Burfield WB, et al: 11. Hickson GB, Clayton EW, Githens PB, et al:
4. Localio AR, Lawthers AG, Brennan TA, et al: Medical malpractice experience of physicians: Factors that prompted families to file medical
Relations between malpractice claims and predictable or haphazard? JAMA 262:3291, 1989 malpractice claims following perinatal injuries.
adverse events due to negligence: results of the 8. Baldwin LM, Larson EH, Hart LG, et al: Char- JAMA 267:1359, 1992
ELEMENTS OF CONTEMPORARY PRACTICE 9 ELEMENTS OF COST-EFFECTIVE CARE — 1
9 ELEMENTS OF COST-EFFECTIVE
NONEMERGENCY SURGICAL CARE
Robert S. Rhodes, M.D., F.A.C.S., and Charles L. Rice, M.D., F.A.C.S.
The citizens of industrialized nations generally enjoy a high level Surgery is a particularly suitable subject for cost-effectiveness
of health, and the positive correlation between life expectancy and analysis because surgical illnesses are usually of relatively short
per capita income is one of the best-known relationships in inter- duration, surgical outcomes are readily quantified, and surgical
national development.1 Yet many of these nations also face major costs often involve global fees. In what follows, we explore some
challenges in controlling the cost and improving the quality of basic principles of cost-effective surgical care and address some of
health care.The United States has attempted to control these costs the complex issues involved in defining such care.We define cost-
through price controls (in the Nixon era), prospective payment (in effectiveness as cost divided by net benefit, with the numerator
the Reagan era), and managed care (in the Clinton era), but none (cost) expressed in dollars and the denominator (net benefit)
of these measures have had any long-term success [see Table 1].2,3 expressed as beneficial outcomes minus adverse outcomes. Since
A consequence of the ongoing growth in health care expendi- cost-effectiveness is integrally related to quality of care issues, we
tures is that health care then increasingly competes with other consider recent changes in the concepts of quality, address the
social goals (e.g., education) for some of the same funds. The complex issues associated with cost, and examine the relation of
anguish of having to choose one social goal over another can be quality to cost. Perhaps most important, we also focus on specific
rationalized when the expenditures on the chosen goal produce skills and attributes that can help surgeons become more cost-
demonstrable improvements. Thus, if increased health spending effective.
generates measurably better health, it seems worthwhile, but if it
does not, it seems wasteful. In the United States, unfortunately,
the latter scenario appears to prevail. Even though the United Demise of “Appropriateness” as Indicator of Quality
States spends a larger fraction of its gross domestic product
DRAWBACKS OF TRADITIONAL VIEW OF QUALITY
(GDP) on health care than other industrialized nations do [see
Table 2], U.S. citizens seem less healthy—often by wide margins— To achieve cost-effective care, it is necessary first to develop a suit-
than citizens in other nations [see Table 3].4 Of further concern are able definition of quality—a task that is considerably more problem-
the data indicating that the greater U.S. spending is attributable atic than it seems.6,7 The traditional definition of quality focused on
largely to higher prices for health care goods and services.5 the appropriateness of the care provided, and the authority (in terms
Controlling health care costs and improving health care out- of knowledge) for such appropriateness was viewed as exclusively the
comes have multiple interwoven perspectives that range from the province of physicians. By the end of the 20th century, however, sev-
macrostructure of the health care system to the wide variety of eral factors had begun to erode appropriateness (and physician au-
individual patient-provider interactions. The relevance of these thority) as the traditional indicator of quality.
interactions is underscored by the fact that physician decision- One such factor was the realization that per capita health care
making accounts for 75% of overall health care costs. The pro- expenditure was not necessarily positively correlated with life
nounced impact of physicians’ choices on health care costs also expectancy. Another factor—one that directly challenged the
explains why those who pay the bills naturally seek to identify the authority of the physician as the arbiter of quality of care—was the
most cost-effective physicians. finding that some procedures have a relatively high incidence of
Table 1 U.S. Health Care Expenditures: Selected Years, 1960–20002,184
Expenditure Expenditure as
Year for Health Services U.S. Population Expenditure Percentage of
GDP ($ billion)
and Supplies (million) per Capita ($) GDP (%)
($ billion)
1960 25.2 190 141 527 5.1
1970 67.9 215 341 1,036 7.1
1980 245.8 230 1,067 2,796 8.8
1990 696.0 254 2,738 5,803 12.0
1995 990.1 268 3,697 7,401 13.4
2000 1,310.0 280 4,672 9,825 13.3
GDP—gross domestic product

Table 2 Percentage of GDP Spent on Health Care in Selected Countries: 1960–2000185
Expenditure as Percentage of GDP
Year Canada France Germany Japan United Kingdom United States OECD Median
1960 5.4 — — 3.0 3.9 5.0 4.1
1970 7.0 — 6.2 4.5 4.5 6.9 5.1
1980 7.1 — 8.7 6.4 5.6 8.7 6.8
1990 9.0 8.6 8.5 5.9 6.0 11.9 7.5
2000 9.2 9.3 10.6 7.6 7.3 13.1 8.0
GDP—gross domestic product OECD—Organisation for Economic Co-operation and Development
inappropriate indications. For instance, a Rand Corporation the intensity of local diagnostic testing and the number of invasive
study found that 32% of carotid endarterectomies, 17% of coro- cardiac procedures subsequently performed.18 Indeed, some
nary arteriograms, and 17% of upper GI endoscopies lacked communities seem to have distinct “practice signatures”—a find-
appropriate indications.8 In another study, one in six hysterec- ing that supports the idea that many medical decisions are based
tomies were deemed inappropriate.9 Caesarean section is also fre- on opinion rather than on evidence.19 It may be tempting to
quently performed for unclear indications. attribute such variations to the inherent potential conflict of inter-
A third factor was the differences in judgments of appropriate- est in a fee-for-service system, but in fact, economic incentives
ness often noted when decisions were made for groups rather than appear to have relatively little influence on physicians in this
for individuals.10 In addition, retrospective assessments often regard. Comparable variations in utilization rates exist among
judged appropriateness on the basis of outcome alone, without Veterans Health Administration medical facilities,20 as well as in
considering processes of care.11 countries that do not have fee-for-service reimbursement.
Yet another factor was the recognition of the great disparities in Whether the high utilization rates observed are too high or the
the frequency of surgical procedures among small geographic low utilization rates are too low is still a matter of debate.The pos-
areas.12-14 These frequency variations are procedure specific, and sibility that low frequency of use may reflect restricted access to
their degree is often related to the degree of consensus regarding care is a particular concern, given the association between varia-
indications.15 Procedures with highly specific indications (e.g., tion and the ratio of hospital beds to population.21 To date, stud-
repair of fractured hips, inguinal herniorrhaphy, and appendecto- ies that have attempted to find evidence supporting other possible
my) often exhibit little frequency variation, whereas procedures explanations of these variations (e.g., differences in disease inci-
with less definite indications (e.g., carotid endarterectomy, hys- dence and differences in the appropriateness of use) have not
terectomy, and coronary angiography) often exhibit a great deal of found such evidence.22 The current belief that the high utilization
variation.16 rates are too high is supported by findings of comparable health
The lack of consensus about the appropriateness of surgical status among patients from widely disparate areas of usage, which
interventions is often related to a lack of evidence. Indeed, a study have led to the conclusion that “marked variability in surgical
from the 1970s estimated that only about 15% of common med- practices and presumably in surgical judgment and philosophy
ical practices had documented foundations in any sort of medical must be considered to reflect absent or inadequate data by which
research.17 This conclusion does not necessarily mean that only to evaluate surgical treatment....”23
15% of care is effective, but it does raise concerns about the lack In addition to these concerns about selection and utilization of
of hard evidence for most care. surgical interventions, specific concerns have been raised about
Variations in procedure frequency also appear to be related to quality of care. For instance, studies suggested that as many as one
provider capacity (usually expressed as the number of hospital fourth of hospital deaths might be preventable,24 that one third of
beds per 1,000 persons): one study noted a close relation between hospital procedures might be exposing patients to unnecessary
Table 3 Health Status and Outcomes in Selected Countries: 1999
United United
Canada France Germany Japan Kingdom States OECD Median
Percentage of population 65 yr of age or

older (%) 12.5 15.8 16.1 16.7 15.7 12.3 14.7
Life expectancy at birth (years)

Female 81.7 82.5 80.7 84.6 79.8 79.4 80.7
Male 76.3 75.0 74.7 77.6 75.0 73.9 74.7
Infant mortality (per 1,000 live births) 5.3 4.3 4.5 3.2 5.8 7.1 5.0
OECD—Organisation for Economic Co-operation and Development

CRITICAL LITERATURE ANALYSIS

risk, that one third of drugs might not be indicated, and that one
third of abnormal laboratory test results were not followed up.25 The ability to evaluate the literature critically is essential for cost-
Large reviews of medical records also revealed alarming error rates effective care because it enables one both to identify the evidence
and showed that approximately half of the adverse events were relevant to the decision being made and to judge the quality of that
associated with errors in surgical care.26,27 The report on medical evidence.Today, the Internet is indispensable in this process.Three
error issued by the Institute of Medicine (IOM) brought these Web sites that are particularly valuable in retrieving and assessing
issues directly into the public spotlight.28 There were also concerns evidence are MEDLINE (http://www.ncbi.nlm.nih.gov/PubMed/
that physicians might be ignoring therapies of proven value (e.g., medline.html), together with other National Library of Medicine
beta blockade after a myocardial infarction). databases; the Cochrane Collaboration31 (http://www.cochrane.org),
An important consequence of the difficulty of measuring qual- an international network of clinicians and epidemiologists that sys-
ity in traditional terms was that the lack of clear data on quality led tematically reviews the best available medical evidence; and the
to a buyer’s market. Health care purchasers began to use the Oxford Centre for Evidence-Based Medicine (http://www.cebm.net).
apparent similarity in quality, despite variations in frequency and Each of these sites has its advantages and disadvantages. For exam-
cost, to justify contracting for less expensive care. As a result, the ple, the Cochrane Collaboration includes sources not always acces-
medical profession, whose authority was once strong enough to sible through MEDLINE, but the former requires a subscription,
forestall system change, now bears the burden of proof. In some whereas the latter is freely accessible. Recent reviews from the
cases, the pendulum may have even swung too far in one direction: Cochrane Collaboration are also abstracted monthly in the Journal
purchasers assume that even in an atmosphere of decreasing of the American College of Surgeons.
income and increasing professional constraints, health care Randomized, controlled trials (RCTs) are considered the gold
providers will not knowingly or willingly sacrifice quality. Indeed, standard of evidence-based medicine, and the number of surgery-
some believe that competition may spark in physicians a drive to related RCTs has grown rapidly. Meta-analysis of individual RCTs
exceed their patients’ expectations. further improves their utility. Unfortunately, RCTs do have poten-
tial drawbacks. One is that the reporting methods still are not stan-
EMERGENCE OF NEW CONCEPT OF QUALITY dardized.32 Another is that the stringent inclusion criteria of RCTs
Perhaps the final blow to appropriateness as the indicator of may limit the applicability of their results to very specific subsets of
quality was the emergence of a new concept of quality that over- patients.That is, the results may not apply well or at all outside the
conditions specified by the RCT. Even when the study findings are
came many of the shortcomings of the traditional concept.29 This
seemingly applicable to a particular patient, it may be difficult to
new concept characterized quality in terms of (1) structure (fac-
reproduce the expected results in a setting that differs from the care-
ulties, equipment, and services), (2) process (content of care), and
fully controlled conditions imposed by the original RCT. Thus, a
(3) outcomes. Moreover, it made use of the quality-control tech-
test or treatment that is efficacious under ideal circumstances may
niques pioneered by W. Edwards Deming in industry, which
not be effective under less than ideal circumstances. Study types
involved minimizing quality variations by examining production
other than RCTs are associated with lower evidence levels; the hier-
systems. In health care, the production systems are the systems of
archy of evidence levels was well summarized in a 2003 review.33
care, with the structure and process of such systems being inde-
Carotid endarterectomy is a good example of a procedure that
pendent variables and the outcomes being a dependent variable. demonstrates the crucial distinction between efficacy and effec-
Good systems predispose to good outcomes (e.g., high quality), tiveness. RCTs have shown this procedure to be efficacious when
and vice versa. performed by surgeons with low rates of perioperative stroke and
This new concept of quality is also compatible with IOM’s view death.34,35 The effectiveness of carotid endarterectomy, however,
of quality in terms of overuse, underuse, and misuse.30 Although depends on whether the incidence of complications can be kept
the new concept is gaining a strong foothold, the traditional con- low: as the incidence of stroke and other complications rises, the
cept continues to hold sway in some quarters, and this persistence, procedure becomes less effective or even ineffective.36-38 Because
in our view, is at least partly responsible for the fears commonly effectiveness may vary over a relatively narrow range of outcomes,
expressed by patients and health care professionals that managed there are strong ethical reasons why surgeons ought to be familiar
care will adversely affect quality. Nonetheless, the concepts of total with their own results. If patients are to give truly informed con-
quality management and continuous quality improvement are sent, they should have access to information about their surgeon’s
increasingly being applied to health care. outcomes in similar patients.
The generalizability of results is a concern for all types of studies,
Application of New Concept of Quality
not just for RCTs. For instance, in a prospective study of computed
tomography in the diagnosis of appendicitis, the clinical likelihood of
Of the three main components of the new concept of quality, appendicitis in 100 patients was estimated by the referring surgeon
outcome assessments have received the most attention. It is impor- and assigned to one of four categories: (1) definitely appendicitis
tant to remember, however, that outcomes are very dependent on (80% to 100% likelihood), (2) probably appendicitis (60% to 79%),
the structure and the processes of care. Moreover, improvement of (3) equivocally appendicitis (40% to 59%), and (4) possibly appen-
both the structure and the processes of care requires a commit- dicitis (20% to 39%).39 These estimates were then compared with
ment to evidence-based medical practice. This commitment, in the estimated probability of appendicitis determined by CT, and the
turn, depends on a capability for critical analysis of the medical lit- pathologic condition (or absence thereof) was then confirmed by op-
erature. Such analysis then becomes the basis of skills that are eration or recovery.The actual incidences of appendicitis in the four
applied to quality improvement: technology assessment (struc- categories were 78%, 56%, 33%, and 44%, respectively.The CT in-
ture), efficient use of diagnostic testing (process), and clinical deci- terpretations had a sensitivity of 98%, a specificity of 98%, a positive
sion analysis (process).These skills often are not emphasized dur- predictive value of 98%, a negative predictive value of 98%, and an
ing formal medical education and thus warrant review here. accuracy of 98% for either diagnosing or ruling out appendicitis.The
difference between the true incidences and the initial clinical esti- Accordingly, it is incumbent on surgeons to know how decisions
mates indicates the potential for inaccuracy in surgeons’ estimation about technology acquisition contribute to excess capacity and cost
of outcomes. within the health care system. The process begins with providers
The results of this study seem relatively clear-cut, but they may be who, out of a compulsion to be the first to have a new technology, ac-
considerably less so when applied to other institutions. For instance, quire it before its value is fully known. Other providers, fearing to be
the authors calculated a savings of $447 per patient. However, costs left behind, then follow suit. If the new technology is successful, the
(and any savings therein) are likely to vary from one institution to an- capacity within a community can exceed the needs; if it is unsuccess-
other in conjunction with a number of factors, including surgeons’ ful, health care cost increases without any increase in benefit to the
differing estimates of the clinical likelihood of appendicitis, the avail- community. Competition among providers is advocated as a way of
ability of less expensive alternatives to in-hospital observation, and restraining health care costs, but when competition is driven by the
the use of the emergency department for triage. In this report, 53% technological imperative, it can contribute to inflationary increases in
of the patients studied had appendicitis, but in other studies, as few these same costs.
as 30% of patients with an admitting diagnosis of appendicitis even- Special challenges result from practice innovations that do not
tually underwent appendectomy.40 involve the introduction of new technology but, rather, involve the
Proper assessment of the literature also requires an awareness of application of existing technology in new ways.65 In this setting,
the distinction between relative and absolute risk reduction. For methodologic problems may prevent surgeons from appreciating
instance, a treatment that reduces the incidence of an undesired potential harm before the innovation has become widely dissemi-
outcome from 5% to 4% and a treatment that reduces it from nated. Laparoscopic cholecystectomy is a particularly good exam-
50% to 40% can both be said to achieve a 20% relative reduction ple of an innovation that diffused rapidly into surgical practice
in risk. Reporting effectiveness in terms of relative improvement before its safety had been fully assesssed. Although laparoscopic
can be misleading if the baseline outcome is ignored.41 Patients’ cholecystectomy is now relatively safe, the learning curve was asso-
participation in adjuvant cancer therapy (and their willingness to ciated with an increased number of bile duct injuries—an out-
tolerate side effects) may be affected more by absolute reductions come that might have been avoided had the procedure been intro-
in risk than by relative reductions. duced in a more systematic fashion.The following four questions,
Another potential pitfall in assessing evidence can arise when an formulated by the American College of Surgeons,66 should be
advance in diagnostic technology allows earlier symptomatic diag- asked whenever a new technology or an innovation in surgical care
nosis or a new or improved screening test allows diagnosis at an is being considered for introduction into widespread use:
asymptomatic stage of a disease. As a result of such developments, 1. Has the new technology been considered adequately tested for
studies intended to compare different treatments of the same dis- safety and efficacy?
ease may actually be comparing treatments of different stages of 2. Is the new technology at least as safe and effective as existing,
the disease process. Earlier diagnosis may appear to improve long- proven techniques?
term survival while in fact only serving to identify the condition for 3. Is the individual proposing to perform the new procedure fully
a longer time.The apparent extended survival with earlier diagno- qualified to do so?
sis is referred to as lead-time bias, and such bias can lead to over- 4. Is the new technology cost-effective?
estimation of disease prevalence.42
Further information on critical analysis of the medical literature EFFICIENT USE OF DIAGNOSTIC TESTING
is available elsewhere,19 particularly in the excellent series pro- Laboratory tests and imaging studies are responsible for a large
duced by the Evidence-Based Medicine Working Group.43-60 share of health care costs and account for much of the reported cost
A final argument for the value of critical literature analysis is variations. Traditionally, the value of a test rested on its sensitivity
physicians’ need to keep pace with patients’ growing access to (i.e., its ability to identify patients with a disease) and specificity (i.e.,
medical information. There are now more than 15,000 health- its ability to identify patients without a disease).67 However, the cost-
related Web sites,61 and it is estimated that tens of millions of effectiveness of a test also depends on disease prevalence. For instance,
adults find health information online. In addition, patients may get if a test with a 98% sensitivity and a 98% specificity is applied to a
information from completely unmonitored sources, such as dis- group of patients with a disease prevalence of 50% (i.e., a group in
ease-specific bulletin-boards. Given that at least some of this infor- which half the patients have the disease being tested for), 245 of
mation is inaccurate, misleading, or unconventional,62 it is vital every 500 patients tested (500 × 0.98 × 0.5) will have true positive
that surgeons be aware of what their patients may know or believe. results and five (500 × 0.02 × 0.5) will have false positive results. If,
Survey results published in 2003 suggest that patient use of the however, this same test is applied to 500 members of a population
Internet may be somewhat less than previous estimates suggested with a disease prevalence of 10%, 49 patients (500 × 0.98 × 0.1) will
and that further patient use may be dependent on subsequent have true positive results and nine (500 × 0.02 × 0.9) will have false
interactions with the physician.63 Issues of reimbursement for positive results.Thus, for any given sensitivity, the ratio of true pos-
Internet-based health care services also need to be resolved.64 itives to false positives increases with increasing prevalence of disease
in a given patient population. In the above example, the incidence of
TECHNOLOGY ASSESSMENT
false positives was 2.0% (5/245) in the first group and 18.4% (9/49)
The prevailing societal attitude that equates the latest with the in the second. Given that most tests are not 98% sensitive and 98%
best—the so-called technological imperative—creates consider- specific, the incidence of false positives in the real world is likely to
able pressure to acquire the newest equipment and techniques, be that much greater.This relation between disease prevalence and
even before their value is completely evident. With the explosive the incidence of false positives serves to establish a test’s value or
growth of technology in recent years, this behavior has been a utility and explains why a test may have relatively little value as a
major contributor to the rapid growth of health care costs. screening test in general practice (where the disease prevalence may
It is undeniable that many technological advances have improved be low) but may have relatively high value in a specialist’s practice
surgical care; however, not every new technology proves successful. (where referrals may increase the relative prevalence of the disease).
allows an appreciation of the impact of specific factors on that out-

come. Some factors may then receive greater consideration, and
others may be discounted.73 This process is exemplified by analy-
ses of the management of penetrating colon trauma74 and asymp-
tomatic carotid artery stenosis.75 Reductions in uncertainty are
Quality of Care
reflected in increased cost-effectiveness.76-78

Some may find the mathematics of such analyses intimidating;
others may perceive it as a cookbook approach to health care.
Nonetheless, it is clear that formal clinical decision analysis yields
estimates of the importance of specific facets of health care that
might be difficult to obtain otherwise.79
1 2 3 4 Understanding Systems of Care

The analytical skills described (see above) are important for
improving cost-effectiveness, but they may not be sufficient by
themselves. An additional critical element that must be in place is
Cost of Care
a solid understanding of the systems of care within which one
Figure 1 Illustrated is the new concept of quality and cost.72 A practices.These systems reflect the processes of care, and the mea-
positive relation between quality and cost still exists in zones 1 sures of these processes (i.e., what is done to a patient) may be a
and 2, but the slope of the curve flattens in zone 3 and actually more sensitive indicator of quality of care than measures of out-
becomes negative in zone 4. Here, further cost increases are
come (i.e., what happens to a patient). After all, poor outcomes do
associated with decreasing quality because increased use of
not occur every time an incorrect decision is made.80 Systems of
sophisticated (albeit riskier) technology in earlier (or even just
suspected) stages of disease may result in a flat slope (zone 3) or care are reflected in critical pathways, coordination of care, and
even a negative one (zone 4). disease management.
CRITICAL PATHWAYS
An example of the role of test utility in clinical decision making Critical pathways, also referred to as practice guidelines, are
is found in the functional assessment of incidental adrenal mass- increasingly used to standardize treatments and are particularly
es.68 Physicians encountering such masses often feel compelled to helpful for high-volume diagnoses. Although criticized by some as
engage in an elaborate workup; however, in the absence of con- embodying a “cookie cutter” approach, they minimize variation by
crete signs and symptoms, measurement of specific hormone lev- displaying optimal goals for both patients and providers. Critical
els may be of little value. Close inspection of many other routine pathways have been developed by a number of groups and orga-
preoperative tests reveals that they, too, may have little value.69,70 nizations and are available commercially, through surgical soci-
As noted [see Demise of “Appropriateness” as Indicator of eties,81 and in focused publications.82 The Agency for Healthcare
Quality, above], increases in diagnostic testing tend to parallel Research and Quality (AHRQ) has also established practice
increases in clinically relevant downstream procedures.71 An guidelines, which are available online (http://www.ahrq.gov or
example is the known association between the intensity of diag- http://www.guideline.gov) or through evidence-based practice
nostic testing and the frequency of subsequent invasive cardiac centers. The guideline.gov site is part of the National Guideline
procedures.18 A consequence of this association is that increases in Clearinghouse and is a comprehensive repository for clinical prac-
the number of patients who undergo cardiac catheterization as a tice guidelines and related materials.
result of false positive screening tests also lead to increases in the Critical pathways, though valuable as explicit expressions of the
number of patients with negative findings who may have compli- processes of care, do have limitations. One is that the focus on qual-
cations of catheterization, because complications of catheteriza- ity and efficiency of care is often adopted after the decision has
tion occur just as frequently in patients with false positive indica- already been made to admit the patient or perform a procedure. A
tions as in those with true positives.The net effect is to flatten the second is that standardization does not automatically result in qual-
cost-benefit curve and steepen the cost-harm curve.29 Thus, the ity improvement. Accordingly, critical pathways must be consid-
relative frequency of false positives affects both the numerator and ered flexible and subject to modification on the basis of experience.
the denominator of cost-effectiveness. Indeed, critical pathways are perhaps best understood not as rigid
The possibility of a relative reduction in benefit coupled with a rel- rules but as ways of codifying experience that can help others avoid
ative increase in harm is the basis of the new relation between quali- mistakes. A third limitation is that some guidelines do not adhere
ty and cost. In the context of the appropriateness concept, the rela- to established methodologic standards.83-86 A great deal of addi-
tion between health care cost and quality was seen exclusively as tional information on pathway development, implementation, and
positive: increasing expenditure was considered to improve quality, troubleshooting is readily available in published sources.87,88
and vice versa. In the light of our current understanding, however,
COORDINATION OF CARE
differential effects on the cost-benefit and the cost-harm curves can
be seen to alter the relation of quality to cost [see Figure 1].72 By preventing duplication of tests and unnecessary delays, coor-
dination of care both improves patient satisfaction and saves
CLINICAL DECISION ANALYSIS
money. The most frequent causes of delay are scheduling of tests
Analysis of clinical decision making involves quantifying the (31%), followed by unavailability of postdischarge facilities (18%),
effect or impact of each option involved in a medical decision.The physician decision making (13%), discharge planning (12%), and
outcome of each decision thereby acquires a probability, and each scheduling of surgery (12%).89 The growing complexity of health
component of the decision tree carries an explicit assumption that care makes teamwork increasingly essential.
DISEASE MANAGEMENT
meaningfulness of a given functional status. For instance, patient
Comprehensive management of disease goes beyond coordina- A may not be able to walk as far as patient B, but whether patient
tion of care and emphasizes preventive measures. Disease man- A actually has a poorer quality of life depends on the context in
agement is most applicable to a relatively large group of patients which that poorer functional status is placed.96
with a given health problem within a given health system or prac- Calculation of QALYs is confounded by several factors.80,97 For
tice. Such management uses an explicit, systematic population- instance, estimates of the future value of an outcome measure may
based approach to identify patients at risk, intervene with specific vary with the circumstances prevailing at the time of assessment
programs of care, and measure clinical and other outcomes.90 (e.g., acute pain) or with the patient’s age (e.g., the elderly often
place great value on the ability to live independently).Thus, quality
of life may be more important than longevity.98 Calculation of
Analysis of Cost-Effectiveness QALYs may also be affected by gender, ethnicity, socioeconomic sta-
In simple terms, cost-effectiveness reflects the cost of a health tus, religious beliefs, and other factors that affect attitudes about
care intervention (usually expressed in dollars) in relation to out- health care.Adjusting outcome measures to account for health status
come. It is distinct both from the cost-benefit ratio, which mea- and severity of illness before treatment can also be difficult.99
sures return on investment (with both the numerator and the Still another factor confounding determination of QALYs is
denominator expressed in dollars), and from efficiency, which that patients, providers, and health care purchasers may have dif-
measures productivity (with outputs divided by inputs). Analysis ferent perspectives on the experiential, physiologic, and resource-
of cost-effectiveness, by definition, compares two approaches to a related dimensions of QALYs. These differences may be reflected
given problem, with the numerator reflecting any difference in cost in different views about which measure is best for judging the out-
come of a given intervention. Thus, the hospital administration is
and the denominator reflecting any difference in quality.The com-
likely to emphasize length of stay and cost, whereas the surgeon
parison can be between two interventions, between an interven-
and the patient are more likely to emphasize morbidity, mortality,
tion and no intervention, or between early and delayed treat-
and subsequent quality of life. When these various perspectives
ment.91 Beneficial changes in one component of the cost-effec-
disagree about the outcome of a decision (as when an outcome
tiveness ratio can be outweighed by adverse changes in the other,
deemed successful by a provider does not satisfy the patient), the
and vice versa. For example, a study of appendicitis noted that for disagreement further complicates the assessment of quality.
each 10% increase in diagnostic accuracy, there was a 14%
increase in the perforation rate.92 In this case, the cost (i.e., DETERMINATION OF COST
increased morbidity from perforation) might be the price paid for Definition and attribution of cost are also complex issues.
the benefit derived (i.e., greater diagnostic accuracy). Any savings Practice costs are relatively easy to identify. Hospital costs, howev-
achieved up front might be lost in the long run because of more er, are much more intricate; as has been well said, “cost is a noun
advanced or complicated illness. that never really stands alone.”100
MEASUREMENT OF QUALITY
A first step in unraveling the complexity of cost is to understand
the distinction between costs and charges. Charges reflect price
To calculate cost-effectiveness, it is necessary to understand the structure but are a poor reflection of actual costs. Costs can be calcu-
principles underlying the measurement of both quality and cost. lated as an aggregate fraction of charges, and this aggregate ratio is
Under the new concept of quality, the preferred outcome measure often relatively constant among institutions. Nevertheless, substantial
is health care–related quality of life, typically expressed in terms of variations exist among institutions regarding the relation between
quality-adjusted life years (QALYs),93,94 which reflect the length of charges and costs for specific goods and services. Such variations re-
time for which a patient experiences a given health status. There sult partly from differences in accounting systems and partly from
are several methods of quantifying QALYs.95 Some of these meth- contractual differences with payors. However, they also arise as a
ods include objective measures (e.g., functional status), whereas consequence of substantial differences in cost attribution, and these
others are based entirely on subjective estimates of well-being.The differences are evident even with the relatively standardized account-
objective measures emphasize patient-desired outcomes and the ing standards required by the Centers for Medicare and Medicaid
Table 4 Categories and Types of Hospital Costs
Category Type Example or Definition
Direct Salaries, supplies, rents, and utilities

Traceability to the object being costed
Indirect Depreciation and employee benefits
Variable Supply
Behavior of cost in relation to output Fixed Depreciation
or activity Semivariable Utilities
Semifixed Number of full-time equivalents per step in output
Management responsibility for control — Often limited to direct, variable costs
Avoidable costs Costs affected by a decision under consideration

Sunk costs Costs not affected by a decision under consideration
Future versus historical Incremental costs Changes in total costs resulting from alternative courses of action
Opportunity costs Value forgone by using a resource in a particular way instead of
in its next best alternative way
Services (CMS) (formerly the Health Care Financing Administra- cedure being offset by an increase in procedure volume and an
tion [HCFA]). For instance, data from 1996 indicated that best actual increase in aggregate costs. Given such results, it is under-
practice for expense per 100 minutes of OR time was $511, but the standable that patients, providers, purchasers, and investigators
national median was $938—a 46% variance.101 It is difficult to de- might all reach differing opinions about the value of new technol-
termine how much of this variation is due to differences in account- ogy. Similarly, the added costs of a complication in a single patient
ing and how much to differences in efficiency. can be considered with respect to the frequency of that complica-
To better understand cost behavior, it is useful to recognize that tion in the entire population undergoing a given treatment.109
health-related costs commonly fall into one of four general cate- Priorities for quality improvement efforts to prevent complications
gories [see Table 4]. For surgeons, the first two—the behavior of cost should consider both the incidence of the complication and its
in relation to output or activity and the traceability of costs—are per- independent contribution to resource use.
haps the most important.Within these general categories, there are Perspectives on cost-saving can vary among the different com-
several types of costs that are worth considering in further detail. ponents of the health care system. A 1996 consensus statement
Variable costs, such as supplies, change in a constant proportion- recommended adoption of better standards to improve the com-
al manner with changes in output; fixed costs do not change in re- parability of cost and quality.94,110,111 The panel advocated that cal-
sponse to changes in volume. Semivariable costs (e.g., utilities) in- culations be based on the perspective of society as a whole rather
clude elements of both fixed and variable costs; there is a fixed basic than on that of patients, providers, or purchasers. Otherwise, the
cost per unit of time and a direct, proportional relation between vol- panel concluded, costs incurred by patients or others, such as out-
ume and cost. Semifixed costs (also known as step costs) may patient medication or home care after hospital discharge, might be
change with changes in output, but the changes occur in discrete deemed irrelevant from the purchaser’s perspective.
steps rather than in a constant proportional manner. An example of A unilateral perspective may also disregard some outcomes. For
a semifixed cost is the number of full-time equivalents (FTEs) re- example, how soon patients return to work after an illness may mat-
quired for a particular output. If one FTE can produce 2,000 wid- ter little to a health maintenance organization (HMO) or a govern-
gets, every 2,000-unit change in widget output will be associated ment program but may matter a great deal to the patients them-
with a change in labor cost: for every 2,000-unit increment in out- selves, their employers, or the government agency responsible for
put, one more FTE is needed (with a concomitant increase in disability payments—and probably to most surgeons.
costs), and for every 2,000-unit decrement, one fewer FTE is need-
QUANTIFICATION OF COST-EFFECTIVENESS
ed (with a concomitant decrease in costs). Unless the step threshold
is attained, costs do not change. Thus, a semifixed cost might be Because it is a ratio, cost-effectiveness may be affected by
considered either a variable cost or a fixed cost, depending on the changes in either the numerator (cost) or the denominator (qual-
size of the steps relative to the range of output. Unfortunately, stan- ity) [see Table 5]. Thus, changes in cost-effectiveness can occur
dard protocols for reporting this information often are not avail- through either a relative reduction in cost or a relative improve-
able,102 and the lack of such protocols makes it more difficult to ment in quality. Moreover, quality improvements will be a func-
compare cost analyses of clinical interventions. tion of both the extent and the duration of the improvement.
Cost traceability is classified as direct or indirect. Examples of The various confounding factors notwithstanding, good data
direct costs are salaries, supplies, rents, and utilities; examples of are available on the relative cost-effectiveness of some common
indirect costs are depreciation and administrative costs associated medical interventions [see Table 6].112 The median medical inter-
with regulatory compliance. However, not all costs classified as vention cost is $19,000/year of life. The figure of $50,000/year of
indirect are necessarily indirect in all circumstances. In some situ- life saved has often been put forward as a threshold for cost-effec-
ations, they could be defined as direct costs, with the specific clas- tiveness; however, any such thresholds remain both arbitrary and
sification depending on the given cost objective. relative and are not necessarily indicative of an intervention’s soci-
One technique that can help clarify costs is the creation of a etal value. For instance, the Oregon state health plan prioritized
matrix in which cost type is plotted against cost traceability.Thus, benefits on the basis of broad input from stakeholders rather than
variable costs can be direct or indirect, and direct costs can be a stratified list of $/QALYs.113 Physician leadership is particularly
variable, semivariable, semifixed, or fixed. More often than not, crucial in this context because the majority of health care costs are
costs are categorized according to a decision maker’s specific related to the decision to provide care, not to the question of
needs. The subcategory to which a given cost is assigned, howev- which options for care should be selected.
er, often depends on whose point of view is assumed—the pur-
chaser, the provider, or the patient.103,104 A key point is that physi-
cians primarily affect costs via their impact on variable costs (e.g., Implications of Outcome Variations
fully variable or semifixed costs), yet these costs typically consti- Although it is human nature for each surgeon to believe that he
tute no more than 15% to 35% of hospital costs.104,105 or she is among the best, the data clearly show considerable vari-
The interval between the intervention and the point of mea- ation in resource use and outcomes among surgeons and among
surement can also affect estimates of cost-effectiveness.106,107 hospitals.114 These variations are often relatively large, sometimes
Whereas patients are likely to view outcomes over the long term, exceeding 200% or even 300%. Some of the discrepancies report-
providers and purchasers tend to focus on the short term (e.g., the ed can be accounted for by the natural variability of biologic
term of a health care contract). This difference in perspective processes, and some by differences in disease severity; however,
affects the calculation of QALYs, which, in turn, affects the deter- the majority of the variations are unexplained.
mination of cost-effectiveness. Health care purchasers are well aware of these variations and
It is also useful to distinguish between per-procedure costs at use claims data to create performance profiles of hospital and
the hospital level and aggregate procedure costs at the insurer physician costs and outcomes and to establish benchmarks toward
level. This distinction was clearly an issue with the advent of which providers are expected to strive.The potential problem with
laparoscopic cholecystectomy,108 which saw lower costs per pro- such benchmarks is that they tend to reflect an ideal or excep-
Table 5 Cost-Effectiveness Studies of Selected Surgical Procedures
Procedure $/QALY ∆ QALY Comment
The initial cost of endarterectomy is offset by the high cost of care after a major
Carotid endarterectomy in asymptomatic stroke; the relative cost of surgical treatment increases substantially with
patients74 8,000 +0.25 increasing age, increasing perioperative stroke rate, and decreasing stroke
rate during medical management
Routine radiation therapy after conservative The ratio is heavily influenced by the cost of radiation therapy and the quality-
28,000 +0.35
surgery for early breast cancer186 of-life benefit that results from a decreased risk of local recurrence
Total hip arthroplasty for osteoarthritis of the 117,000 in The cost savings result from the high cost of custodial care associated with
+6.9
hip: 60-year-old woman187 cost savings dependency
Total hip arthroplasty for osteoarthritis of the

4,600 +2 —
hip: 85-year-old man187
Endoscopic versus open carpal tunnel Cost-effectiveness is very sensitive to a major complication such as median
195 +0.235
release188 nerve injury
Cost-effectiveness results from the moderate costs of lumbar diskectomy and

Lumbar diskectomy189 29,200 +0.43
its substantial effect on quality of life
tional patient population.115 Thus, efforts to meet the mandated some states publicly disclosed provider-specific data on outcomes
performance levels might actually increase the risk of adverse out- of cardiac surgery. Their intent was to educate the public regard-
comes in complicated patients who need more extensive care. ing the choice of health care providers. Although these efforts used
A significant limitation of practice profile comparisons is that more criteria than were available through DRGs alone,125,126 the
they cannot fully account for disease-severity factors that affect profiles remained highly controversial because they still did not
outcome. Adjustments for disease severity are difficult to make on adequately account for all the differences in case severity. Because
the basis of claims data because in many cases, the requisite data current severity adjustments may not reflect differences attribut-
either is not collected or is miscoded.116 Medical-record review is able to patient selection, surgeons operating on truly high-risk
much better at accounting for severity, but it is also significantly patients will, all other factors being equal, have poorer outcomes
more cumbersome and costly. Even with medical-record review, than surgeons operating on lower-risk patients. However, all other
the effects of comorbid conditions on cost and outcome can be factors may not be equal. If the latter group of surgeons operated
difficult to sort out; as a result, much of the cost variation will still on the former group’s patients, the outcomes might even be worse,
be unaccounted for.117 Moreover, some differences in cost and and if the former group operated on the latter group’s patients, the
length of stay are related to factors that are not under surgeons’ outcomes might even be better. Such patient selection among
direct control, such as patient age, patient gender, and various cul- practices is a well-recognized phenomenon.127
tural, ethnic, or socioeconomic factors extrinsic to the medical Public release of provider outcome data may also have unin-
care system.118-120 Selection bias may affect outcome reporting as tended consequences. For instance, it has been suggested that
well.121 High rates of functional health illiteracy can also have an publicizing provider outcomes creates incentives to reduce risk-
adverse effect on compliance (and hence on outcomes).122 adjusted mortality by avoiding high-risk patients.128,129 In a 1996
Current methods, therefore, can result in very different estimates study, although consumer guides containing provider-specific out-
of cost-effectiveness for the same intervention. Despite the short- come data appeared to improve quality of care, they also appeared
comings of these methods, it is likely that health care purchasers will to have limited credibility among cardiovascular specialists.129
continue to use claims data and medical record review to assess cost- Surveys also indicated that the data were of limited value to the
effectiveness.The issue, then, is not whether such assessments will be target audience (i.e., patients undergoing cardiac surgery).
made but rather to what extent they will be used and for what pur- The success of provider report cards in prompting quality
poses.The Leapfrog Group (http://www.leapfroggroup.org) has tak- improvement depends on several factors.130 The added value of
en the lead in this area.This organization increasingly focuses on the such reports is likely to result in an increase in their availability to
differences in cost and outcome evidence and uses these data to rec- the public.131 As examples, one Web site (http://www.healthgrades.
ommend referral patterns. A 1995 national survey found that 39% com) contains hospital specialty data on cardiac, orthopedic, neu-
of managed care organizations were moderately or largely influenced rologic, pulmonary, and vascular surgery; transplantation out-
in initial physician selection by the physician’s previous patterns of comes are available from the United Network for Organ Sharing
costs or utilization, and nearly 70% profiled their member physi- (http://www.unos.org). There are numerous other Web sites that
cians.123 At least one HMO recognized that practices with high focus on health care quality [see Table 7].
scores on service and quality indicators attracted significantly more In contrast to the equivocal results of payor-based efforts, physi-
new enrollees than practices with lower scores did.124 cian-based quality-improvement efforts have had unquestioned
A somewhat controversial step has been the distribution of success. Perhaps the most notable of these latter efforts is that ini-
provider outcomes directly to the public in the form of report tiated by the Northern New England Cardiovascular Disease
cards. In an early effort, HCFA (now CMS) calculated mortality Study Group, which has developed a multi-institutional regional
data for individual hospitals using a risk-adjustment model based model for the continuous improvement of surgical care.132 The
on DRGs. After many years, however, HCFA acknowledged the success of this group’s approach rests on several key characteris-
flaws in the associated mortality model and stopped releasing tics: there is no ambiguity of purpose, the data are not owned by
these data. Subsequently, both HCFA (using Medicare data) and any member or subgroup of members, members have an estab-
lished safe place to work, a forum is set up for discussion, and reg- effective change strategies include reminders, patient-mediated
ular feedback is provided. Using a systems approach, the group interventions, outreach visits, input from opinion leaders, and mul-
effected a 24% reduction in hospital mortality for cardiac surgery tifaceted activities. Specific factors reported to increase the proba-
and reduced variation in outcomes among group members. The bility of a practice change are peer interaction, commitment to
decrease in mortality was considerably greater than that reported change, and assessment of the results of change.133 Additional evi-
by HCFA and by state report cards for similar procedures. Despite dence suggests that improvement in care is more likely to occur
concerns that releasing such findings would lead to unfavorable with CME activity that is directly linked to processes of care.134-138
publicity, no such reaction occurred. It is noteworthy that the Indeed, many of these features of practice change were employed
process the group developed did not involve personal criticism or both in the model developed by the Northern New England
attempt to identify the proverbial bad apples.Three important con- Cardiovascular Disease Study Group and in the subsequent
clusions can be drawn from the results reported: (1) physician-ini- national study by the Society of Thoracic Surgeons, which used
tiated interventions are likely to be more effective than external process measures to improve outcomes from coronary artery
review in improving quality, (2) a systems approach to quality bypass graft (CABG) surgery.139
improvement is better than the bad-apple approach, and (3) it is The current interest in assessing surgeons’ performance is not
possible to conduct quality-improvement programs involving prac- new, nor is the plea for that assessment from surgeons. In the early
tice groups that might otherwise be viewed as competitors. years of the 20th century, Ernest A. Codman, a Boston surgeon,
Although self-assessment of quality and cost-effectiveness may crusaded for hospitals and surgeons to publicize their results; his
seem daunting, the most difficult step may be the willingness to efforts typically met with varying degrees of disinterest or even
initiate the process. Studies of practice change in relation to con- defensiveness.140 Today, in the early years of the 21st century, it is
tinuing medical education (CME) consistently emphasize that clear that efforts to profile surgeons, despite their methodologic
shortcomings, are unlikely to go away. Surgeons who respond to
such efforts dismissively or defensively (e.g., by attempting to
explain away any outcome variations simply by stating, “My
Table 6 Cost-Effectiveness of Common
patients are sicker”) will be forgoing the opportunity to reestablish
Surgical Interventions92 the authority of the medical profession on the issue of quality.
Surgeons who preemptively familiarize themselves with their own
Cost-Effectiveness outcome data, on the other hand, will be better positioned to
Intervention ($/QALY)
respond appropriately to external review.
Mammography and breast exam (versus exam One must accept from the outset that self-assessment is an
95,000
alone) annually for women 40–49 yr of age ongoing process akin to peeling an onion: initial steps inevitably
lead to deeper analyses. Even simple data charts may reveal
Mammography and breast exam (versus exam
alone) annually for women 40–64 yr of age
17,000 changes or patterns in a surgeon’s outcomes or resource con-
sumption that might not otherwise be obvious.141 Sometimes,
Postsurgical chemotherapy for premenopausal
18,000
merely standardizing a process is enough to improve outcomes sig-
women with breast cancer nificantly. With time, strategies for optimal practice emerge.142,143
An important concept in looking at outcome measures and
Bone marrow transplant and high (versus standard)
130,000 processes of care is that for any given outcome measure to be a
chemotherapy for breast cancer
valid index of improved quality, it should also be intimately relat-
Cervical cancer screening every 3 yr for women ed to the processes of care.30
≤ 0*
older than 65 yr
Cervical cancer screening annually (versus every

3 yr) for women older than 65 yr
49,000 Relation of Volume to Outcome
An emerging aspect of cost-effective surgery is the finding,
Cervical cancer screening annually for women reported in numerous studies, that outcome appears to be posi-
82,000
beginning at age 20
tively correlated with volume: surgeons and hospitals that do an
One stool guaiac colon cancer screening for operation more frequently tend to do it better.144-149 This finding
660
persons older than 40 yr led the National Cancer Policy Board of the Institute of Medicine
and the National Research Council to conclude that patients
Colonoscopy for colorectal cancer screening for
90,000 requiring complicated cancer operations or chemotherapy should
persons older than 40 yr
be treated at high-volume facilities. There also appears to be an
Left main coronary artery bypass graft surgery
2,300 inverse relation between volume and cost.150,151 Thus, high volume
(versus medical management)
may have a positive effect on both the numerator and the denom-
Coronary artery bypass surgery for octogenarians190 10,424 inator of the cost-effectiveness ratio. Similar arguments have been
made with regard to the issue of surgical subspecialty training.152
Exercise stress test for asymptomatic men 60 yr
40
These findings form the basis of the Leapfrog Group’s recom-
of age mendations regarding the minimum numbers of CABG proce-
Compression stockings to prevent venous
dures, esophagectomies, carotid endarterectomies, and aortic
≤ 0* aneurysmectomies required for acceptable outcomes.
thromboembolism
It must be kept in mind, however, that the data in these studies
Preoperative chest x-ray to detect abnormalities represent associations and probabilities, not cause-and-effect rela-
360,000
in children
tionships.153 Thus, one cannot conclude that low volume is always as-
*Saves more resources than it consumes. sociated with poorer outcomes and high volume with better out-
QALY—quality-adjusted life year comes. Because some measures can be convincingly assessed only in
Table 7 Selected Web Sites Focusing on Health Care Quality
Organization (Web Address) Comment
The NCQA accredits managed health care plans and develops and refines the Healthplan Employ-
National Committee for Quality Assurance (NCQA)
er Data and Information Set (HEDIS). Many of the measures involve screening (e.g., mammogra-
(www.ncqa.com)
phy) and/or prevention (e.g., smoking cessation).
FACCT is a national organization dedicated to improving health care by advocating for an account-
Foundation for Accountability (FACCT) (www.facct.org)
able and accessible system.
National Forum for Health Care Quality Measurement NQF is a private, not-for-profit membership organization created to develop and implement a na-
and Reporting (ww.nqf.org) tional strategy for health care quality measurement and reporting.
Leapfrog is composed of more than 140 public and private organizations that provide health bene-
The Leapfrog Group (www.leapfroggroup.org) fits. The group works with medical experts to identify problems and to propose solutions that it
believes will improve hospital safety. It represents more than 34 million health care consumers in
all 50 states.
Joint Commission on Accreditation of Healthcare

The JCAHO develops standards and accredits health care organizations throughout the United States.
Organizations (JCAHO) (www.jcaho.org)
The institute offers resources and services to help health care organizations make dramatic and
Institute for Healthcare Improvement (www.ihi.org)
long-lasting improvements that enhance outcomes and reduce costs.
Institute for Health Policy (www.mgh.harvard.edu/

The institute is dedicated to conducting world-class research on central health care issues.
healthpolicy)
This organization was created to build consumer demand by providing information on quality rat-
QualityCounts (www.qualitycounts.org) ings for medical groups and hospitals in its network; tips for choosing doctors or hospitals; and in-
formation on dealing with medical errors.
The Commonwealth Fund supports and publishes studies in the broad area of health care quality.
The Commonwealth Fund (www.cmwf.org)
The study results are available on its Web site.
The NPSF identifies and creates a core body of knowledge; identifies pathways to apply that
National Patient Safety Foundation (www.npsf.org) knowledge; develops and enhances the culture of receptivity to patient safety; and raises
public awareness and fosters communications about patient safety.
Agency for Healthcare Research and Quality AHRQ is a branch of the Department of Health and Human Services that focuses on funding and
(www.ahrq.org) reporting health services research. Its Web site is an excellent resource of knowledge.
A nonprofit advocacy organization active in both state (primarily New York) and national efforts to
Center for Medical Consumers (www.medicalconsumers.org) improve the quality of health care. Its Web site is regularly updated with articles on issues of
health care quality, including a report on volume-outcomes in carotid endarterectomy.
large patient populations, outcome comparisons can be highly prob- physician-initiated) alternatives do not emerge, then other, less
lematic when one is dealing with unusual or infrequent cases. More- desirable options are likely to be imposed.
over, the relative importance of hospital volume and surgeon volume
may vary with specific procedures: complex, team-dependent proce-
dures (e.g., CABG surgery) may be more dependent on hospital vol- Practical Issues in Improving Cost-Effectiveness
ume, whereas less complicated procedures may be more dependent The OR is a frequent target for improved efficiency, and specif-
on surgeon volume. In the Veterans Administration National Surgi- ic guidelines for achieving this end are available.158-160 Perceived
cal Quality Improvement Project’s large study of eight common sur- delays in room turnover are a common complaint, for which the
gical procedures, which used medical-record data rather than claims responsibility is variously assigned to nurses, anesthesiologists, and
data, no correlation could be established between institutional oper- surgeons themselves. Maintaining large inventories to satisfy indi-
ative volume and postoperative mortality.154 It remains unclear, vidual surgeon preferences also contributes to higher costs, and
therefore, whether practice makes perfect or perfect makes practice. the growth of minimally invasive surgery has added new dimen-
The announced thresholds for given procedures are also fraught sions to this challenge [see 1:1 Preparation of the Operating Room].161
with methodologic problems.155 Key issues in this setting include reusable versus disposable equip-
The empirical relation between surgical volume and outcome ment, the varying costs of different types of equipment used to
has led to proposals for regionalization of care.156 Regionalization accomplish the same task, and just-in-time inventory. Major pieces
has proved effective in trauma care, but the basis of the improved of equipment are often duplicated to allow similar cases to be per-
quality in this setting may be better systems of care, not higher vol- formed simultaneously in different rooms, but this duplication
ume per se.This view is consistent with the findings that not every often means that the equipment may be idle for relatively long
high-volume provider has better outcomes and not every low-vol- periods. More efficient use of such equipment reduces costs, but
ume provider has poor outcomes. Regionalization of care without it requires levels of cooperation and coordination among surgical
a solid understanding of the basis of the volume-outcome rela- staff members that can be hard to achieve.
tionship has the potential to create unintended or even adverse To improve efficiency, the surgical team must think of the OR
consequences for other types of care. Consequently, many believe less as a workshop and more as a factory. Surgeons, having been
that it is too soon to use these volume-outcome data as surrogates steeped in the view that they are the “captain of the ship,” often
for quality or as criteria for establishing policy.157 Nonetheless, the have a hard time embracing the view that all members of the sur-
pressure to reduce cost remains strong; if suitable (preferably gical team have interdependent goals for quality maintenance and
cost reduction. However, these two perspectives are not mutually how effectively they can address the issues of quality and cost. In
exclusive. Successful team efforts have led to cost reductions in particular, it is essential that they address both variations in interven-
trauma care162,163 and to the use of protocols to guide ventilator tion rates and variations in outcomes. Medical decision making
weaning.164,165 Moreover, the relative contributions of individual must increasingly be evidence based. Financial constraints will place
and institutional cost-effectiveness are such that improving the growing pressure on payors to reimburse surgeons and hospitals
former may have little impact if the latter is not improved as well. only for those procedures with clear indications, suitably low mor-
Ambulatory surgical units are often heralded as a cost-saving bidity and mortality, or both.This has already occurred with lung re-
measure. However, the aggregate savings are likely to depend on duction surgery for end-stage chronic obstructive pulmonary disease
existing OR capacity and on specific payor issues.166 (COPD). Although this procedure was being performed more and
It is worthwhile for surgeons to familiarize themselves with the more frequently, there was little hard evidence indicative of long-
broader organizational efforts aimed at improving quality in term efficacy. As a result, HCFA announced that it would pay for
health care [see Table 7].167-169 Such efforts may indeed help the procedure only if it was performed as part of a clinical trial aimed
improve care significantly; however, the most meaningful at confirming such efficacy; other payors quickly followed suit.173
improvements in care are likely to arise from efforts initiated at the Only in the past few years did the results of an RCT clarify the role
grassroots level. of lung reduction surgery for COPD.174
Academic medical centers are no more immune to the current
changes in health care than nonacademic centers are. In fact, they
Ethical and Legal Concerns face special challenges.175 Teaching hospitals are under growing
Efforts to improve cost-effectiveness are often seen as forcing pressure to subsidize education and research from their clinical
health professionals to face conflicts between the ethic of patient incomes, even while reimbursement is being increasingly restrict-
advocacy, on one hand, and pressures to make clinical decisions for ed.176 A 1997 study examining the relation between National
societal purposes and on behalf of third parties, on the other. Institutes of Health awards and managed care penetration in aca-
Although resolving these tensions may seem difficult,170 the med- demic medical centers found the two to be inversely related.177
ical profession is no stranger to such potential conflicts. The vast Other studies indicated that increased competitiveness within
majority of physicians successfully avoid the temptations inherent health care markets seemed to hinder the capacity of academic
in fee-for-service care, and at least as many appear to avoid incen- health centers to conduct clinical research and foster the careers
tives to undertreat. Although some believe that evidence-based of young faculty members.178,179 Nevertheless, despite higher
practices derived from large populations may not be readily applic- costs, teaching hospitals continue to demonstrate better out-
able to individual patients, the rationale for this belief is not clear. comes, even for rather low-technology interventions.180,181
One area that frequently generates controversy is the high costs A concern for the future is that academic medical centers may
of the terminal stages of life, particularly among patients who lose the capacity for producing the evidence on which cost-effec-
require intensive care. To mitigate the dilemma faced by physi- tive practice must be based—circumstances that would be tanta-
cians involved in making life-ending decisions, increasing empha- mount to eating the proverbial seed corn.182
sis is being placed on patient self-determination. However, even It is curious that despite the frequently expressed concerns
when physicians and institutions make efforts to comply with the about quality, competition over price still appears to be a much
choices of patients or their families in the setting of terminal ill- more urgent issue than competition over quality is.183 It seems log-
ness, costs are not always reduced, nor are outcomes always ical, however, that at some point, concerns about how much is
improved.171 The actual savings may be small.172 being paid out will give way to questions about why something is
being paid for. Physicians are the only participants in the health
care system who have the knowledge and skills needed to address
The Future the challenges of identifying cost-effective care. If they can
Physicians undoubtedly have a role to play in the ongoing discus- respond constructively to these challenges, rather than simply
sion and debate on the future of the health care system in the United ignore or dismiss them, they stand a good chance of recapturing
States.The extent of their input in this debate is likely to depend on much of their lost status and autonomy.
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ELEMENTS OF CONTEMPORARY PRACTICE 10 HEALTH CARE ECONOMICS: THE LARGER CONTEXT — 1
10 HEALTH CARE ECONOMICS:

THE LARGER CONTEXT
Charles L. Rice, M.D., F.A.C.S., and Robert S. Rhodes, M.D., F.A.C.S.
In another chapter [see ECP:9 Elements of Cost-Effective Non- rent reflection of a long-term trend in which health care costs in
emergency Surgical Care], we review the principles of cost-effective the United States have risen continuously since 1966 (the year in
surgical care and discuss the implications of such principles for which Medicare and Medicaid were implemented) [see Figure 1].
health care spending. Our primary focus there is on the interac- Economists differ on whether such spending represents a risk to
tion between an individual surgeon and an individual patient. In the overall economic well-being of the United States. Those who
this chapter, we explore some of the issues surrounding health care are concerned about both the amount that is spent on health care
spending on a larger (i.e., national) scale. Although the data pre- and the rate at which this amount is growing cite the following
sented come from the United States, many of the challenges iden- concerns:
tified are faced by other industrialized nations as well. We believe
1. In spending more on health care, society spends less on
that it is important for surgeons to have a broad understanding of
other goods and services—a process referred to as dis-
these issues, in particular because such concerns are increasingly
placement. Thus, health care consumes resources that
becoming the subject of political debate.
might otherwise have been allocated to services such as
education or public safety.
United States Health Care Expenditures 2. The health care market is imperfect; therefore, some health
care spending is inevitably wasteful [see ECP:9 Elements of
SPENDING LEVELS Cost-Effective Nonemergency Surgical Care].
3. The health care sector of the economy is so large—not only
In 2002, U.S. National Health Expenditures (NHE) amounted
in terms of the amounts of money involved but also in
to $1.6 trillion (approximately 14.9% of the gross domestic prod-
terms of the number of people employed—that short-term
uct [GDP]).1 According to data from the World Bank
changes in its growth rate (in either direction) necessarily
(http://www.worldbank.org/data/databytopic/GDP.pdf), if the cur-
exert substantial and painful economic effects.
rent level of U.S. health care spending were viewed as a separate
4. As costs increase, voluntary participation by employers in
economy, it would be the fourth largest economy in the world, sur-
the provision of health insurance to employees and retirees
passing the GDP of the United Kingdom. This level of spending
comes under increasing pressure, with the result that
translates into a per capita expenditure of $5,440, which surpass-
employers either shift more and more of the costs of insur-
es the per capita expenditure for the next highest-spending coun-
ance to employees or decide to stop providing health insur-
try, Switzerland, by almost 30%.
ance altogether.2
Between 2000 and 2002, the average annual growth rate for per
capita health care spending was 7.1%, a rate that, if sustained, A major concern about the considerable swings in the rate of
would result in a figure of $3.1 trillion (17.7% of the GDP) for growth is that it creates the appearance of a health care system in
total NHE by 2012 [see Table 1]. This high growth rate is the cur- constant crisis.3 One need look no further than the news stories in
Table 1 Average Annual Growth from Previous Year:

United States, 2000–2002
2000 2001 2002
Category
Total (Growth) Total (Growth) Total (Growth)
National health expenditures (NHE) ($ billion) 1,309.4 (6.2%) 1,420.7 (8.5%) 1,553.0 (9.3%)
Hospital care expenditures ($ billion) 413.2 (4.0%) 444.3 (7.5%) 486.5 (9.5%)
Physician and clinical services expenditures 290.3 (6.4%) 315.1 (8.6%) 339.5 (7.7%)
($ billion)
Prescription drug expenditures ($ billion) 121.5 (17.1%) 140.8 (15.9%) 162.4 (15.3%)
Population (million) 280.4 (0.9%) 282.9 (0.9%) 285.5 (0.9%)
Per capita NHE ($) 4,670 (5.2%) 5,021 (7.5%) 5,440 (8.3%)
Gross national product (GDP) ($ billion) 9,825 (5.7%) 10,082 (2.6%) 10,446 (3.6%)
NHE as percentage of GDP (%) 13.3 14.1 14.9

have profound implications for efforts aimed at constraining fur-

ther growth in health care spending.
Per Capita National Health Spending ($)
4,000 In 1996, almost half (44.2%) of total NHE was accounted for
by just 15 conditions [see Table 2].8 Even a casual glance at this
3,200 short list of conditions reveals how many of them are potentially
avoidable; obvious examples include motor vehicle accidents,
chronic obstructive pulmonary disease, and respiratory malignan-
2,400
cies. These findings illustrate how public policy decisions (or the
lack of them) can result in costs that are attributed to the health
1,600 care system. Another study found that in 1998, 9.1% of total
NHE ($78.5 billion) was related to obesity and overweight—a
percentage comparable to that related to smoking.9
800
It is also noteworthy that a small fraction of the population
accounts for the majority of health care spending. An analysis of
0 data from the 1987 National Medical Expenditure Survey and the
1966 1970 1980 1990 2001
1996 Medical Expenditure Panel Survey revealed that for both
Year periods surveyed, 5% of the population accounted for more than
Figure 1 Shown is the increase in per capita national health
half (55%) of total spending and 10% of the population for near-
care spending between 1996 and 2001.2 ly 70%.10 One implication of these findings is that any efforts to
constrain health care spending that focus on the 90% of the pop-
ulation responsible for only one third of expenditures are unlikely
the press in the United States to read of bankrupt hospital systems to have a major impact.
on one hand and cases of excessive profit-taking on the other.
Those who do not hold this pessimistic view of current health Factors Influencing Demand for Health Care
care spending argue that the health care share of GDP has no nat-
ural limit and that the only issue is whether the value of health AGING OF POPULATION
care spending is higher or lower than that of the spending it dis-
places.4 Intrinsic to this argument is the notion that the appropri- Although many believe that the aging of the United States pop-
ateness of spending can be judged only by taking the long view. ulation is a key factor driving the increase in HCE, several studies
Proponents of this viewpoint assert that it is alarmist to be overly suggest otherwise. A 1992 study estimated that total NHE in 2030
concerned about short-term changes in the rate of growth and would be $16 trillion, reflecting an estimated average growth rate
maintain that over the long term, the current growth rate is sus- of 8.3% (a rate that proved to be remarkably close to the observed
tainable. According to this school of thought, it is health care increase over the subsequent decade).11 Only 0.5% of this $16 tril-
spending in the economy as a whole that ought to be the focus, lion could be attributed to the aging of the population. A subse-
not the fraction of the total cost borne by a specific sector.5 quent report estimated that less than 1 percentage point of the
Regardless of which perspective is closer to the truth, it is abun- annual growth through the 1990s could be accounted for by
dantly clear that to date, no approach by either the public or the aging.12 Studies involving the Canadian population13 and multiple
private sector has significantly reduced—much less reversed—the national populations14 reached similar conclusions.
rate at which health care spending is growing [see Figure 2].6 The implications of these findings for health policy are not
entirely clear. It has been argued, however, that if the gradual aging
SERVICES PURCHASED of the United States population over the coming three decades
Elsewhere [see ECP:9 Elements of Cost-Effective Nonemergency is accompanied by a change in practice patterns from those
Surgical Care], we discussed the appropriateness (or lack thereof)
of a variety of services purchased with health care dollars.We also
Change in Per Capita Private Health Spending (%)
+10
pointed out that the United States ranks well behind other indus-
trialized countries in a number of well-accepted indicators of a +8
population’s health.
However, we need not look beyond the United States for evi- +6
dence that increased health care expenditures are not invariably
associated with demonstrable improvements in health outcomes. +4
Several major studies have shown that patients treated in higher-
spending regions of the United States do not have either better +2
health outcomes or greater satisfaction with their care than
patients treated in lower-spending regions.7 One such study 0
reported that the differences in spending were largely attributable
to the higher frequency of physician visits, the tendency to consult -2
specialists more readily, the ordering of more tests, the perfor-
mance of more minor procedures, and the more extensive use of -4
1961 1965 1970 1975 1980 1985 1990 1995 2000
hospital and intensive care services in the higher-spending
Year
regions. The authors could find no evidence that these types of
increased utilization resulted in improved survival, better func- Figure 2 Depicted are the percentage changes in per capita pri-
tional status, or enhanced satisfaction with care. These findings vate health care spending between 1961 and 2000.6
spending is a reversal of a trend seen in the mid-1990s, in which

Table 2 The 15 Most Costly Medical Conditions such spending actually declined. Hospital prices increased by 5.1%
in the United States in 2002, a rise fueled in part by the increased payment rates hospi-
tals have negotiated with health plans and in part by increased
Estimated No. of demand for services.
Condition Patients National Cost Projecting future spending on hospital services is difficult.
(Million) ($ Billion)
Some authorities assert that because of declining disability rates,
Ischemic heart disease 3.4 21.5 the rate at which spending grows will fall over the next several
years.19 Others argue that the factors responsible for the recent
Motor vehicle accident 7.3 21.2 and current increases in spending growth are more likely to con-
tinue than to lessen. Advances in technology are a major factor,
Acute respiratory infection 44.5 17.9
but so too is the current capacity constraint.20
Arthropathy 16.8 15.9 A factor that is likely to play an increasingly important role in
the higher cost of hospital services is the growing cost of labor.
Hypertension 26.0 14.8 From 2001 to 2002, hospital payrolls rose by nearly 8%, a much
greater increase than was seen in other industries. This pro-
Back problem 13.2 12.2
nounced rise is probably attributable to the well-publicized short-
Mood disorder 9.0 10.2 age of nursing and other skilled personnel, which is predicted to
persist for a considerable period despite rising wages. Several fac-
Diabetes 9.2 10.1 tors have been implicated in the reluctance of high-school gradu-
ates to pursue careers in health care, including (1) the perception
Cerebrovascular disease 2.0 8.3
that health care is a low-tech industry, (2) the hierarchical nature
Cardiac dysrhythmias 2.9 7.2 of health care, and (3) the regular hours required by health care
professions.
Peripheral vascular disease 3.4 6.8
TECHNOLOGY
COPD 12.4 6.4
In virtually every sector of the economy, the introduction of
Asthma 8.6 5.7 new technology tends to reduce the cost of a particular service
or good. Health care is one of the few exceptions to this general
Congestive heart failure 1.1 5.2 rule. A 2003 analysis of the relationship between the availability
Respiratory malignancy 0.3 5.0
of advanced technologies and health care spending found that
for certain technologies (e.g., diagnostic imaging, cardiac
COPD—chronic obstructive pulmonary disease catheterization facilities, and intensive care facilities), increased
availability was often accompanied by increased usage (and,
employed in higher-cost regions to those employed in lower-cost
regions, the United States health care system should be able to 250
accommodate the retiring baby-boom generation with minimal
disruption.15
Growth Rate of Major Components
200
PRESCRIPTION DRUGS
of Health Spending (%)
The cost of prescription drugs is increasing much faster than the

cost of any other major component of health care spending [see 150
Figure 3]. It is noteworthy that spending on prescription drugs has
risen sharply since the introduction of direct-to-consumer (DTC)
marketing. Drug companies spend approximately $20 billion per 100
year on advertising and promotion—roughly the same amount that
they spend on research and development.16 Few physicians have
escaped the pressure brought to bear by patients who have heard 50
the promise of a better life in advertisements, and few have been
able to resist the ensuing demand for prescriptions. How this cate-
gory of spending will be affected by the Medicare prescription drug 0
provision enacted in 2003 remains to be seen, but this provision is 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
not generally expected to slow the rate of growth. On the basis of
projections developed before the enactment of this law, prescription Year
drug expenditures were expected to account for one seventh of Nursing Home and
Prescription Drugs Home Health
total health care expenditures by 2012.17
Physician and
Hospital Care
HOSPITAL SERVICES Clinical Services
Spending on hospital services accounts for nearly a third Figure 3 Shown are the growth rates for major components of
(31.3%) of all NHE. Since 2001, growth in spending on hospital health care spending between 1991 and 2001. Data from the
services has slowed somewhat, though it continues to outpace infla- Centers for Medicare and Medicaid Services (www.cms.hhs.gov/
tion and growth in GDP.18 The current growth in hospital inpatient statistics/nhe/historical).
hence, increased spending).21 Although this relationship is not Minneapolis area but more than twice that amount ($8,414) in
uniform across all technologies, the data reinforce the increasing the Miami area.25 Despite the sizable difference in expenditures,
evidence that technological change is the key driver of increased the authors found no differences in outcomes on a risk-adjusted
health spending. basis. A strong case can be made that if no differences in quality,
From a policy perspective, it might be tempting to conclude access, or satisfaction can be demonstrated, much of the difference
that one way of constraining the growth of health care spending in spending may be unnecessary, inappropriate, or ineffective.
would be to restrain the introduction or dissemination of new It is unclear precisely what proportion of total health care
technologies. For political reasons, however, such a step might expenditures represents costs that are greater than the benefits
prove difficult, if not impossible, to implement. In a survey con- that result. Some authors argue the figure is at least one third,26
trasting the interest in new medical technologies demonstrated by but others doubt whether it is that high.27 No one, however, main-
Americans with that demonstrated by Europeans, Americans were tains that this figure is zero. Unfortunately, no system has yet been
found to be more interested in such technologies and to have high- devised that will eliminate such unproductive spending.
er expectations regarding medicine’s capacity for managing illness
COST OF REGULATION AND ADMINISTRATION
or disability.22 To curb Americans’ appetite for new technologies
would require a considerable change in public opinion and per- The United States health care system is notable for its bewil-
ception of the value of such technologies, extensive education of dering array of insurers and contracts.Virtually every physician in
the public regarding realistic expectations, or a willingness on the the United States has had to expend considerable time and effort
part of United States political leaders to impose such a restraint in on dealing with complicated, arcane, and apparently deliberately
the face of public opposition.The last scenario is difficult to imag- confusing rules and practices. As a reaction to this state of affairs,
ine, given current campaign financing. some critics of the system in the United States have asserted that
the adoption of a simplified Canadian-style single-payor health
FAILURE OF MARKET FORCES insurance system would yield large savings in administrative costs
Some economists—and a considerable number of politicians— that could then be used to expand coverage to those who are cur-
believe that unleashing market forces will suffice to constrain the rently uninsured.
cost of health care. It appears, however, that health care does not A 2003 study compared administrative health care costs in the
behave like other sectors of the economy, for a number of reasons. United States with those in Canada. In 1999, per capita health
For one thing, it is difficult for health care consumers to become administration costs amounted to $1,059 in the United States (for
fully informed. For another, health services have the characteris- a total cost of $294 billion), contrasted with $307 in Canada [see
tics of public goods. In addition, health insurance leads to the so- Table 3].28 The authors arrived at these figures by analyzing data
called moral-hazard effect. This term moral hazard warrants a from governments, hospitals, insurance companies, and physi-
brief discussion here. It originated with the purchase of fire insur- cians. They argued that much of the difference between the two
ance in the 19th century, when it was recognized that the owner countries was accounted for by the multiple sources of health cov-
of a property that was insured might have an incentive to incur a erage in the United States, as opposed to the single source in the
loss either by deliberately setting a fire (a moral hazard) or by not Canadian system.
taking steps to reduce the likelihood of fire.The implication of the In an editorial accompanying this report,29 Aaron raised three
moral hazard effect for health care spending is that those who are questions29: (1) Are the differences reported accurate? (2) Would
insured (or more generously insured) will tend to use more health the difference in administrative costs cover the costs for addi-
services. (There is an obvious contrast with automobile insur- tional services under universal coverage? (3) What are the impli-
ance: no one would argue that insured drivers are more likely to cations for the answers for health policy? Aaron argued that the
deliberately wreck their cars.) In the health care setting, such significance of the differences in administrative spending were
behavior is logical in economic terms because for fully insured exaggerated—first, because of the methodology used to compare
persons, the cost of additional health services is borne by all those purchasing power between the two currencies, and second,
who pay insurance premiums. As a consequence, there may be because the original analysis assumed that the relative compen-
substantial demand for services that are of only minimal benefit. sations of clinical and administrative employees were the same in
Because minimally beneficial services may cost as much as any the two countries. He further argued that there was no reason to
other service, the overall benefit derived may be vastly overshad- believe that any costs potentially saved by simplifying adminis-
owed by the cost. tration in the United States would be used to extend coverage.
A complete exposition of this important topic is beyond the Aaron was certainly no defender of the current U.S. system:
scope of this chapter. Further discussion may be found in two I look at the U.S. health care system and see an administrative
excellent texts on health economics.23,24 monstrosity, a truly bizarre mélange of thousands of payers with
payment systems that differ for no socially beneficial reason, as
well as staggeringly complex public systems with mind-boggling
Inefficiencies in Health Care administered prices and other rules expressing distinctions that
can only be regarded as weird.
INEFFECTIVE OR INAPPROPRIATE CARE
Nevertheless, he concluded, as have most other observers of the
In another chapter [see ECP:9 Elements of Cost-Effective Non- United States system, that the administrative structure of any
emergency Surgical Care], we explored a number of considerations nation’s health care system evolves from its political history and
related to either the delivery of services of limited or nonexistent institutions and that to be durable, a health care system must
value or the failure to employ services of demonstrated benefit. reflect prevailing political values.
The actual cost incurred by these factors is difficult to estimate but
is certainly large. In a study that compared utilization of medical COSTS OF MEDICAL INJURY
resources by Medicare beneficiaries in various regions of the The Institute of Medicine has produced two reports that have
United States, per capita spending in 1996 was $3,341 in the received considerable attention in both the scientific and the lay
Table 3 Administrative Costs of Health Care: United States versus Canada
United States Canada
Administrative Cost Category Total Cost Per Capita Total Cost Per Capita
($ billion) Cost ($) ($ billion) Cost ($)
Insurance overhead 72 259 1.43 47
Employer costs 15.9 57 0.257 8
Hospital administration 87.6 315 3.1 103
Practitioners 89.9 324 3.3 107
Total 294.3 1,059 9 307
press. The first, To Err Is Human,30 concluded that mistakes were ing.35 According to the CBO’s estimates, malpractice costs
frequently made in the health care system and that the conse- amounted to $24 billion in 2002, or less than 2% of overall nation-
quences of these mistakes were considerable in both human and al health spending; thus, even a 25% reduction in malpractice
economic terms. The second, Crossing the Quality Chasm,31 out- costs would lower health care costs by only about 0.4%. Because
lined steps that must be taken to ensure that patients are not of the political interests invested in the issue, however, malpractice
injured by the care intended to help them. Although the magni- liability is certain to remain the subject of public discussion for the
tude of the problem identified in the two reports has been vigor- foreseeable future.
ously debated, the existence of the problem is undeniable. A 2003
analysis based on a review of 7.5 million hospital discharge ab-
stracts from nearly 1,000 hospitals in 28 states documented siz- Implications for Surgeons
able variations in length of stay and expenditure related to medical In a now-classic article describing the consequences of contin-
injury.32 The authors concluded that despite this variability, med- ued population growth, Hardin first articulated the notion of the
ical injuries both pose significant risks for patients and result in tragedy of the commons36:
considerable cost to society. It is difficult to argue with the propo- Picture a pasture open to all. It is to be expected that each herds-
sition that systems for minimizing these risks and reducing the man will try to keep as many cattle as possible on the commons.
associated cost must be developed and implemented. Such an arrangement may work reasonably satisfactorily for cen-
turies because tribal wars, poaching, and disease keep the num-
COST OF MEDICAL MALPRACTICE
bers of both man and beast well below the carrying capacity of the
Physicians have long argued that the tort system of compensa- land. Finally, however, comes the day of reckoning, that is, the day
tion for alleged medical injuries or adverse outcomes is expensive, when the long-desired goal of social stability becomes a reality. At
punitive, and arbitrary. Furthermore, they assert that the threat of this point, the inherent logic of the commons remorselessly gen-
litigation induces them to practice defensive medicine. As a con- erates tragedy. As a rational being, each herdsman seeks to maxi-
mize his gain. [H]e asks, “What is the utility to me of adding one
crete example, a 2002 report from the American Academy of
more animal to my herd?”
Orthopaedic Surgeons indicated that concerns about liability had [T]he rational herdsman concludes that the only sensible
caused nearly half of the surgeons surveyed to alter their practice course for him to pursue is to add another animal to his herd. And
and nearly two thirds to order more diagnostic tests.33 another; and another.… But this is the conclusion reached by
The sharp rise in premiums for medical malpractice liability each and every rational herdsman sharing a commons.Therein is
insurance over the past several years has led many professional the tragedy. Each man is locked into a system that compels him
associations to lobby Congress and state legislatures for caps on to increase his herd without limit—in a world that is limited. Ruin
noneconomic damages, as well as for other changes in the tort lia- is the destination toward which all men rush, each pursuing his
bility system. Proponents of such changes point to the loss of own best interest in a society that believes in the freedom of the
access to care in the only level 1 trauma center in Las Vegas in commons. Freedom in a commons brings ruin to all.
2002; the difficulty of providing on-call surgical care to emergency The comparison with health care may seem far-fetched at first
rooms in Jacksonville, Florida, and in Mississippi in 2003; and the glance, but as practitioners continue to seek to maximize utility for
loss of neurosurgical services in the northern panhandle of West themselves or their patients, the eventual outcome—assuming that
Virginia in 2002. Concerned about continued increases, the the resources available for health care are, like the commons,
reform advocates cite the reduced rates of increase in premiums finite—may well turn out to be as tragic as the one described by
reported in states that have imposed caps on noneconomic losses Hardin. Surgeons can help avert this fate by helping to develop,
(e.g., California, Colorado, and Montana). and then adhering to, evidence-based approaches such as the one
Two reports cast doubt on these arguments, however. A study we outline elsewhere [see ECP:9 Elements of Cost-effective Non-
conducted by the General Accounting Office was unable to con- emergency Surgical Care], thereby minimizing the likelihood that
firm the existence of any widespread access problems that could procedures that are of limited value or whose benefit is less than
be attributed to concerns about malpractice premiums.34 A report their cost will be performed. The importance of one-on-one edu-
from the Congressional Budget Office (CBO) concluded that any cation in the context of surgical care must also be emphasized.
savings resulting from a federally imposed cap on damage awards Such education, by placing patient interests ahead of surgeon
would not have a significant impact on total health care spend- interests, truly defines professionalism.
References
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2. Altman SH,Tompkins CP, Eilat E, et al: Escalating Washington, D.C., September 2002, p 1 implications of regional variations in Medicare
health care spending: is it desirable or inevitable? 13. Barer ML, Evans RG, Hertzman C: Avalanche or spending, pt 1: the content, quality, and accessibil-
Health Aff (Millwood), Web Exclusives, 8 January glacier? Health care costs and demographic ity of care. Ann Intern Med 138:273, 2003
2003 rhetoric. Can J Aging 14:193, 1995
26. Brook RH, Vaiana ME: Appropriateness of Care: A
http://content.healthaffairs.org/cgi/content/
14. Gruber J, Wise D: An international perspective on Chartbook. National Health Policy Forum,Washing-
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Reacting to Hyperturbulence. Organizational 27. Aaron HJ: Should public policy seek to control the
Hopkins University Press, Baltimore, 2002
Change and Redesign: Ideas and Insights for growth of health care spending? Health Aff
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Improving Performance. Huber GP, Glicks WH,
really drive the demand for health care? Health Aff http://content.healthaffairs.org/cgi/content/full/
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16. Francis DR: Healthcare costs are up: here are the 28. Woolhandler S, Campbell T, Himmelstein DU:
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Health Aff (Millwood), Web Exclusives, 8 January culprits. Christian Science Monitor, December 15, Costs of health care administration in the United
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ELEMENTS OF CONTEMPORARY PRACTICE 11 Benchmarking Surgical Outcomes — 1
11 BENCHMARKING SURGICAL
OUTCOMES
Emily V. A. Finlayson, M.D., M.S., and John D. Birkmeyer, M.D., F.A.C.S.
Currently, there is growing interest in obtaining information about nary artery bypass grafting (CABG). All of these states release
surgical outcomes. Patients and their families are increasingly hospital-specific performance data, but only some report surgeon-
looking for—and finding—hospital- and surgeon-specific quality specific information.
data as they try to make informed decisions about where and from Public reporting programs related to other surgical procedures
whom to receive surgical care.1,2 Payers, both private and public, generally rely on administrative data. A few states use data from
are also seeking information about surgical performance for their their discharge abstract databases to determine and report volume
value-based purchasing initiatives. For example, the Leapfrog and risk-adjusted mortalities for selected procedures, including
Group (www.leapfroggroup.org), a large coalition of health-care major cancer resections. The most widely available providers of
purchasers, is collating data on hospital volume, process, and out- data on noncardiac surgical outcomes are proprietary rating firms,
come measures in an effort to steer patients to the centers likely to which rely primarily on public-use Medicare files. Of these rating
have the best results [see ECP:2 Performance Measures in Surgical firms, the most notable is probably Healthgrades (www.health-
Practice]. As part of its Surgical Care Improvement Program grades.com), which currently allows users to select from 31 differ-
(SCIP) and Centers of Excellence projects, the Centers for ent procedures or conditions and to obtain data on hospitals in
Medicare and Medicaid Services (CMS) is requiring that hospi- any specified geographic region. For each procedure, hospitals are
tals report outcome data for selected procedures, as well as other given a ranking, ranging from 5 stars (best) to 1 star (worst), on
performance measures. the basis of risk-adjusted mortality and, in some cases, morbidity.
Surgeons should be just as interested in surgical outcome data Hospital-specific information is provided free of charge, but a
as patients and payers are, for several reasons. First, it is essential small fee is charged for information on specific surgeons.
that surgeons be able to provide patients with accurate, realistic The clinical outcome data from the state cardiac surgery reg-
information about the risks and benefits they can expect from spe- istries are generally considered robust. The other sources of pub-
cific procedures. Unfortunately, the medical literature is not licly reported outcome data, however, have several important limi-
always reliable for this purpose: it is limited by publication bias [see tations, some of which pertain to the use of administrative rather
ECP:12 Evidence-Based Surgery], and the findings tend to be than clinical data [see Public-Use Administrative Databases, below]
skewed by case series from large, nonrepresentative referral cen- and some of which are specific to the vendor. For example, Health-
ters, which may not reflect outcomes in the “real world.” Second, grades is often criticized on the grounds that its methods of calcu-
as patients increasingly turn to the Internet for information, sur- lating rates and risk adjustment are insufficiently transparent.3 It is
geons need to be aware of what data their patients are seeing and also criticized for its reliance on categorical rankings and its failure
prepared to address their questions. Third, and most important, to provide actual rates (along with numerators and denominators).
surgeons require information about surgical outcomes to bench-
mark their own performance against both national norms and the
performance of their peers, as well to help guide their own efforts Public-Use Administrative Databases
at improvement. As an alternative to relying on outside analysis, surgeons can
In this chapter, we review various data sources for benchmark- obtain administrative data and perform the analysis themselves.
ing surgical outcomes, including ongoing public reporting pro- Although this approach requires a certain level of data skills, it may
grams, public-use administrative databases that can be analyzed be practical for surgeons with sufficient analytic expertise (or else
for benchmarking purposes, and improvement-oriented clinical access to analytic support). Public-use administrative databases
outcomes registries, such as the National Surgical Quality [see Table 1] are increasingly available, remain relatively inexpen-
Improvement Program (NSQIP) now being promoted by the sive, and no longer require special equipment for data transmis-
American College of Surgeons (ACS). In particular, we consider sion or storage.
the strengths and weaknesses of these sources and provide repre- Most of the administrative databases that are useful for bench-
sentative surgical mortality data from some of them. marking surgical outcomes consist of hospital discharge abstracts,
which contain information on patients admitted to acute care hos-
pitals.The information collected includes demographic data (e.g.,
Public Reporting Programs name, age, sex, race/ethnicity, and place of residence), admission
The most readily available sources of surgical outcome data are and discharge dates, total charges, expected payment source,
Internet-based public reporting programs. At present, the only admission type (elective, urgent, or emergency), and discharge dis-
such programs that are based on clinical data are in the field of position. In addition, the abstracts may list attending physicians
cardiac surgery. Following the lead of New York State, which first and surgeons, identified by means of Unique Physician Identifi-
initiated public reporting in 1989, state agencies in New Jersey, cation Numbers (UPINs). Claims for surgical admissions contain
Pennsylvania, California, and Massachusetts now administer lon- procedure-specific codes from the International Classification of
gitudinal clinical registries and regularly release (on the Internet Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). In
and elsewhere) information on risk-adjusted mortality for coro- addition, hospital discharge abstracts contain fields for at least 10
Table 1 Public-Use Administrative Databases and Clinical Registries
Database/Registry Patients Participating Hospitals Strengths Limitations
Medicare recipients ≥ 65 Limited to elderly patients; not

Medicare years old undergoing inpa- All U.S. hospitals treating Large sample size; population- specific for some procedure
tient surgery Medicare patients based codes; no detailed clinical in-
formation for risk adjustment
Limited to inpatient mortality;

Nationwide Inpatient Patients undergoing inpatient 20% sample of all U.S. nonfed- not specific for some proce-
Sample (NIS) surgery eral hospitals (~ 1,000 hospi- All ages; large sample size dure codes; no detailed clin-
tals in 37 states) ical information for risk
adjustment
National Surgical Quality Patients undergoing general Costly to participate in; not de-
Prospectively acquired clinical
Improvement Program and vascular surgery > 100 private sector hospitals signed to assess procedure-
data
(NSQIP) specific performance
Registry participants account-

Society of Thoracic Patients undergoing cardio- ing for > 70% of all adult car- Prospectively acquired clinical Historically rather than exter-
Surgeons (STS) National thoracic surgery diothoracic operations per- data nally audited
Database
formed annually in the U.S.
Patients undergoing surgery ~1,400 hospitals nationwide Prospectively acquired clinical

National Cancer Data Base
for cancer (~ 75% of incident cancer data; detailed cancer-specif- Not externally audited
(NCDB)
cases in the U.S.) ic data
diagnosis codes, which are used to record preexisting medical con- Nevertheless, reliance on administrative data for benchmarking
ditions or medical complications of surgery for billing purposes. outcomes also has certain drawbacks. Some of these drawbacks
There are a number of different administrative databases that are related to the specific database under consideration. For
surgeons can use for benchmarking surgical outcomes. For exam- example, Medicare data apply primarily to elderly patients and
ple, most states maintain discharge abstract databases that are thus are not useful for evaluating the outcomes of procedures that
available for public use (though the accessibility of these databas- are most commonly performed in younger patients. In addition,
es and other details vary widely from state to state). Moreover, they miss large numbers of elderly patients in regions of the
surgeons can conveniently obtain data from the Nationwide United States with a high penetration of Medicare-managed care.
Inpatient Sample (NIS) for this purpose at relatively low cost. As another example, all-payer databases, including state-level files
Developed as part of the Healthcare Cost and Utilization Project and the NIS, provide in-hospital mortality data but not 30-day
(HCUP), a federal-state-industry partnership sponsored by the mortality data, and unlike Medicare databases, they usually do
Agency for Healthcare Research and Quality (www.hcup- not contain codes identifying hospitals or surgeons. Thus, these
us.ahrq.gov), the NIS is an all-payer inpatient care database that databases are useful for generating national or state-level norms
collects information from approximately 8 million hospital admis- for specific procedures, but not for assessing the outcomes
sions annually. It includes all patients from a 20% sample of all achieved by specific providers.
nonfederal hospitals (approximately 1,000 facilities) from 37 The most important drawbacks of administrative databases,
states and is designed to provide nationally representative esti- however, are related to problems with the accuracy, completeness,
mates of health care utilization and outcomes.To this end, hospi- and clinical precision of the data coding.4,5 The ICD-9-CM diag-
tals are selected to be as representative as possible with respect to nosis codes used to identify comorbidities are often clinically
ownership/control, bed size, teaching status, rural/urban location, imprecise, do not reflect disease severity, and cannot differentiate
and geographic region. Finally, surgeons can obtain public-use preadmission conditions from acute complications. For this rea-
Medicare data for benchmarking surgical outcomes, just as some son, risk adjustment and measurement of postoperative compli-
proprietary rating firms do.The Medicare inpatient database (i.e., cations are possible only to a limited extent when administrative
the Medicare Provider Analysis and Review [MEDPAR] file) is databases are employed. The ICD-9-CM procedure codes,
the most accessible and widely used source of such data. It con- though generally much more reliable than the diagnosis codes,
tains data on all fee-for-service acute care admissions for still lack sufficient clinical specificity, particularly in relation to the
Medicare recipients, including most Americans older than 65 Current Procedural Terminology (CPT) codes used for physician
years, disabled patients younger than 65 years, and patients with billing. For example, they often fail to distinguish between laparo-
end-stage renal disease. scopic and open procedures or between similar procedures that
Primary analysis of administrative databases has a number of are associated with different baseline risk levels (e.g., laparoscop-
advantages for surgeons interested in benchmarking outcomes. In ic antireflux surgery and repair of paraesophageal hernias).
the absence of comparable clinical databases (except for cardiac
surgery), administrative databases are currently the only source of
population-based outcome data. By accessing these databases Clinical Registries
directly, surgeons can obtain information on virtually any inpa- Of course, the ideal sources of information for benchmarking
tient procedure of interest to them, not just those procedures cur- surgical outcomes are clinical outcome registries containing
rently targeted by proprietary rating firms. Because the sample prospectively collected data [see Table 1]. As noted [see Public
sizes are so large, surgeons can effectively analyze the outcomes Reporting Programs, above], several states administer such reg-
even of infrequently performed procedures. istries for cardiac surgery as part of their efforts at quality
NATIONAL CANCER DATA BASE

improvement and public reporting. In the past few years, howev-
er, a number of professional organizations, including the ACS, A joint effort of the ACS Commission on Cancer (CoC) and
have launched national outcome registries in other clinical areas. the American Cancer Society, the National Cancer Data Base
Outcome data from these registries are not reported publicly but (NCDB) is a national registry that tracks information related to
are used to provide confidential feedback on performance to hos- the treatment and outcome of cancer patients (www.facs.org/dept/
pitals and surgeons for the purposes of internal quality improve- cancer/ncdb/index.html). About 1,400 hospitals participate in the
ment. With one prominent exception (NSQIP), the currently NCDB, which currently captures approximately 75% of incident
available outcome registries target specific specialties, conditions, cancer cases in the United States. The participating centers pro-
or procedures. vide data on patient characteristics, tumor stage and grade, type of
treatment, disease recurrence, and survival. Health care providers
NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM at CoC-approved cancer centers are able to access benchmark
Perhaps the most visible and powerful source of benchmarking reports that summarize the data from the user’s own center and
information is the NSQIP. Originally developed and implemented compare them with state, regional, or national data, as well as with
in Veterans Affairs (VA) hospitals, the NSQIP was later applied in data from other individual cancer centers. Although the NCDB is
a consortium of large academic medical centers and private sector undoubtedly the richest source of clinical data for benchmarking
hospitals and subsequently marketed by the ACS to all types of the outcomes of cancer surgery, it has certain limitations. As with
hospitals. As of 2006, more than 100 non-VA hospitals had the STS National Database, the data are not externally audited to
enrolled. At participating hospitals, NSQIP data are collected ensure accuracy and completeness. Moreover, unlike most clinical
through review of the medical records by dedicated nurse abstrac- outcome registries, the NCDB was not originally designed for
tors. Preoperative risk factors, intraoperative variables, and 30-day tracking outcomes related to quality; it only recently began col-
postoperative mortality and morbidity outcomes for patients lecting information on comorbidity (for the purposes of risk
undergoing major operations are submitted. Risk-adjusted mor- adjustment), and it provides no information on outcomes other
bidity and mortality results for each hospital are calculated semi- than mortality.
annually and are reported as observed-to-expected (O/E) ratios.
NATIONAL TRAUMA DATA BANK
As private-sector participation grows, the NSQIP is becoming a
valuable resource for benchmarking surgical outcomes. Because The ACS, along with its Committee on Trauma, also oversees
the clinical data are prospectively collected, robust risk adjustment the National Trauma Data Bank (NTDB) (www.facs.org/trau-
is possible. In addition, participants can readily access their own ma/ntdb.html). At present, approximately 556 hospitals submit
outcome data on a user-friendly Web interface. Moreover, they can data to the NTDB, including 70% of level I trauma centers and
easily navigate through different procedures and outcomes to 53% of level II centers. Participating hospitals submit extensive
obtain a range of information pertaining to their own specialty and information about comorbid conditions, patient status on arrival
can benchmark their own results against those of community cen- at the hospital, procedures performed, complications, and mortal-
ters, academic centers, or both. Nonetheless, the NSQIP current- ity.They also have access to the primary data, so that they can per-
ly has several weaknesses that reduce its usefulness in benchmark- form their own analyses. Although the NTDB captures a large
ing surgical outcomes. First, it is expensive to administer. Besides percentage of trauma admissions in the United States, it should be
paying an annual fee, each center is required to hire and train a kept in mind that data submission to NTDB is voluntary and that
dedicated surgical clinical nurse reviewer to review and enter data. the data are not externally audited.
Second, the NSQIP is not designed for assessing procedure-spe-
cific performance. Risk adjustment is based on a common set of REGISTRIES FOR BARIATRIC SURGERY
preoperative variables that apply to all procedures, not on differing In the past few years, two competing programs for tracking the
sets of risk factors that are specific to individual procedures. outcomes of bariatric procedures have been launched: the ACS
Furthermore, the program collects data on a sample of the proce- Bariatric Surgery Center Network (www.facs.org/cqi/bscn) and
dures performed at each hospital, not on all procedures.Thus, the the Surgical Review Corporation (SRC) (www.surgicalreview.org).
sample sizes are relatively small, and as a result, procedure-specif- The details of these two clinical registries have not yet been
ic outcome measures may be imprecise.Third, the NSQIP’s glob- released or even fully developed, but it is clear that these programs
al measures of morbidity and mortality may be limited in terms of are intended to support hospital accreditation and “center of
how well they account for differences in procedure mix across hos- excellence” designations in bariatric surgery. In the ACS Bariatric
pitals. Surgery Network, hospitals that are participating in the NSQIP
submit all their data via their Web-based portals and compare their
SOCIETY OF THORACIC SURGEONS NATIONAL DATABASE
bariatric surgery results with those of other centers, as is done with
The Society of Thoracic Surgeons (STS) National Database is other procedures included in the NSQIP. Hospitals that are not
the best source of national data for benchmarking the outcomes of participating in the NSQIP submit only their bariatric outcome
cardiac procedures.6 This database includes clinical data on more data and receive annual summaries of their outcomes, which are
than 70% of all cardiothoracic operations performed in adults not adjusted for risk or benchmarked against the outcomes of
each year in the United States. Participating hospitals receive reg- other programs. The SRC, which is closely aligned with the
ular feedback on mortality after adult and congenital cardiac and American Society for Bariatric Surgery, is a nonprofit organization
general thoracic surgery. The main strengths of the STS registry that assesses bariatric surgery programs, analyzes outcome data,
are the robust and procedure-specific risk adjustment and the high and formulates practice guidelines. Participating centers must
hospital participation rate (which suggests that the STS outcome report their outcomes annually in order to maintain their status as
data should be highly generalizable). Historically, its major weak- SRC-approved centers. In addition to access to their own data,
ness has been the lack of external auditing to ensure that the out- SRC-approved centers have access to benchmark outcome data
come data submitted by hospitals are accurate and complete. aggregated from all participating institutions.
Table 2 Operative Mortality for Selected would need over a 3-year period to be reasonably confident that
Procedures in Two National Databases their higher mortality figures were real and not just statistical arti-
facts.7 The estimated minimal caseloads varied by procedure,
ranging from 77 for esophagectomy to 2,668 for hip replacement.
Database According to the authors’ analysis of the NIS, the only procedure
for which a majority of U.S. hospitals met these caseload criteria
Operation Medicare (2003) NIS (2003) was CABG.
Another limitation has to do with generalizability. In this regard,
Mortality Mortality
N (%) N (%) it is illustrative to consider the overall reported mortalities for sev-
eral procedures, determined on the basis of data from two different
Cardiac procedures national databases: the Medicare Inpatient File (2003) and the NIS
CABG 79,704 3.8 32,123 2.2 (2003) [see Table 2]. These databases have their own distinct char-
Aortic valve replacement 21,464 5.8 7,221 4.0 acteristics (e.g., a particular patient population or method of defin-
Mitral valve replacement 6,844 8.9 2,903 5.9 ing mortality), and the different datasets yield different mortality
Vascular procedures estimates. For example, the predominantly elderly Medicare popu-
Lower-extremity bypass 31,861 2.9 10,830 1.3 lation had the highest mortalities across all procedures, ranging
Elective aortic aneurysm 16,481 5.1 5,757 3.6 from 0.9% for carotid endarterectomy to 11.7% for pneumonec-
repair tomy. In the NIS population, operative mortalities were consider-
Carotid endarterectomy 67,895 0.9 21,441 0.4 ably (sometimes more than 3%) lower for all procedures than in
Cancer procedures the Medicare population (e.g., 5.2% versus 9.1% for pancreatico-
Pulmomary lobectomy 14,696 3.8 5,298 1.9 duodenectomy and 3.5% versus 6.6% for gastrectomy). Although
Pneumonectomy 1,184 11.7 563 8.7 neither the Medicare estimates nor the NIS estimates are wrong,
Esophagectomy 2,760 7.5 1,198 5.0 they should not be considered universally applicable. Surgeons
Gastrectomy 5,929 6.6 2,776 3.5 must recognize that risk estimates derived from any given database
Pancreaticoduodenectomy 1,424 9.1 629 5.2 are dependent on the distinct composition of that database and
Colectomy 56,669 3.5 23,074 1.5
therefore may not be generalizable to their own practice.
Abdominoperineal resection 3,680 2.8 1,489 1.1
Our primary focus in this chapter has been on sources of infor-
Gastric bypass 5,663 1.0 14,056 0.2 mation about morbidity and mortality; however, there are other
measures related to surgical quality that surgeons may also be
CABG—coronary artery bypass grafting NA—not available
interested in benchmarking. For example, information about hos-
pital volumes can be obtained from Healthgrades, the Leapfrog
Additional Considerations
Group, and a growing number of state agencies. As another exam-
Although it is important to understand that the various sources ple, information pertaining to selected processes of care (e.g.,
of surgical benchmarking data all have their own distinct strengths processes related to preventing surgical site infection, venous
and weaknesses, it is also worthwhile to keep in mind that these thromboembolism, cardiac events, and ventilator-acquired pneu-
sources all have certain limitations in common. One such limita- monia after operation) is now being collected by CMS as part of
tion has to do with sample size. Whereas the benchmark data SCIP; although this information is not currently available, there
themselves usually are based on large numbers and thus are sta- are plans for eventual public reporting. Finally, information about
tistically robust, the outcome data of the hospitals and surgeons patient satisfaction can be obtained from several private vendors.
assessing their own performance against these benchmarks are A large number of hospitals participate in a survey measurement
not, particularly at the level of individual procedures. When sam- program administered by Press-Ganey, a health care satisfaction
ple sizes are too small, it may be difficult to determine whether survey business that has created national databases of comparative
complication rates higher than the benchmark rate reflect genuine satisfaction information. In addition, both HCIA Inc. (formerly
problems or are simply the result of chance. A 2004 study consid- called Health Care Investment Analysts) and the Medical Group
ered hypothetical hospitals with operative mortalities twice the Management Association offer patient satisfaction comparison
national average and estimated how many cases these hospitals services.
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ELEMENTS OF CONTEMPORARY PRACTICE 12 Evidence-Based Surgery — 1
12 EVIDENCE-BASED SURGERY
Samuel R. G. Finlayson, M.D., M.P.H., F.A.C.S.
Evidence-based surgery may be defined as the consistent and judi- interpreting the best scientific evidence. Scientific reviews serve as
cious use of the best available scientific evidence in making decisions secondary sources for evidence-based practice and are increasing-
about the care of surgical patients. It is not an isolated phenomenon; ly found in journals, in books, and on the Internet. Prominent
rather, it is one part of a broad movement—evidence-based medi- examples include Clinical Evidence (published semiannually by
cine—whose aim is to apply the scientific method to all of medical the British Journal of Medicine and continually updated online
practice.The historical roots of this broad movement lie in the pio- [http://www.clinicalevidence.com]) and the Cochrane Database of
neering work of the Scottish epidemiologist Archibald Cochrane Systematic Reviews (http://www.cochrane.org). SCIP serves as a
(1909–1988), for whom the preeminent international organization clearinghouse for evidence-based guidelines that specifically
for research in evidence-based medicine (the Cochrane Collabo- address surgical practices.
ration) is named.The term evidence-based medicine itself was pop- These efforts to summarize and disseminate information about
ularized by a landmark article that appeared in the Journal of the evidence-based surgery provide a convenient means of access to
American Medical Association in 1992.1 This article advocated a new the surgical literature that can be very helpful to practicing sur-
approach to medical education, urging physicians and educators to geons. Such aids, however, are far from complete, and new evi-
deemphasize “intuition, unsystematic clinical experience, and patho- dence emerges continually. Accordingly, modern evidence-based
physiologic rationale as sufficient grounds for clinical decision mak- surgeons cannot afford to rely entirely on these sources: they must
ing.” In essence, advocates of evidence-based medicine seek to demote also learn to assess the quality of individual scientific studies for
so-called expert opinion from its previous relatively high standing, themselves, as well as to interpret the implications of these studies
regarding it as being, in fact, the least valid basis for making clinical for their own practices.
decisions. As a consequence of the growth of this movement, the
LEVELS OF EVIDENCE
discipline of surgery, once driven more by the eminence of tradition
than by the evidence of science, now increasingly requires its stu- Evidence for surgical practices comes in many forms, with vary-
dents to adopt evidence-based scientific standards of practice. ing degrees of reliability. At one end of the spectrum is an empir-
The imperative that surgical care be delivered in accordance ical impression that a practice makes physiologic sense and seems
with the best available scientific evidence is only one facet of evi- to work well; much of what surgeons actually do falls into this cat-
dence-based surgery. Other facets include systematic efforts to egory and has not been formally tested. At the other end of the
establish standards of care supported by science and the move- spectrum is evidence accumulated from multiple carefully con-
ment to popularize evidence-based practice. Systematic reviews of ducted scientific experiments that yield consistent and repro-
the literature are often generated by independent researchers or ducible results.The ultimate task of the evidence-based surgeon is
collaborative study groups (e.g., Cochrane collaborations) and to select practices that conform to the best evidence available; to
published as review articles in journals or disseminated as practice that end, it is essential to be able to judge the reliability of scientif-
guidelines. The movement to popularize evidence-based surgical ic evidence.
practice is a relatively recent phenomenon that is exemplified by In an effort to help clinicians judge the strength of scientific evi-
the activities of the Surgical Care Improvement Project (SCIP) dence, researchers have attempted to create hierarchies of evi-
(http://www.medqic.org/scip/scip_homepage.html). Although re- dence, in which the highest places are occupied by those sources
searchers are charged with generating and disseminating scientif- that are most reliable and the lowest places by those that are least
ic evidence, the greatest responsibility for the success of evidence- sure.With the understanding that not all practices have been sub-
based surgery ultimately lies with individual surgeons, who must jected to the highest levels of scientific scrutiny, clinicians are
not only practice evidence-based surgery but also understand and advised to base practices on evidence gleaned from studies as high
appropriately interpret an immense surgical literature. on the evidence hierarchy as possible.
In this chapter, I provide a framework for evaluating the An oft-cited example of such an evidence hierarchy is the levels-
strength of evidence for surgical practices, examining the validity of-evidence system popularized by the United States Preventive
of scientific studies in surgery, and assessing the role of evidence- Medicine Task Force (USPMTF) [see Table 1].2 Since the incep-
based surgery in measuring and improving the quality of surgical tion of this system, the terms and concepts it employs have
care.These are the basic conceptual and analytic tools that a mod- become common parlance among clinicians—hence, for example,
ern evidence-based surgeon needs to navigate the surgical litera- the frequently heard references to level 1 evidence (i.e., evidence
ture and implement practices that are based on sound science. from well-conducted, randomized, controlled trials). However,
almost as soon as the USPMTF levels-of-evidence system was
released, debate about its adequacy began.3 The predominant
Evaluation of Strength of Evidence for Surgical Practices criticism has been that the system is too simple and inflexible to
provide a precise description of the strength of evidence for clini-
GUIDELINES AND SECONDARY SOURCES OF SCIENTIFIC
cal practices. Although the system identifies the design of the study
EVIDENCE
from which the evidence is drawn, it does not consider certain
To meet the growing demand for evidence-based practice infor- other important factors that influence the quality of the study. For
mation, a market has developed around the process of pooling and example, in the USPMTF system, the same grade is awarded to a
randomized, double-blind, placebo-controlled trial with 50,000 Table 1 Levels of Evidence According to
subjects as to a randomized, unblinded trial with 30 subjects. USPMTF Schema
Furthermore, a higher grade is awarded to the latter trial than to
a well-designed, well-conducted, multi-institution, prospective co-
Level of Evidence Source of Evidence
hort study with 10,000 subjects.
In response to the deficiencies of the USPMTF system, nu- I At least one properly randomized, controlled trial
merous alternative grading systems have been developed that take II-1 Well-designed controlled trials without randomization
into account factors other than study design, such as quality, con- II-2 Well-designed cohort or case-control analytic study,
sistency, and completeness. Nevertheless, it is widely recognized preferably from more than one center or research group
that no grading system yet developed is perfect.4 Consequently, II-3 Multiple time-series with or without intervention or, pos-
surgeons are often required to judge the quality and applicability sibly, dramatic results from uncontrolled trials (e.g.,
penicillin treatment in 1940s)
of scientific evidence for themselves.
III Opinions from respected authorities based on clinical
experience, descriptive studies, and case reports or
APPRAISING SCIENTIFIC EVIDENCE opinions from committees of experts
Specific study designs are associated with different levels of
confidence about cause and effect. The clinical study design that Category of Basis of Recommendation
Recommendation
is considered to have the greatest potential for determining causa-
tion is the randomized, controlled clinical trial. However, even Level A Good and consistent scientific evidence
studies with this design can lead to erroneous conclusions if they Level B Limited or inconsistent scientific evidence
are not performed properly.Therefore, in evaluating the quality of Level C Consensus, expert opinion, or both
clinical evidence, it is not sufficient simply to ascertain the design
USPMTF–United States Preventive Medicine Task Force
of the study that produced the evidence: one must also take a
close look at how the study was conceived, implemented, ana-
lyzed, and interpreted. are two types of chance-related errors: type I and type II. Type I
Scientific evidence from studies of clinical practice relies on two error (also called α error) occurs when researchers erroneously re-
important inferences.The first inference is that the observed out- ject the null hypothesis—that is, they infer that there is a differ-
come is the result of the practice and cannot be attributed to some ence in outcomes when no difference really exists. Type II error
alternative explanation.When this inference is deemed to be true, (also called β error) occurs when researchers erroneously confirm
the study is considered to have internal validity.The second infer- the null hypothesis—that is, they infer that there is no difference
ence is that what was observed in the clinical study is relevant to in outcomes when a difference really does exist.
scenarios outside the study in which the surgeon seeks to imple-
ment the practice. The extent to which this inference is true is Type I errors Statistical testing is used to quantify the likeli-
referred to as external validity or generalizability.Whereas internal hood of a type I error. A variable commonly employed for this
validity is determined by how well the study is conducted and purpose is the P value, which is a measure of the probability that
how accurately the results are analyzed, external validity is deter- observed differences between groups might be attributable to
mined by how well the study plan reflects the real-world clinical chance alone. The threshold for statistical significance is conven-
question that inspired it and how well the study’s conclusions tionally set at a P value of 0.05, which signifies that the likelihood
apply to real-world scenarios outside the study [see Figure 1]. that the observed differences would occur by chance alone is 5%.
External validity can also refer to the difference between an inter- Although a P value of 0.05 falls short of absolute certainty, it is
vention’s efficacy (how well it works when applied perfectly) and generally accepted as sufficient for scientific proof.
its effectiveness (how well it works when applied generally in an An alternative expression of statistical likelihood is the confi-
uncontrolled environment); when this difference is substantial, the dence interval, which is a measure of the probability that the
study’s external validity is poor. observed difference would occur if the same study were repeated
an infinite number of times. For example, a confidence interval of
95% indicates that the observed difference would be present in
Assessment of Validity of Scientific Studies in Surgery 95% of the repetitions of the study.
There are many statistical tests that can be used to calculate P
INTERNAL VALIDITY: EVALUATING STUDY QUALITY values and confidence intervals. Which statistical test is most
Assessment of the internal validity of a study requires an under- appropriate for a particular situation depends on several factors,
standing of the potential influence of three key factors: chance, including the number of observations in the comparison groups,
bias, and confounding. Chance refers to unpredictable random- the number of groups being compared, whether two or more
ness of events that might mislead researchers. Bias refers to sys- groups are being compared to each other or one group is being
tematic errors in how study subjects are selected or assessed. compared to itself after some time interval, what kind of numeri-
Confounding refers to differences in the comparison groups (other cal data are being analyzed (e.g., continuous or categorical), and
than the intended difference that is the subject of the comparison) whether risk adjustment is required. It is likely that only a minor-
that lead to differences in outcomes. ity of surgeons will have a firm grasp of all the nuances of the more
complex statistical analyses. Fortunately, however, most clinical
Chance surgical studies are designed simply enough to employ statistical
In clinical studies that compare outcomes between two or more tests that are within the reach of the nonstatistician.
groups, the assumption that there is no difference in outcomes is
called the null hypothesis. Erroneous conclusions with regard to Type II errors Type II errors often occur when the sample
the null hypothesis can sometimes occur by chance alone. There size is simply too small to permit detection of small but clinically
important differences in outcomes between comparison groups. in a trial of medical versus surgical treatment of gastroesophageal
When a study’s sample size is insufficient for identification of out- reflux disease, selecting study subjects from a group of diners at a
come differences, the study is said to lack sufficient statistical power. Szechuan Chinese restaurant might lead to results favoring med-
Once a study is complete, no amount of analysis can correct for in- ical treatment (in that consumers of Szechuan Chinese food may
sufficient statistical power. Therefore, before starting a study, re- be more likely to have well-controlled reflux). When assessing the
searchers should perform what is known as a power calculation, which validity of scientific evidence, surgeons must carefully consider the
involves determining the minimum size a difference must have to characteristics of the subjects selected for study.
be meaningful, then calculating the minimum number of observa-
tions that would be required to demonstrate such a difference sta- Information bias The term information bias applies to any
tistically. Surgeons should be particularly cautious when evaluating problem caused by the way in which outcome data or other perti-
studies with null findings, particularly when no power calculation nent data are obtained. As an example, in a study of sexual func-
is explicitly reported. It is wise to remember that, as the adage has it, tion after surgical treatment of rectal cancer, subjects may report
no evidence of effect is not necessarily evidence of no effect. symptoms differently in an in-person interview from how they
would report them in an anonymous mailed survey. As another
Bias example, in a study of hernia repair outcomes, rates of chronic
The term bias refers to a systematic problem with a clinical postoperative pain might be incorrectly reported if surgeons assess
study that results in an incorrect estimate of the differences in out- outcomes in their own patients. Also, recall bias (i.e., selective
comes between comparison groups. There are two general types memory of past events) is a type of information bias to which ret-
of bias: selection bias and information bias. The former results rospective clinical studies are particularly vulnerable.
from errors in how study subjects are chosen, whereas the latter Information bias is often more subtle than selection bias;
results from errors in how information about exposures or out- accordingly, particular attention to the reported study methods is
comes (or other pertinent information) is obtained. required to control this problem. Measures employed to control
information bias include blinding and prospective study design.
Selection bias The term selection bias applies to any imper- Confounding
fection in the selection process that results in a study population
The term confounding refers to differences in outcomes that
containing either the wrong types of subjects (i.e., persons who are
occur because of differences in the respective baseline risks of the
not typical of the target population) or subjects who, for some rea-
comparison groups. Confounding is often the result of selection
son unrelated to the intervention being evaluated, are more likely
bias. For example, a comparison of mortality after open colectomy
to have the outcome of interest. As an example, paid volunteer
with that after laparoscopic colectomy might be skewed because of
subjects may be more motivated to comply with treatment regi-
the greater likelihood that open colectomy will be performed on
mens and report favorable results than unpaid subjects are, and an emergency basis in a critically ill patient. In other words, sever-
this difference may result in overestimation of the effect of an ity of illness might confound the observed association between
intervention. Such overestimation may involve both the internal mortality and surgical approach.
validity and the external validity of the study. As another example, Confounding can be effectively addressed by means of random-
ization. When subjects are randomized, potentially confounding
variables (both recognized and unrecognized) are likely to be
evenly distributed across comparison groups. Thus, even if these
REAL WORLD
variables influence the baseline rates of certain outcomes in the
cohort as a whole, they are unlikely to have a significant effect on
and Design Study
Apply Evidence
differences observed across comparison groups.When randomiza-

Ask Questions
tion is not practical, confounding can be minimized by tightly con-

to Practice
trolling the study entry criteria. For instance, in the aforemen-

tioned comparison of open and laparoscopic colectomy (see
Processes Related above), one might opt to include only elective colectomies. It should
to External Validity
be kept in mind, however, that restrictive entry criteria can some-
times limit generalizability. Another way to combat confounding is
to use statistical risk-adjustment techniques; the downside to these
is that they can reduce statistical power.
EXTERNAL VALIDITY: INTERPRETING AND APPLYING
Study
Conduct
Processes Related
e t Results
te na lyze and
EVIDENCE TO PRACTICE
to Internal Validity
Once one is convinced that a clinical study is internally valid
(i.e., that the observed outcome is the result of the exposure or
r pr
A
Measure intervention and cannot be attributed to some alternative explana-

Results In
tion), the challenge is to assess the study’s external validity (i.e., to
determine whether the findings are applicable to a particular clin-
ical scenario). To make an assessment of the external validity of a
STUDY clinical study, it is necessary to examine several components of the
study, including the patient population, the intervention, and the
Figure 1 Schematically depicted are processes that affect the outcome measure. This process can be illustrated by briefly con-
internal and external validity of a clinical study. sidering the example of a large, prospective, randomized clinical
trial of laparoscopic versus open inguinal hernia repair performed repair (TEP).8 Surgeons who avoid using TAPP might reasonably
in Veterans’ Affairs (VA) medical centers.5 question the generalizability of the VA study to their practices.
The VA trial concluded that the outcomes of open hernia repair Finally, the type of outcome measured can affect the generaliz-
were superior to those of laparoscopic repair. The trial was well ability of clinical studies.The outcomes chosen for clinical studies
designed and well conducted, but it generated substantial discus- may be those that are most convenient or most easily quantified
sion about the generalizability of the results. As noted [see Internal rather than those that are of greatest interest to patients. In the VA
Validity: Evaluating Study Quality, Bias, above], subject selection hernia trial, several outcomes were studied, including operative
bias can adversely affect the external validity (generalizability) of a complications, hernia recurrence, pain, and length of convales-
study’s results: if the study population is in some important respect cence. Some of the outcome differences favored open repair,
different from a particular population for which a surgeon is mak- whereas others favored laparoscopic repair. To interpret the evi-
ing clinical decisions, the results may not be entirely generalizable dence as favoring one type of repair or the other involves making
to the latter population. In the VA hernia trial, the subjects were implicit value judgments regarding which outcomes are most
military veterans, who tend to be, on average, older than the non- important to patients. Surgeons interested in applying the evi-
veteran general population. If older persons are more vulnerable dence from the VA hernia trial to their own decisions about hernia
to the risks of laparoscopic hernia repair (e.g., complications asso- repair will have to examine the specific outcomes measured before
ciated with general anesthesia), one might expect that any differ- they can determine to what extent this study is generalizable to
ences between open and laparoscopic herniorrhaphy with respect specific patients with specific values and interests.
to morbidity outcomes would be exaggerated in a trial that includ-
ed a higher number of older subjects, as the VA trial did. Accord-
ingly, a surgeon attempting to assess the external validity of the VA Role of Evidence-Based Surgery in Measuring and
trial might consider the evidence provided by the trial to be applic- Improving Quality of Care
able to older patients but might reserve his or her judgment on the In clinical studies, the efficacy of a surgical practice is measured
use of laparoscopy to repair hernias in younger, healthier patients. in terms of the resulting patient outcomes. Until relatively recent-
A striking example of the potential effect of selection bias on ly, efforts to assess the quality of surgical care have focused almost
generalizability comes from the Asymptomatic Carotid Artery exclusively on clinical outcomes. In the past few years, however, the
Stenosis (ACAS) trial.6 In this large, prospective, randomized evidence-based surgery movement has begun to promote an alter-
study, volunteers for the trial were substantially younger and native measure of surgical quality—namely, adherence to process-
healthier than the average patient who undergoes carotid es of care supported by the best available scientific evidence.
endarterectomy. As a result, the observed perioperative mortality The question of whether efforts to assess quality should focus on
in the ACAS trial was considerably lower than that observed in the evidence-based processes of care or clinical outcomes is as much
general population—and, for that matter, lower even than the practical as philosophical.The practical argument against outcome
overall perioperative mortality in the very hospitals where the trial measures is largely driven by a growing recognition that when hos-
was conducted.7 Although the results of the ACAS trial signifi- pitals and surgeons are considered on an individual basis, adverse
cantly changed practice, an argument could be made that the evi- outcomes generally are not numerous enough to allow identifica-
dence provided by this trial, strictly speaking, was generalizable tion of meaningful differences between providers.9 In other words,
only to younger populations. outcome-based studies of the quality of care supplied by individ-
The external validity of a clinical study can also be affected by ual providers tend to have insufficient statistical power.The practi-
who provides the intervention. For example, in the VA hernia trial, cal argument against evidence-based process-of-care measures is
surgeons had varying degrees of experience with the laparoscopic driven by the paucity of high-leverage, procedure-specific process-
approach, and there were twofold differences in hernia recurrence es for which sound evidence is available, as well as by the logistical
rates between surgeons who had done more than 250 cases and challenge of measuring such processes. The issues surrounding
surgeons who had less experience. Surgeons considering whether assessment of quality of care are discussed in greater detail else-
the evidence supports the use of laparoscopic repair will therefore where [see ECP:2 Performance Measures in Surgical Practice].
have to examine their own experience with this approach before Given its current momentum, the evidence-based surgery
they can determine to what extent the results of the VA trial are movement is likely to play a progressively larger role in efforts to
generalizable to their own practices. assess and improve quality of surgical care. Furthermore, as pay-
Furthermore, external validity can be influenced by what type of ers increasingly turn to pay-for-performance strategies to improve
intervention is provided. For example, some have argued that one quality and control costs, the demand for evidence-based practice
of the laparoscopic techniques commonly used in the VA trial, guidelines is likely to grow. Ultimately, it is certain that identifica-
transabdominal preperitoneal repair (TAPP), is outmoded and tion and implementation of evidence-based surgical practices will
more hazardous than the competing approach, totally extraperitoneal provide patients with safer, better care.
References
1. Evidence-Based Medicine Working Group: Evidence- grading the quality of evidence and the strength of 7. Wennberg DE, Lucas FL, Birkmeyer JD, et al:
based medicine: a new approach to teaching the recommendations I: critical appraisal of existing Variation in carotid endartectomy mortality in the
practice of medicine. JAMA 268:2420, 1992 approaches—the GRADE Working Group. BMC Medicare population: trial hospitals, volume, and
Health Services Research 4:38, 2004 patient characteristics. JAMA 279:1278, 1998
2. Harris RP, Helfand M, Woolf SH, et al: Current
methods of the US Preventive Services Task Force: 5. Neumayer L, Giobbe-Hurder O, Johansson O, et al:
8. Grunwaldt LJ, Schwaitzberg SD, Rattner DW, et al:
a review of the process. Am J Prev Med 20(suppl Open mesh versus laparoscopic mesh repair of
Is laparoscopic inguinal hernia repair an operation
3):21, 2001 inguinal hernia. N Engl J Med 350:1819, 2004
of the past? J Am Coll Surg 200:616, 2005
6. Executive Committee for the Asymptomatic Carotid
3. Woloshin S: Arguing about grades. Eff Clin Pract 9. Dimick JB,Welch HG, Birkmeyer JD: Surgical mor-
Atherosclerosis Study: Endarterectomy for asymp-
3:94, 2000 tality as an indicator of hospital quality: the problem
tomatic carotid artery stenosis. JAMA 273:1421,
4. Atkins D, Eccles M, Flottorp S, et al: Systems for 1995 with small sample size. JAMA 292:847, 2004
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREPARATION OF THE OR — 1
1 PREPARATION OF THE
OPERATING ROOM
Rene Lafrenière, M.D., C.M., F.A.C.S., Ramon Berguer, M.D., F.A.C.S., Patricia C. Seifert, R.N., Michael Belkin, M.D.,
F.A.C.S., Stuart Roth, M.D., Ph.D., Karen S.Williams, M.D., Eric J. De Maria, M.D., F.A.C.S., and Lena M. Napolitano,
M.D., F.A.C.S., for the American College of Surgeons Committee on Perioperative Care
Today’s operating room is a complex environment wherein a vari- during the operation, critical devices must be positioned so that
ety of health care providers are engaged in the sacred ritual of they can readily be brought into use for monitoring and life sup-
surgery, controlling and modifying nature’s complicated orchestra port. The supplies and instruments likely to be needed must be
of disease entities. In what follows, we discuss certain key aspects easily available. Effective communication must be in place among
of the OR environment—design, safety, efficiency, patient factors, the members of the OR team, the OR front desk, and the rest of
and the multidisciplinary team—with the aim of improving sur- the hospital. Built-in computer, phone, imaging, and video sys-
geons’ understanding and comprehension of this complex world. tems can enhance efficiency and safety by facilitating access to
In particular, we focus on emerging technologies and the special clinical information and decision-making support. Finally, the
OR requirements of the burgeoning fields of endovascular surgery design of the OR must facilitate cleaning and disinfection of the
and minimally invasive surgery. room as well as permit efficient turnover of needed equipment and
supplies for the next procedure.
A modern OR must include adequate storage space for imme-
General Principles of OR Design and Construction diately needed supplies. Equally important, it must include ade-
quate storage space for the multitude of equipment and devices
PHYSICAL LAYOUT
required in current surgical practice. All too often, storage space is
The basic physical design and layout of the OR have not changed inadequate, with the result that equipment and supplies must be
substantially over the past century. In the past few years, however, stored in hallways and in the ORs themselves, thereby creating
major changes have occurred in response to continuing technologi- obstructions and hazards for personnel and patients.
cal developments in the areas of minimally invasive surgery, intraop- The basic design of today’s OR consists of a quadrangular room
erative imaging, invasive nonsurgical procedures (e.g., endoscopic, with minimum dimensions of 20 × 20 ft. More often, the dimen-
endovascular, and image-guided procedures), patient monitoring, sions are closer to 30 × 30 ft to accommodate more specialized
and telemedicine. cardiac, neurosurgical, minimally invasive, or orthopedic proce-
The exact specifications for new construction and major remodel- dures. Smaller rooms, however, are generally adequate for minor
ing of ORs in the United States depend, first and foremost, on state surgery and for procedures such as cystoscopy and eye surgery.
and local regulations, which often incorporate standards published Ceiling height should be at least 10 ft to allow mounting of oper-
by the Department of Health and Human Services.1 The American ating lights, microscopes, and other equipment on the ceiling. An
Institute of Architects publishes a comprehensive set of guidelines for additional 1 to 2 ft of ceiling height may be needed if x-ray equip-
health care facility design that includes a detailed discussion of OR ment is to be permanently mounted.
design.2 The design of new ORs must also take into account recom-
VOICE, VIDEO, AND DATA COMMUNICATION
mendations generated by specialty associations and regulatory agen-
cies.3-6 Finally, there are numerous articles and books that can be The operating suite should be wired to provide two-way voice,
consulted regarding various aspects of OR design.7-11 video, and data communication between the OR and the rest of the
The architectural design process for modern ORs should in- health care facility. Teleconnection of the OR to other areas of the
clude knowledgeable and committed representatives from hospi- hospital (e.g., the pathology department, the radiology department,
tal clinical services, support services, and administration. Impor- the emergency department, conference rooms, surgeons’ offices, and
tant design considerations include the mix of inpatient and outpa- wet/dry laboratories) can greatly enhance both patient care and
tient operations, patient flow into and out of the OR area, the teaching by improving the exchange of crucial information while
transportation of supplies and waste materials to and from the keeping noncritical traffic out of the OR environment.Two-way au-
OR, and flexibility to allow the incorporation of new technologies. dio and video teleconferencing can improve surgical management by
This planning phase benefits greatly from the use of architectural facilitating proctoring of less experienced practitioners, real-time
drawings, flow diagrams, computer simulations, and physical consultation with experienced specialists or the scientific literature,
mockups of the OR environment. and immediate viewing of x-ray images, specimens, and histologic
For an operation to be successful, multiple complex tasks must findings. Archiving of visual data also permits efficient sharing of in-
be carried out, both serially and in parallel, while care is exercised formation with other practitioners, to the point where even the most
to ensure the safety of both the patient and OR personnel.To this complex operative situation can be experienced on a nearly firsthand
end, it is vital that the OR be designed so as to permit patients, OR basis. It is largely true that our newfound technological ability to
personnel, and equipment to move and be moved as necessary share the OR environment between institutions has greatly facilitat-
without being unduly hindered by overcrowding or by obstruction ed the rapid development of advanced laparoscopic surgical proce-
from cables, wires, tubes, or ceiling-mounted devices. Before and dures on a global level.The superior educational value of a shared
audio and visual environment for teaching and learning complex patients because conservation of body heat is critical in these
surgical procedures is now well established. patients. Generally, surgeons who are actively working and fully
gowned prefer a temperature of 18° C (64.4° F), but anesthesiol-
ACCOMMODATION OF NEW TECHNOLOGIES
ogists prefer 21.5° C (70.7° F).14
In developing the OR of the future, it is essential to remain Humidity in the OR is generally maintained at between 50%
abreast of new technologies and incorporate them as appropriate; and 60%; humidity greater than 60% may cause condensation on
however, this should be done in such a way as to make the OR cool surfaces, whereas humidity less than 50% may not suppress
environment simpler rather than more complicated and less inti- static electricity.
midating rather than more so. Any new technical development
LIGHTING
must undergo rigorous evaluation to ensure that the correct tech-
nology is introduced in the correct manner at the correct time.12 Well-balanced illumination in the OR provides a surgeon with a
Properly utilized, technology can greatly facilitate surgical man- clear view of the operative field, prevents eye strain, and provides ap-
agement. A potential example is the bar coding now seen in every propriate light levels for nurses and anesthesiologists. Much of our
facet of our daily lives. At a patient’s first office visit, he or she can factual knowledge of OR illumination has been gained through the
be given a bar code, which is entered into a computer. On the efforts of Dr.William Beck and the Illuminating Engineering Soci-
morning of surgery, the computer can give the patient a wake up ety.15,16 A general illumination brightness of up to 200 footcandles
call at 5:30 A.M. Upon arrival at the surgical center, the patient (ft-c) is desirable in new constructions.The lighting sources should
can be logged in by bar code. Each step in the process can be not produce glare or undesirable reflection.
tracked: how many minutes it took for the patient to get to the The amount of light required during an operation varies with
OR, how long it took for the anesthesiologist and the resident to the surgeon and the operative site. In one study, general surgeons
interview the patient in the preoperative holding area, and how operating on the common bile duct found 300 ft-c sufficient;
long it took to position the patient. Essentially, this process is a because the reflectance of this tissue area is 15%, the required
variation on patient tracking and data acquisition that minimizes incident light level would be 2,000 ft-c.17 Surgeons performing
variability with respect to data entry. Tracking information can coronary bypass operations require a level of 3,500 ft-c.17 Whether
also be displayed on a video monitor, so that the patient’s location changes in the color of light can improve discrimination of differ-
and current status within the surgical care process are available on ent tissues is unknown.
an ongoing basis. Another facet of OR lighting is heat production. Heat may be
produced by infrared light emitted either directly by the light
MAXIMIZATION OF EFFICIENCY IN DESIGN AND PROCESS
source or via energy transformation of the illuminated object.
With the proliferation of technology, the increased complexity of However, most of the infrared light emitted by OR lights can be
surgical procedures, and the ongoing advances in surgical capabili- eliminated by filters or by heat-diverting dichroic reflectors.
ties, surgery today is a highly involved undertaking. As the number
of potential processes and subprocesses in surgical care has in-
creased, so too has the potential for inefficiency. Often, the organiza- Basic Safety Concerns in the OR
tional tendency to keep doing things the way they have always been The OR presents a number of environmental hazards to both
done prevents necessary improvements from being made, even in surgical personnel and patients. Chemical hazards exist from the use
the face of significant pressure from corporate interests to improve of trace anesthetic gases, flammable anesthetic agents, various deter-
and simplify processes. Decreasing turnover time and increasing ef- gents and antimicrobial solutions, medications, and latex products.18
ficiency during procedures are essential and can be accomplished by Other ever-present physical hazards include electrical shock and
simplifying rather than complicating the processes involved. An ex- burns, exposure to radiation from x-ray equipment, and injuries
ample of such an approach was documented in a 2002 article caused by lasers.19 In addition to causing injury directly, the use of
demonstrating that the redesign of a neurosurgical operating suite lasers can expose OR personnel to papillomavirus in smoke plumes.20
simplified processes and procedures related to neurosurgical opera- Hazards that are less often considered include noise pollution21 and
tions, resulting in a 35% decrease in turnover time.13 In addition, light hazards from high-intensity illumination.22 The most effective
team efficiency was significantly increased, leading to further time way of minimizing the particular hazards in a given OR is to have an
savings. The time commitment required of the specialist and the active in-hospital surveillance program run by a multidisciplinary
team members to make the necessary changes was modest, but the team that includes surgeons.
presence of OR administrators, staff members, surgeons, and anes-
MINIMIZATION OF HAZARDS TO PATIENT
thesia personnel, all cooperating to make working conditions more
productive and rewarding for everyone, was deemed crucial to the Patient safety, the first order of business in the OR,23 begins
success of the experiment. with proper handling of patients and their tissues, which is partic-
ularly important where patients are in direct contact with medical
devices. It is imperative that physicians, nurses, and technicians
Environmental Issues in the OR protect patients from injuries caused by excessive pressure, heat,
abrasion, electrical shock, chemicals, or trauma during their time
TEMPERATURE AND HUMIDITY
in the OR. Equipment must be properly used and maintained
The ambient temperature of the OR often represents a com- because equipment malfunctions, especially in life-support or
promise between the needs of the patient and those of the staff; monitoring systems, can cause serious harm.
the temperature desired by staff itself is a compromise between
the needs of personnel who are dressed in surgical gowns and Anesthetic Considerations
those who are not. In Europe and North America, OR tempera- Surgery, by its very nature, makes demands on the body’s
tures range from 18° to 26° C (64.4° to 78.8° F). A higher tem- homeostatic mechanisms that, if unchecked, would be injurious.
perature is necessary during operations on infants and burn It is the role of the anesthesiologist to anticipate these demands,
compensate for them, and protect the patient by supporting the becomes supine, the blood flow becomes essentially uniform from
body’s own efforts to maintain homeostasis [see 1:3 Perioperative apex to base.29 During spontaneous ventilation in the supine posi-
Considerations for Anesthesia]. Patient protection demands that con- tion, the patient can compensate for the altered flow, but when he
cerned physicians understand the effects of their perioperative in- or she is anesthetized, paralyzed, and placed on positive pressure
terventions, both positive and negative, and act to minimize the ventilation, the weight of the abdominal contents prevents the pos-
unintended consequences. terior diaphragm from moving as freely as the anterior diaphragm,
Even with straightforward surgical procedures, issues related to thus contributing to a ventilation-perfusion mismatch.30
patient positioning can lead to unintended consequences. Gen- After the supine position, the lithotomy position is the next
eral, regional, and monitored anesthesia care render patients help- most common position for surgical procedures. Approximately
less to protect themselves from the stresses of an uncomfortable 9% of operations are conducted with the patient in the lithotomy
position. As the physician who renders the patient helpless, the position.26 Because the lithotomy position is basically a modifica-
anesthesiologist is responsible for protecting the patient from the tion of the supine position, there is still a risk of upper-extremity
results of the position. The surgeon, who chooses the position for neuropathy; however, the risk of lower-extremity neuropathy is sig-
the procedure that maximizes exposure and facilitates the opera- nificantly greater. The main hemodynamic consequence of the
tion, is responsible for the consequences of that choice. The OR lithotomy position is increased cardiac output secondary to the
team is responsible for procuring and maintaining whatever spe- gravity-induced increase in venous return to the heart caused by
cialized equipment is needed to position the patient properly.The elevation of the lower extremities above the level of the heart.28 Of
American Society of Anesthesiologists (ASA) Practice Advisory on greater concern is the effect on the lower extremity of the various
the Prevention of Perioperative Peripheral Neuropathies recom- devices used in positioning. Damage to the obturator, sciatic, lat-
mends that when practical, the patient should be placed in the eral femoral cutaneous, and peroneal nerves after immobilization
intended position before the procedure to see if it is comfortable.24 in the lithotomy position, though rare, has been reported.31,32 Such
If the position is uncomfortable when the patient is awake, it complaints account for only 5% of all closed claims for nerve dam-
should be modified until it is comfortable. age in the Closed Claims Data Base.25
The consequences of patient discomfort from positioning may Other patient positions can also lead to physiologic and neuro-
include postoperative myalgias, neuropathies, and compartment logic complications, including the lateral decubitus, prone, sitting,
syndromes. The greatest risk in the supine position, peripheral Trendelenburg, and reverse Trendelenburg positions.
neuropathy, arises from the positioning of the upper extremity.
MINIMIZATION OF OCCUPATIONAL INJURIES TO
The two most common peripheral neuropathies reported to the
HEALTH CARE TEAM
ASA Closed Claim Study as of 1999 were ulnar neuropathy and
brachial plexopathy.25 Approximately 28% of the closed claims for Work-related musculoskeletal injuries are a major cause of de-
peripheral neuropathy were for ulnar neuropathy and 20% for creased productivity and increased litigation costs in the United
brachial plexopathy.25 With regard to upper-extremity positioning, States.23 In the OR, occupational injuries can be caused by excessive
the ASA Practice Advisory recommends that the arms be abduct- lifting, improper posture, collision with devices, electrical or thermal
ed no more than 90°.24 The arms should also be positioned so as injury, puncture by sharp instruments, or exposure to bodily tissues
to decrease pressure on the postcondylar groove of the humerus. and fluids.Temporary musculoskeletal injuries resulting from poor
When the arms are tucked, the neutral position is recommended. posture (particularly static posture) or excessive straining are less
Prolonged pressure on the radial nerve in the spiral groove of the commonly acknowledged by members of the surgical team but oc-
humerus should be avoided. Finally, the elbows should not be cur relatively frequently during some operations.
extended beyond a comfortable range so as not to stretch the To reduce injuries from awkward posture and excessive strain-
median nerve. ing, OR devices should be positioned in an ergonomically desir-
Approximately 80% of surgical procedures are performed with able manner, so that unnecessary bending, reaching, lifting, and
patients in the supine position.26 Its ubiquity notwithstanding, the twisting are minimized. Visual displays and monitors should be
supine position has certain physiologic consequences for the placed where the surgical team can view them comfortably.
patient, including gravitational effects on both the circulatory sys- Devices that require adjustment during operations should be read-
tem and the pulmonary system.27 The most immediate hemody- ily accessible. Placement of cables and tubes across the OR work-
namic effect noted upon assumption of the supine position is space should be avoided if possible.The patient and the operating
increased cardiac output resulting from enhanced return of lower- table should be positioned so as to facilitate the surgeons’ work
extremity venous blood to the heart.28 If this effect were unop- while maintaining patient safety. Lifting injuries can be prevented
posed, systemic blood pressure would rise. This rise does not by using proper transfer technique and obtaining adequate assis-
occur, however, because baroreceptor afferent impulses lead to a tance when moving patients in the OR.
reflexive change in the autonomic balance, which decreases stroke
volume, heart rate, and contractility,29 thereby serving to maintain
blood pressure. Inhaled, I.V., and regional anesthetics all have the Equipment
capacity to blunt or abolish these protective reflexes, thus causing Modern surgery uses an ever-increasing number of devices in
hypotension in supine, anesthetized patients and necessitating the the OR to support and protect the patient and to assist the work
administration of additional fluids or, occasionally, pressors. of the surgical team [see Table 1]. All OR equipment should be eval-
Immediate effects of the supine position on the respiratory sys- uated with respect to three basic concerns: maintenance of patient
tem include cephalad and lateral shifting of the diaphragm and safety, maximization of surgical team efficiency, and prevention of
cephalad shifting of the abdominal contents, resulting in decreased occupational injuries.
functional residual capacity and total lung capacity.27,28 In addition,
ELECTROSURGICAL DEVICES
perfusion of the lung changes as the supine position is assumed.
When the patient is upright, the dependent portions of the lungs The electrosurgical device is a 500 W radio-frequency genera-
receive the bulk of the blood flow23; however, when the patient tor that is used to cut and coagulate tissue. Although it is both
Table 1 Devices Used in the OR evacuator should be attached to the laser to improve visualization,
reduce objectionable odor, and decrease the potential for papillo-
Anesthesia delivery devices
mavirus infection from the laser smoke plume.37
Ventilator
For support POWERED DEVICES
of patient Physiologic monitoring devices
Warming devices The most common powered device in the OR is the surgical
I.V. fluid warmers and infusers table. Central to every operation, this device must be properly
positioned and adjusted to ensure the safety of the patient and the
Sources of mechanical, electrical, and internal power,
including power tools and electrocautery, as well as laser efficient work of the surgical team. Manually adjustable tables are
and ultrasound instruments simple, but those with electrical controls are easier to manage. OR
Mechanical retractors table attachments, such as the arm boards and leg stirrups used to
Lights mounted in various locations position patients, must be properly maintained and secured to pre-
For support Suction devices and smoke evacuators
of surgeon
vent injuries to patients or staff. During transfer to and from the
Electromechanical and computerized assistive devices, such
as robotic assistants OR table, care must be taken to ensure that the patient is not
Visualization equipment, including microscopes, endoscopic injured and that life-support, monitoring, and I.V. systems are not
video cameras, and display devices such as video moni- disconnected. Proper transfer technique, personnel assistance, and
tors, projection equipment, and head-mounted displays
the use of devices such as rollers will help prevent musculoskeletal
Data, sound, and video storage and transmission equipment
injuries to the OR staff during this maneuver.
Diagnostic imaging devices (e.g., for fluoroscopy, ultrasonog-
raphy, MRI, and CT) Other powered surgical instruments common in the OR
include those used to obtain skin grafts, open the sternum, and
Surgical instruments, usually packaged in case carts before
each operation but occasionally stored in nearby fixed or
perform orthopedic procedures. Powered saws and drills can
mobile modules cause substantial aerosolization of body fluids, thereby creating a
Tables for display of primary and secondary surgical potential infectious hazard for OR personnel.38,39
For support instruments
of OR team
Containers for disposal of single-use equipment, gowns, VIEWING AND IMAGING DEVICES
drapes, etc.
Workplace for charting and record keeping OR microscopes are required for microsurgical procedures.
Communication equipment Floor-mounted units are the most flexible, whereas built-in micro-
scopes are best employed in rooms dedicated to this type of pro-
cedure.40 Microscopes are bulky and heavy devices that can cause
common and necessary in the modern OR, it is also a constant obstructions and collision hazards in the OR. All controls and dis-
hazard and therefore requires close attention.33 When in use, the plays must be properly positioned at or below the user’s line of
electrosurgical unit generates an electrical arc that has been asso- sight to allow comfortable and unobstructed viewing.
ciated with explosions.This risk has been lessened because explo- Today’s less invasive operations require more accurate intraop-
sive anesthetic agents are no longer used; however, explosion of erative assessment of the relevant surgical anatomy through the
hydrogen and methane gases in the large bowel is still a real—if use of x-ray, computed tomography, magnetic resonance imaging,
rare—threat, especially when an operation is performed on an and ultrasonography. Intraoperative fluoroscopy and ultrasonog-
unprepared bowel.34 Because the unit and its arc generate a broad raphy are most commonly used for this purpose. Intraoperative
band of radio frequencies, electrosurgical units interfere with ultrasonography requires a high-quality portable ultrasound unit
monitoring devices, most notably the electrocardiographic moni- and specialized probes. Depending on the procedure and the
tor. Interference with cardiac pacemaker activity also has been training of the surgeon, the presence of a radiologist and an ultra-
reported.35 sound technician may be required. The ultrasound unit must be
The most frequently reported hazard of the electrosurgical unit positioned near the patient, and the surgical team must be able to
is a skin burn. Such burns are not often fatal, but they are painful, view the image comfortably. In some cases, the image may be dis-
occasionally require skin grafts, and raise the possibility of litiga- played on OR monitors by means of a video mixing device.
tion.The burn site can be at the dispersive electrode, ECG moni- Dedicated open radiologic units are usually installed either in the
toring leads, esophageal or rectal temperature probes, or areas of OR proper or immediately adjacent to the OR to permit intraop-
body contact with grounded objects. The dispersive electrode erative imaging of the selected body area. As image-guided proce-
should be firmly attached to a broad area of dry, hairless skin, dures become more commonplace, OR designers will have to
preferably over a large muscle mass.34 accommodate such devices within the OR workplace in a user-
friendly manner.
LASERS
ADDITIONAL DEVICES
Lasers generate energy that is potentially detrimental. Lasers
have caused injuries to both patients and staff, including skin The use of sequential compression stockings (SCDs), with or
burns, retinal injuries, injuries from endotracheal tube fires, pneu- without additional medical anticoagulation, has become the stan-
mothorax, and damage to the colon and to arteries.36 Some design dard of care for the prevention of venous thromboembolism in the
changes in the OR are necessary to accommodate lasers. The OR majority of operations for which direct access to the lower extrem-
should not have windows, and a sign should be posted indicating ities is not required [see 6:6 Venous Thromboembolism].41 This is par-
that a laser is in use. The walls and ceiling in the room should be ticularly true in operations lasting more than 4 hours for which the
nonreflective. Equipment used in the operative field should be patient is in the lithotomy position. The pump often must be
nonreflective and nonflammable. The concentration of O2 and placed near the patient on the floor or on a nearby cart.The pres-
N2O in the inhaled gases should be reduced to decrease the pos- sure tubing from the stockings to the pump must be routed out of
sibility of fire. In addition, personnel should wear goggles of an the surgical team’s way to prevent hazards and enlargements, par-
appropriate type to protect the eyes from laser damage. A smoke ticularly during operations for which perineal access is required.
Suction devices are ubiquitous in the OR, assisting the surgeon Table 2 ICRP-Recommended
in the evacuation of blood and other fluids from the operative Radiation Dose Limits43
field. A typical suction apparatus consists of a set of canisters on a
wheeled base that receive suction from a wall- or ceiling-mounted Dose Limit
source. The surgeon’s aspirating cannula is sterilely connected to
these canisters. Suction tubing is a common tripping hazard in the Occupational Public
OR, and the suction canisters fill rapidly enough to require repeat- 20 mSv/yr averaged over
ed changing. Effective dose 1 mSv/yr
defined periods of 5 yr
Portable OR lights or headlights are often used when the light-
ing provided by standard ceiling-mounted lights is insufficient or Annual equivalent dose in
Lens of the eye 150 mSv 15 mSv
when hard-to-see body cavities prove difficult to illuminate. Head-
Skin 500 mSv 50 mSv
lights are usually preferred because the beam is aimed in the direc-
Hands and feet 500 mSv —
tion the surgeon is looking; however, these devices can be uncom-
fortable to wear for prolonged periods. The fiberoptic light cord ICRP—International Commission on Radiological Protection mSv—millisievert
from the headset tethers the surgeon to the light source, which can
exacerbate crowding.
Units of Exposure
CASE CARTS AND STORAGE Radiation exposure is expressed in several ways. One of the
In the case cart system, prepackaged sterile instruments and most commonly used terms is the rad (radiation absorbed dose),
supplies for each scheduled operation are placed on a single open defined as the amount of energy absorbed by tissue (100 erg/g =
cart (or in an enclosed cart) and delivered from the central sterile 1 rad). In the Système International, the gray (Gy) is used in place
supply area to the OR before the start of the procedure. of the rad (1 Gy = 100 rad).The newest of the units in current use,
Instrument sets should be sterilized according to facility policy. It the millisievert (mSv), was introduced as a measure of the effec-
is not recommended that instrument sets be flash sterilized imme- tive absorbed dose to the entire body (accounting for different sen-
diately before use in order to avoid purchasing additional instru- sitivities of exposed tissues).The amount of radiation generated by
ment sets.42 Instruments that are used less frequently or are used the x-ray tube is determined by the energy generated by the beam,
as replacements for contaminated items can be kept in nearby which in turn is determined both by the number of x-ray photons
fixed or mobile storage modules for ready access when required. generated (measured in milliamperes [mA]) and by the power or
Replacements for frequently used items that may become conta- penetration of the beam (measured in kilovolts [kV]). Most mod-
minated (e.g., dissecting scissors and hemostats) should be sepa- ern fluoroscopes automatically balance mA levels against kV lev-
rately wrapped and sterile so that they are readily available if need- els on the basis of the contrast of the image so as to optimize image
ed during an operation. quality and minimize x-ray exposure.
Exposure of human beings to radiation is broadly categorized as
either public (i.e., environmental exposure of the general public)
The Endovascular OR or occupational. The International Commission on Radiological
The field of vascular surgery has rapidly expanded over the past Protection (ICRP) has established recommended yearly limits of
decade to encompass a wide variety of both established and in- radiation exposure for these two categories [see Table 2].43 A 2001
novative endovascular procedures that are new to the OR en- study determined that with appropriate protection, radiation
vironment. Such procedures include complex multilevel dia- exposure for busy endovascular surgeons fell between 5% and 8%
gnostic arteriography, balloon angioplasty (with and without of ICRP limits, whereas exposure for other OR personnel fell
stenting), and endoluminal grafting of aortic aneurysms. Many between 2% and 4%.44 Average radiation exposure for patients
of these procedures can be performed in the radiologic interven- undergoing endovascular aneurysm repair was 360 mSv/case
tion suite as well as in the cardiac catheterization laboratory. (range, 120 to 860).44
However, the sterile environment, the option of performing com-
Basic Safety Rules
bined open surgical and endovascular procedures, and the op-
portunity to provide one-stop diagnostic and therapeutic care A few simple rules and procedures can help ensure a safe envi-
make the OR the favored location for efficient and safe man- ronment for patients and OR staff. The simplest rule is to mini-
agement. Although most OR personnel are familiar with fluoro- mize the use of fluoroscopy. Inexperienced operators are notorious
scopic procedures as well as simple diagnostic arteriography, the for excessive reliance on fluoroscopy. Such overutilization results
development of a comprehensive and successful endovascular both from needing more time to perform endovascular maneuvers
program in the OR requires significant personnel training, than a more experienced surgeon would need and, more impor-
commitment of resources, and preparation. In what follows, we tant, from performing excessive and unnecessary (and frequently
review certain basic considerations in the evolution of such a unintentional) imaging between maneuvers.The use of pulsed flu-
program, focusing primarily on space and equipment. Tech- oroscopy and effective collimation of the images will also minimize
nical details of endovascular procedures are addressed in the dose of radiation administered. Minimal use of high-definition
more detail elsewhere [see 6:8 Fundamentals of Endovascular fluoroscopy and unnecessary cine runs (both of which boost radi-
Surgery]. ation output) are desirable. Most important, surgeons and OR
staff should maximize their working distance from radiation
RADIATION SAFETY sources. Radiation scatter drops off rapidly with increasing dis-
A detailed discussion of radiation physics and safety is beyond tance from the fluoroscope.
the scope of this chapter.There are, however, certain fundamental
Safety Equipment and Monitoring
concerns that should be emphasized here to ensure the safety of
patients and staff members. All OR personnel should wear protective lead aprons (0.25 to
0.5 mm in thickness). Wraparound designs are preferred because Table 3 Standard Equipment for
members of the OR team will invariably turn their backs to the Endovascular ORs
radiation source on occasion. The apron should include a thyroid
shield. High-level users must wear protective lead-containing lens-
Entry needle (16-gauge beveled)
es. A mobile shield (e.g., of lead acrylic) is a useful adjunct that Entry wire (J wire or floppy-tip wire)
may be employed to reduce exposure during cine runs. All per- Arterial sheath (5 Fr)
sonnel should wear radiation safety badges. Although these badges Catheters
afford no direct protection, they do allow direct monitoring of Diagnostic Multipurpose nonselective (pigtail, tennis racquet,
individual cumulative exposure on a monthly basis. arteriography straight, etc.)
Selective (cobra head, shepherd’s crook, etc.)
PHYSICAL LAYOUT Guide wires (floppy, steerable, angled, hydrophilic, etc.)
Contrast agent (nonionic preferred)
The design of the endovascular OR depends on the balance of Power injector
institutional and programmatic needs. For large institutions with a
significant endovascular volume, a dedicated endovascular OR Sheaths (various lengths and diameters)
may be desirable. Ideally, such a room would combine fixed ceil- Guide catheters
ing-mounted imaging equipment with a dedicated “floating” flu- Balloons (various lengths and diameters)
Balloon stent
Stents
oroscopy table. The main advantage of a dedicated endovascular angioplasty
Balloon expandable (various lengths and diameters)
OR is that it provides state-of-the-art imaging techniques and Self-expanding (various lengths and diameters)
capabilities in the OR setting; the main disadvantage is that it is Inflation device
relatively inflexible and is not useful for other procedures. For
many institutions, such a room may not be cost-effective. For- Large-caliber sheaths (12–24 Fr)
tunately, with careful design, a high-quality endovascular suite can Super-stiff guide wires
Endovascular Endovascular stent grafts
be set up that is flexible enough to allow both complex endovas- aneurysm Main body and contralateral iliac limb
cular procedures and conventional open vascular and nonvascular repair
Aortic and iliac extension grafts
operations to be performed. Such a room should be at least 600 Endovascular arterial coils
sq ft in area, with sufficient length and clearance for extension
tables and angiographic wires and catheters.
digital C-arms have increased dramatically. State-of-the-art
EQUIPMENT
portable C-arms are considerably less expensive than fixed sys-
tems ($175,000 to $225,000) while retaining many of their advan-
Imaging Equipment tages. The variable image intensifier size (from 6 to 12 in.) offers
There are two fundamental physical designs for OR imaging valuable flexibility, with excellent resolution at the smaller end and
equipment. The first is the fixed ceiling-mounted system that is an adequate field of view at the larger end.With some portable C-
also employed in catheterization laboratories and dedicated radio- arm systems, it is possible to vary the distance between the image
logic interventional suites. The second is a system using portable intensifier and the x-ray tube, as with a fixed system (see above).
C-arms with dedicated vascular software packages designed for Pulsed fluoroscopy, image collimation, and filtration are standard
optimal endovascular imaging. Each of these systems has advan- features for improving imaging and decreasing radiation exposure.
tages and disadvantages. Sophisticated software packages allow high-resolution digital sub-
Notable benefits of the fixed ceiling-mounted system include traction angiography, variable magnification, road mapping (i.e.,
higher power output and smaller focal spot size, resulting in the high- the superimposition of live fluoroscopy over a saved digital arteri-
est-quality images. Larger image intensifiers (up to 16 in.) make pos- ogram), and a number of other useful features. Improvements in
sible larger visual fields for diagnostic arteriograms; thus, fewer runs C-arm design allow the surgeon to use a foot pedal to select vari-
need be made, and injection of dye and exposure to radiation are re- ous imaging and recording modes as well as to play back selected
duced accordingly.The variable distance between the x-ray tube and images and sequences.
the image intensifier allows the intensifier to be placed close to the Unlike fixed systems, which require patients to be moved on a
patient if desired, thereby improving image quality and decreasing floating table to change the field of view, C-arm systems require the
radiation scatter. Fixed systems are accompanied by floating angiog- image intensifier to be moved from station to station over a fixed pa-
raphy tables, which allow the surgeon to move the patient easily be- tient. Although more cumbersome than fixed systems, the newest C-
neath the fixed image intensifier. It is generally accepted that such arms have increased mobility and maneuverability. Patients must be
systems afford the surgeon the most control and permit the most ef- placed on a special nonmetallic carbon fiber table.To provide a suffi-
fortless and efficient imaging of patients. cient field of view and permit panning from head to toe, the tables
Unfortunately, fixed ceiling-mounted systems are quite expen- must be supported at one end with complete clearance beneath. Al-
sive (typically $1 million to $1.5 million), and major structural though these tables do not flex, they are sufficient for most opera-
renovations are often required for installation in a typical OR. tions. Furthermore, they are mobile and may be replaced with con-
Perhaps more important for most ORs, however, is that these sys- ventional operating tables when the endovascular suite is being used
tems are not particularly flexible. The floating angiography tables for standard open surgical procedures.
and the immobility of the image intensifiers render the rooms
unsuitable for most conventional open surgical procedures. Interventional Equipment
Consequently, fixed imaging systems are generally restricted to The performance of endovascular procedures in the OR
high-volume centers where utilization rates justify the construc- requires familiarity with a wide range of devices that may be unfa-
tion of dedicated endovascular ORs. miliar to OR personnel, such as guide wires, sheaths, specialized
As endovascular procedures in the OR have become increas- catheters, angioplasty balloons, stents, and stent grafts [see Table 3].
ingly common, the imaging capability and versatility of portable In a busy endovascular OR, much of this equipment must be
Aortic Extender
Contralateral Leg
Trunk/Ipsilateral Leg
Iliac Extender
Figure 1 Shown are the component parts of a modular aortic stent graft.
stocked for everyday use, with the remainder ordered on a case-by- planted by less invasive endovascular alternatives.Today’s vascular
case basis. The expense of establishing the necessary inventory of surgery ORs must be prepared and equipped for a safe and effi-
equipment can be substantial and can place a considerable burden cient transition as this trend continues.
on smaller hospitals that are already spending sizable amounts on
stocking similar devices for their catheterization laboratories and
interventional suites. Fortunately, many companies are willing to The Laparoscopic OR
supply equipment on a consignment basis, allowing hospitals to
PHYSICAL LAYOUT
pay for devices as they are used.
With the advent of laparoscopy, it has become necessary to reeval-
Aortic Stent Grafts uate traditional OR concepts with the aim of determining how best
Endovascular repair of an abdominal aortic aneurysm (EVAR) to design a surgical environment suitable for the demanding require-
is the most common and important endovascular procedure per- ments of advanced minimally invasive surgical procedures.
formed in the OR [see 6:11 Repair of Infrarenal Abdominal Aortic As noted (see above), until the early 1990s, ORs were constructed
Aneurysms]. As of spring 2003, three EVAR devices had been in much the same way as they had been for nearly 100 years.The ef-
approved by the FDA for commercial use, with numerous others fect of the explosion in minimally invasive surgical procedures that
at various stages of the FDA approval process. All EVAR grafts are occurred in that decade, along with the demonstration that patients
expensive (> $10,000). Although busy hospitals may maintain an benefited from significantly reduced recovery times, was to force OR
inventory of devices, most grafts are ordered on a case-by-base personnel to move rapidly into a new age of technology, with little or
basis. The favored devices are configured as bifurcated aortoiliac no preparation. During the early days of laparoscopic surgery, sur-
grafts. Most such grafts are modular in design, comprising two geons noted significant increases in turnover time and procedural
main pieces [see Figure 1], though one unibody device has been down time.45 Adding to the problem was that the OR environment
approved. Nonbifurcated grafts connecting the aorta to a single was becoming increasingly cluttered as a consequence of the addi-
iliac artery are available for special circumstances. Grafts are con- tion of endoscopic video towers and other equipment.This equip-
structed of either polyester or polytetrafluoroethelyne (PTFE) ment often proved to be complicated to use and expensive to repair.
and have varying amounts of stent support. Proximal fixation is The increasing expenditure of money and time, coupled with an op-
accomplished in different ways, ranging from friction fit to the use erating environment that increasingly promoted confusion rather
of hooks and barbs. Various extension components for both ends than patient care, constituted a clear signal that the OR, as designed
of the graft are available; in many cases, these components are a century before, had been stretched beyond its capabilities and
necessary to complete the repair. needed to be redesigned.
Endovascular therapy is a rapidly evolving field within the dis- A key component of OR redesign for laparoscopic surgery is the
cipline of vascular surgery. Many operations traditionally per- placement of patient contact equipment on easily movable booms
formed as open surgical procedures are increasingly being sup- that are suspended from the ceiling.This arrangement makes rooms
easier to clean and thus speeds turnover. All patient contact equip-
ment and monitors are placed on these booms, and all other equip-
ment is moved to the periphery of the surgical suite, usually in a
nurse’s command and control center.Thus, control of all equipment
is at the fingertips of the circulating nurse, and the disruption and in-
convenience of manipulating equipment on carts is avoided.
Rearranging monitors is much simpler with the easily movable
booms than with carts, and there are no wires to trip OR person-
nel, because the wiring is done through the boom structure.
Furthermore, because the wiring moves with the equipment, there
is less risk that settings will be accidentally changed or wires
unplugged—and thus less wear and tear on equipment and staff.
The booms are easily moved to the periphery of the room, allow-
ing the room to be used for multispecialty procedures, including
non–minimally invasive procedures [see Figure 2].
LAPAROSCOPIC SURGICAL TEAM
The issue of time efficiency in the OR is at the heart of 21st-cen-

tury surgical practice. Prolonged operating time, excessive setup
time, and slow turnover can all affect productivity adversely. As
Figure 2 The new OR suites at the Medical College of Virginia
managed care continues to evolve, less productive health care incorporate the Endosuite design (Stryker Communications,
providers will be left behind. The right equipment and the right San Jose, Calif.) for advanced laparoscopic procedures.
room design provide the basic foundation for a more productive
OR. Without the right team, however, time efficiencies cannot be
optimized.To achieve quick turnover time and efficient procedur- sible to produce cameras that are smaller and less expensive than
al flow in the laparoscopic OR, it is critical to inculcate a team ori- three-chip cameras; however, resolution and sensitivity are both
entation in all OR personnel.46 compromised.
It is clear that a team of circulating nurses and scrub techs spe- The trend in laparoscopic surgery has been toward smaller
cially designated for minimally invasive surgical procedures can scope diameters. In particular, there has been a large migration
accomplish their tasks more quickly and efficiently than a random from 10 mm to 5 mm rigid scopes. As a result, it is essential to
group of circulating nurses and scrub techs could. The time sav- choose a camera that can perform under the reduced lighting con-
ings can be channeled into a larger volume of procedures and a ditions imposed by the use of 5 mm devices.The nature and inten-
more relaxed, patient care–driven OR environment. sity of the light source must be factored in as well.When a laparo-
Training seminars to improve the OR staff’s familiarity with scopic procedure is being performed through 5 mm ports, it is
and performance of laparoscopic procedures should be given. often preferable to use a xenon light source so as to maximize light
Sessions in which surgeons present the technical issues involved in throughput and optimize resolution.
advanced laparoscopic procedures, including room setup, choice
of equipment, and procedural steps, are beneficial. Video-tower Surgeon’s Control of Equipment:Touch Panels,Voice Activation,
setup and troubleshooting can be taught in small group sessions, and Robotics
with an emphasis on solving common technical problems by a There are some inherent shortcomings in the way OR equip-
process analogous to working through a differential diagnosis. ment has traditionally been accessed, and those shortcomings have
been exacerbated by the advent of minimally invasive procedures.
EQUIPMENT
Because most of the equipment needed for minimally invasive
In addition to having the correct room design, the laparoscopic surgery resides outside the sterile field, the point person for critical
OR must include equipment that provides the highest level of controls became the circulating nurse. Often, the circulating nurse
video quality and incorporates the latest developments in com- would be out of the room at the precise moment when an adjust-
mand and control systems. ment (e.g., in the level of the insufflator’s CO2) had to be made.
Surgeons grew frustrated at the subsequent delays and at their
Cameras and Scopes inability to take their own steps to change things. Additionally, nurs-
No other device is as critical to the success of a laparoscopic es grew weary of such responsibilities; these constant interactions
procedure as the video camera. Without high-quality image cap- with the video tower pulled them away from patient-related tasks
ture and display, accurate identification and treatment of the dis- and from necessary clerical and operational work. The answer was
ease process are impossible.The video cameras used for minimal- to improve surgeons’ access to these critical devices via methods
ly invasive surgery contain solid-state light-sensitive receptors such as touchscreen control and, more recently, voice activation.
called charge-coupled devices (CCDs, or chips) that are able to Development of voice activation began in the late 1960s. The
detect differences in brightness at different points throughout an goal was a simple, safe, and universally acceptable voice recogni-
image. Generally, two types are available: one-chip cameras and tion system that flawlessly carried out the verbal requests of the
three-chip cameras.Three-chip cameras provide the greatest reso- user. However, attempts to construct a system capable of accu-
lution and light sensitivity; however, they are also the most expen- rately recognizing a wide array of speech patterns faced formida-
sive. One-chip cameras augment their single CCD with an overlay ble technological hurdles that only now are beginning to be over-
of millions of colored filters; electronics within the camera or the come. Although voice recognition is not yet a mature technology,
camera control unit then determine which filter the light hitting a it is clearly here to stay, and it has begun to permeate many facets
specific point in the CCD is passing through. In this way, it is pos- of everyday life.
In 1998, the first FDA-approved voice activation system, given the known inherent problems with surgeons’ voluntary self-
Hermes (Computer Motion, Santa Barbara, Calif.), was intro- reporting of infections occurring in the ambulatory surgical set-
duced into the OR. Designed to provide surgeons with direct ting.47 Each infection is estimated to increase total hospital stay by
access and control of surgical devices, Hermes is operated via an average of 7 days and add more than $3,000 in charges.
either a handheld pendant or voice commands from the surgeon. SSIs have been divided by the CDC into three broad categories:
The challenges of advanced laparoscopic surgery provide a fertile superficial incisional SSI, deep incisional SSI, and organ/space SSI
ground for demonstrating the benefits of voice activation [see Table [see Table 5 and 1:2 Prevention of Postoperative Infection].48 Factors
4]. Two-handed laparoscopic procedures make it very difficult for that contribute to the development of SSI include (1) those arising
a surgeon to control ancillary equipment manually, even if touch- from the patient’s health status, (2) those related to the physical
screens are sterile and within reach. environment where surgical care is provided, and (3) those result-
Voice activation gives surgeons immediate access to and direct ing from clinical interventions that increase the patient’s inherent
control of surgical devices, and it provides the OR team with crit- risk. Careful patient selection and preparation, including judi-
ical information. To operate a device, the surgeon must take cious use of antibiotic prophylaxis, can decrease the overall risk of
approximately 20 minutes to train the recognition system to his or infection, especially after clean-contaminated and contaminated
her voice patterns and must wear an audio headset to relay com- operations.
mands to the controller. The learning curve for voice control is
minimal (two or three cases, on average). Many devices can now HAND HYGIENE
be controlled by voice activation software, including cameras, light Hand antisepsis plays a significant role in preventing nosocomial
sources, digital image capture and documentation devices, print- infections.When outbreaks of infection occur in the perioperative pe-
ers, insufflators, OR ambient and surgical lighting systems, operat- riod, careful assessment of the adequacy of hand hygiene among OR
ing tables, and electrocauteries. personnel is recommended. U.S. guidelines recommend that agents
In the future, more and more devices will be accessible to the used for surgical hand scrubs should substantially reduce microor-
surgeon through simple voice commands, and the time will soon ganisms on intact skin, contain a nonirritating antimicrobial prepara-
arrive when telesurgical and telementoring capabilities will be an tion, possess broad-spectrum activity, and be fast-acting and persis-
integral part of the system.The voice interface will allow surgeons tent.49 In October 2002, the CDC published the most recent version
to interact with the world at large in such a way that the perfor- of its Guideline for Hand Hygiene in Health-Care Settings.50 The
mance of a surgical procedure is actively facilitated rather than Guideline’s final recommendations regarding surgical hand antisep-
interrupted. The OR will cease to be an environment of isolation. sis included the following:
• Surgical hand antisepsis using either an antimicrobial soap or
Infection Control in the OR an alcohol-based hand rub with persistent activity is recom-
Infection control is a major concern in health care in general, mended before donning sterile gloves when performing surgical
but it is a particularly important issue in the sterile environment of procedures (evidence level IB).
the OR, where patients undergo surgical procedures and are at sig- • When performing surgical hand antisepsis using an antimicro-
nificant risk for perioperative nosocomial infection. Even the best bial soap, scrub hands and forearms for the length of time rec-
OR design will not compensate for improper surgical technique or ommended by the manufacturer, usually 2 to 6 minutes. Long
failure to pay attention to infection prevention. scrub times (e.g., 10 minutes) are not necessary (evidence level
Surgical site infection (SSI) is a major cause of patient morbid- IB).
ity, mortality, and health care costs. In the United States, accord- • When using an alcohol-based surgical hand-scrub product with
ing to the Centers for Disease Control and Prevention (CDC), persistent activity, follow the manufacturer’s instructions.
about 2.9% of nearly 30 million operations are complicated by Before applying the alcohol solution, prewash hands and fore-
SSIs each year. This percentage may in fact be an underestimate, arms with a nonantimicrobial soap, and dry hands and fore-
arms completely. After application of the alcohol-based prod-
uct, allow hands and forearms to dry thoroughly before don-
ning sterile gloves.
Table 4 Benefits of Voice Activation
Technology in the Laparoscopic OR GLOVES AND PROTECTIVE BARRIERS
Because of the invasive nature of surgery, there is a high risk of

Gives surgeons direct and immediate control of devices pathogen transfer during an operation, a risk from which both the
Frees nursing staff from dull, repetitive tasks patient and the surgical team must be protected. The risk can be
Reduces miscommunication and frustration between
Benefits to surgical
surgeons and staff
reduced by using protective barriers, such as surgical gloves.
team Wearing two pairs of surgical gloves rather than a single pair is con-
Increases OR efficiency
Alerts staff when device is malfunctioning or setting off sidered to provide an additional barrier and to further reduce the
alarm risk of contamination. A 2002 Cochrane review concluded that
Saves money, allowing shorter, more efficient operations
wearing two pairs of latex gloves significantly reduced the number
Contributes to better OR utilization and, potentially, of perforations of the innermost glove.51 This evidence came from
performance of more surgical procedures trials undertaken in low-risk surgical specialties—that is, specialties
Benefits to hospital
Lays foundation for expanded use of voice activation that did not include orthopedic joint surgery.
in ORs
The Occupational Safety and Health Administration (OSHA)
Allows seamless working environment
requires that personal protective equipment be available in the
Reduces operating time, which—coupled with improved health care setting, and these requirements are spelled out in detail
Benefit to patient optics, ergonomics, and efficiency—leads to better in the OSHA standard on Occupational Exposure to Bloodborne
surgical outcome
Pathogens, which went into effect in 1992. Among the require-
Table 5 Criteria for Defining a Surgical Site Infection (SSI)71

Superficial incisional SSI 1. Purulent drainage from the deep incision but not from the organ/space
Infection occurs within 30 days after the operation, and infection involves component of the surgical site
only skin or subcutaneous tissue of the incisions, and at least one of the 2. A deep incision spontaneously dehisces or is deliberately opened by
following: a surgeon when the patient has at least one of the following signs or
1. Purulent drainage, with or without laboratory confirmation, from the symptoms: fever (> 38º C [100.4º F]), localized pain, or tenderness, un-
superficial incision less site is culture negative
2. Organisms isolated from an aseptically obtained culture of fluid or 3. An abscess or other evidence of infection involving the deep incision is
tissue from the superficial incision found on direct examination, during reoperation, or by histopathologic
or radiologic examination
3. At least one of the following signs or symptoms of infection: pain or
tenderness, localized swelling, redness, or heat; and superficial 4. Diagnosis of a deep incisional SSI by a surgeon or attending physician
incision is deliberately opened by surgeon, unless incision is culture Notes:
negative 1. Report infection that involves both superficial and deep incision sites
4. Diagnosis of superficial incisional SSI by the surgeon or attending as deep incisional SSI
physician 2. Report an organ/space SSI that drains through the incision as a deep
Do not report the following conditions as SSI: incisional SSI
1. Stitch abscess (minimal inflammation and discharge confined to the
points of suture penetration) Organ/space SSI
2. Infection of an episiotomy or newborn circumcision site Infection occurs within 30 days after the operation if no implant* is left in
place or within 1 yr if implant is in place and the infection appears to be
3. Infected burn wound related to the operation, and infection involves any part of the anatomy
4. Incisional SSI that extends into the fascial and muscle layers (see deep (e.g., organs or spaces), other than the incision, which was opened or
incisional SSI) manipulated during an operation, and at least one of the following:
Note: Specific criteria are used for identifying infected episiotomy and 1. Purulent drainage from a drain that is placed through a stab wound†
circumcision sites and burn wounds into the organ/space
Deep incisional SSI 2. Organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space
Infection occurs within 30 days after the operation if no implant* is left
in place or within 1 yr if implant is in place and the infection appears 3. An abscess or other evidence of infection involving the organ/space
to be related to the operation, and infection involves deep soft tissues that is found on direct examination, during reoperation, or by
(e.g., fascial and muscle layers) on the incision, and at least one of the histopathologic or radiologic examination
following: 4. Diagnosis of an organ/space SSI by a surgeon or attending physician
*National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or
hip prosthesis) that is permanantly placed in a patient during surgery.
†
If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth.
ments is the implementation of the CDC’s universal precau- SSIs completely, but by sharing information and influencing sub-
tions,52 designed to prevent transmission of human immunodefi- sequent behavior, it is certainly possible to reduce their incidence.
ciency virus, hepatitis B virus, and other bloodborne pathogens. A 2002 study documented successful institution of a surveil-
These precautions involve the use of protective barriers (e.g., lance program after a period of high infection rates in an orthope-
gloves, gowns, aprons, masks, and protective eyewear) to reduce dic surgical department.54 This program contributed to a signifi-
the risk that the health care worker’s skin or mucous membranes cant reduction in SSI rates after elective hip and knee replacement
will be exposed to potentially infectious materials. Performance procedures and was successful in creating awareness of infection
standards for protective barriers are the responsibility of the FDA’s control practices among hospital staff members.
Center for Devices and Radiological Health. These standards
ANTIMICROBIAL PROPHYLAXIS
define the performance properties that these products must exhib-
it, such as minimum strength, barrier protection, and fluid resis- SSIs are established several hours after contamination.55
tance.The current CDC recommendation is to use surgical gowns Administration of antibiotics before contamination reduces the
and drapes that resist liquid penetration and remain effective bar- risk of infection but is subsequently of little value.56 Selective use
riers when wet. of short-duration, narrow-spectrum antibiotic agents should be
Compliance with universal precautions and barrier protection is considered for appropriate patients to cover the usual pathogens
notably difficult to achieve. A 2001 study, however, found that ed- isolated from SSIs [see Table 6]. Optimal surgical antimicrobial
ucational interventions aimed at OR personnel improved compli- prophylaxis is based on the following three principles: (1) appro-
ance significantly, particularly with regard to the use of protective priate choice of antimicrobial agent, (2) proper timing of antibiot-
eyewear and double-gloving. Furthermore, such interventions ic administration before incision, and (3) limited duration of
were associated with a reduced incidence of blood and body fluid antibiotic administration after operation.
exposure.53 Recommendations for antibiotic prophylaxis are addressed in
more detail elsewhere [see 1:2 Prevention of Postoperative Infection].
INFECTION SURVEILLANCE PROGRAMS
When a preoperative antibiotic is indicated, a single dose of thera-
Surveillance is an important part of infection control [see CP:7 peutic strength, administered shortly before incision, usually suf-
Infection Control in Surgical Practice]. The success of a surveillance fices.57 (The dose may have to be increased if the patient is morbidly
program depends on the ability of the infection control team to obese.58) A second dose is indicated if the procedure is longer than
form a partnership with the surgical staff. Creating a sense of own- two half-lives of the drug or if extensive blood loss occurs. Con-
ership of the surveillance initiative among the members of the sur- tinuation of prophylaxis beyond 24 hours is not recommended.
gical staff enhances cooperation and ensures that the best use is With respect to redosing of the antimicrobial agent in lengthy
made of the information generated. It is not possible to eliminate procedures, consistency is important but can be difficult to obtain.
OR design can be helpful in this regard. In a 2003 study, signifi- nonwarmed patients but in only 13 (5%) of 277 warmed patients
cant improvement of intraoperative antibiotic prophylaxis in pro- (P = 0.001).Wound scores were also significantly lower in warmed
longed (> 4 hours) cardiac operations was achieved by employing patients (P = 0.007).
an automated intraoperative alert system in the OR, with alarms The safest and most effective way of protecting patients from
both audible and visible on the OR computer console at 225 min- hypothermia is to use forced-air warmers with specialized blankets
utes after administration of preoperative antibiotics.59 Intraop- placed over the upper or lower body. Alternatives include placing
erative redosing of antibiotics was significantly more frequent a warming water mattress under the patient and draping the
in the reminder group (68%) than in the control group (40%; patient with an aluminized blanket. Second-line therapy for main-
P < 0.0001).The use of an automatic reminder system in the OR taining normothermia is to warm all I.V. fluids. Any irrigation flu-
improved compliance with guidelines on perioperative antibiotic ids used in a surgical procedure should be at or slightly above
prophylaxis. body temperature before use. Radiant heating devices placed
above the operative field may be especially useful during opera-
NONPHARMACOLOGIC PREVENTIVE MEASURES
tions on infants. Use of a warmer on the inhalation side of the
Several studies have confirmed that certain nonpharmacologic anesthetic gas circuit can also help maintain the patient’s body
measures, including maintenance of perioperative normothermia temperature during an operation.
and provision of supplemental perioperative oxygen, are effica-
cious in preventing SSIs.60 Supplemental Perioperative Oxygen
Destruction by oxidation, or oxidative killing, is the body’s most
Perioperative Normothermia important defense against surgical pathogens. This defensive
A 1996 study showed that warming patients during colorectal response depends on oxygen tension in contaminated tissue. An
surgery reduced infection rates.61 A subsequent observational easy method of improving oxygen tension in adequately perfused
cohort study found that mild perioperative hypothermia was asso- tissue is to increase the fraction of inspired oxygen (FIO2). Supple-
ciated with a significantly increased incidence of SSI.62 A ran- mental perioperative oxygen (i.e., an FIO2 of 80% instead of 30%)
domized, controlled trial, published in 2001, was done to deter- significantly reduces postoperative nausea and vomiting and
mine whether warming patients before short-duration clean pro- diminishes the decrease in phagocytosis and bacterial killing usu-
cedures would have the same effect.63 In this trial, 421 patients ally associated with anesthesia and surgery. Oxygen tension in
scheduled to undergo clean (breast, varicose vein, or hernia) pro- wound tissue has been found to be a good predictor of SSI risk.64
cedures were randomly assigned either to a nonwarmed group or
Avoidance of Blood Transfusion
to one of two warmed groups (locally warmed and systemically
warmed). Warming was applied for at least 30 minutes before The association between blood transfusion and increased peri-
surgery. Patients were followed, and masked outcome assessments operative infection rates is well documented. In a 1997 study,
were made at 2 and 6 weeks. SSIs occurred in 19 (14%) of 139 geriatric hip fracture patients undergoing surgical repair who
received blood transfusion had significantly higher rates of peri-
operative infection than those who did not (27% versus 15%),
Table 6 Distribution of Pathogens Isolated and this effect was present on multivariate analysis.65 Another
from SSIs: National Nosocomial Infections 1997 study, involving 697 patients undergoing surgery for col-
Surveillance System, 1986–199648 orectal cancer, yielded similar findings: 39% of transfused
patients had bacterial infections, compared with 24% of non-
Percentage of Isolates* transfused patients, and the relative risk of infection was 1.6 for
Pathogen
transfusion of one to three units of blood and 3.6 for transfusion
1986–1989 1990–1996
of more than three units.66
(N=16,727) (N=17,671)
A large prospective cohort study published in 2003 evaluated
Staphylococcus aureus 17 20 the association between anemia, blood transfusion, and perioper-
Coagulase-negative staphylococci 12 14
ative infection.67 Logistic regression analysis confirmed that intra-
operative transfusion of packed red blood cells was an indepen-
Enterococcus species 13 12 dent risk factor for perioperative infection (odds ratio, 1.06; con-
fidence interval, 1.01 to 1.11; P > 0.0001). Furthermore, transfu-
Escherichia coli 10 8
sion of more than four units of packed red blood cells was associ-
Pseudomonas aeruginosa 8 8 ated with a 9.28-fold increased risk of infection (confidence inter-
val, 5.74 to 15.00; P < 0.0001).
Enterobacter species 8 7
Proteus mirabilis 4 3
Housekeeping Procedures
Klebsiella pneumoniae 3 3
FLOORS AND WALLS
Other Streptococcus species 3 3
Despite detailed recommendations for cleaning the OR [see
Candida albicans 2 3 Table 7],68 the procedures that are optimal to provide a clean envi-
ronment while still being cost-effective have not been critically
Group D streptococci (nonenterococci) — 2
analyzed.
Other gram-positive aerobes — 2 Only a few studies have attempted to correlate surface contam-
ination of the OR with SSI risk. In one study, for example, ORs
Bacteroides fragilis — 2
were randomly assigned to either a control group or an experi-
*Pathogens representing less than 2% of isolates are excluded. mental group.69 The control rooms were cleaned with a germici-
Table 7 OR Cleaning Schedules are those cases in which a fresh traumatic wound is present or
gross spillage of GI contents occurs. Dirty or infected operations
Surgical lights and tracks include those in which bacterial inflammation occurs or in which
Fixed ceiling-mounted equipment pus is present.The infection rate may be as high as 40% in a con-
Furniture and mobile equipment, including wheels taminated or dirty operation.
OR and hall floors Fear that bacteria from dirty or heavily contaminated cases
Areas requiring daily Cabinet and push-plate handles could be transmitted to subsequent cases has resulted in the devel-
cleaning Ventilation grills opment of numerous and costly rituals of OR cleanup. However,
All horizontal surfaces there are no prospective studies and no large body of relevant data
Substerile areas
to support the usefulness of such rituals. In fact, one study found
Scrub and utility areas
no significant difference in environmental bacterial counts after
Scrub sinks
clean cases than after dirty ones.73 Numerous authorities have rec-
Ventilation ducts and filters ommended that there be only one standard of cleaning the OR
Recessed tracks after either clean or dirty cases.68,73,74 This recommendation is rea-
Areas requiring routinely Cabinets and shelves sonable because any patient may be a source of contamination
scheduled cleaning Walls and ceilings
caused by unrecognized bacterial or viral infection; more impor-
Sterilizers, warming cabinets, refrigerators, and
ice machines tant, the other major source of OR contamination is the OR
personnel.
Rituals applied to dirty cases include placing a germicide-
dal agent and wet-vacuumed before the first case of the day and soaked mat outside the OR door, allowing the OR to stand idle for
between cases; in the experimental rooms, cleaning consisted only an arbitrary period after cleanup of a dirty procedure, and using
of wiping up grossly visible contamination after clean and clean- two circulating nurses, one inside the room and one outside. None
contaminated cases. Both rooms had complete floor cleanup after of these practices has a sound theoretical or factual basis.
contaminated or dirty and infected cases. The investigators found Traditionally, dirty cases have been scheduled after all the clean
that bacterial colony counts obtained directly from the floors were cases of the day. However, this restriction reduces the efficiency
lower in the control rooms but that counts obtained from other with which operations can be scheduled and may unnecessarily
horizontal surfaces did not differ between the two OR groups. In delay emergency cases.There are no data to support special clean-
addition, wound infection rates were the same in the control ing procedures or closing of an OR after a contaminated or dirty
rooms and the experimental rooms and were comparable with operation has been performed.75 Tacky mats placed outside the
rates reported in other series. Another study found that floor dis- entrance to an OR suite have not been shown to reduce the num-
infectants decreased bacterial concentration on the floor for only ber of organisms on shoes or stretcher wheels, nor do they reduce
2 hours; colony counts then returned to pretreatment levels as per- the risk of SSI.76
sonnel walked on the floor.70 These investigators recommended
discontinuing routine floor disinfection.
Even when an OR floor is contaminated, the rate of redispersal Data Management in the OR
of bacteria into the air is low, and the clearance rate is high. It is In this era of capitated reimbursement and managed care, con-
unlikely, therefore, that bacteria from the floor contribute to SSI. tainment of health care costs is a prime concern; consequently,
Consequently, routine disinfection of the OR floor between clean OR efficiency has become a higher priority for many institutions.77
or clean-contaminated cases appears unnecessary. No OR environment can even function, let alone improve its effi-
According to CDC guidelines for prevention of SSI, when visi- ciency, without data. Data control every facet of the activities with-
ble soiling of surfaces or equipment occurs during an operation, in the OR environment. For evaluating procedural time, OR uti-
an Environmental Protection Agency (EPA)–approved hospital lization and efficiency, OR scheduling, infection rates, injury pre-
disinfectant should be used to decontaminate the affected areas vention, and other key measures of organizational function, it is
before the next operation.71 This statement is in keeping with the essential to have current, high-quality data.
OSHA requirement that all equipment and environmental sur- To obtain good data, it is necessary first to determine what
faces be cleaned and decontaminated after contact with blood or information is required. For example, assessment of OR utilization
other potentially infectious materials. Disinfection after a contam- and efficiency depends on how utilization is measured. Before an
inated or dirty case and after the last case of the day is probably a OR can meaningfully be measured against a target figure, it is nec-
reasonable practice, though it is not supported by directly perti- essary to know exactly how the organization calculates utilization
nent data.Wet-vacuuming of the floor with an EPA-approved hos- and how the parameters are defined.There is no accepted nation-
pital disinfectant should be performed routinely after the last oper- al standard. The future of the organization—not to mention the
ation of the day or night. jobs of the people who work there—may depend on how well it
understands and controls OR utilization.
DIRTY CASES
It is generally agreed that 80% to 85% is the maximum utiliza-
Operations are classified or stratified into four groups in relation tion level that an OR can be expected to reach. At higher utiliza-
to the epidemiology of SSIs [see 1:2 Prevention of Postoperative tion levels, the OR loses flexibility, and the hospital should con-
Infection].72 Clean operations are those elective cases in which the sider adding capacity. It is important that utilization of all OR
GI tract or the respiratory tract is not entered and there are no resources by the various sectors of the institution be reasonable
major breaks in technique.The infection rate in this group should and balanced, because higher OR utilization can be achieved only
be less than 3%. Clean-contaminated operations are those elective when this is the case. To improve the use of OR time, it is impor-
cases in which the respiratory or the GI tract is entered or during tant (1) to limit the number of ORs available to the number
which a break in aseptic technique has occurred.The infection rate required to achieve good utilization, (2) to have nurses rather than
in such cases should be less than 10%. Contaminated operations attending surgeons control access to the surgical schedule, (3) to
OR SCHEDULING
provide good scheduling systems that allow surgeons to follow
themselves, and (4) to maintain systems that enable and enforce For optimal OR utilization, it is important to have a system for
efficient turnover between cases.78 releasing OR time efficiently and appropriately. Surgical services
It has been estimated that 30% of all health care outlays are fill their OR time at different rates. In a 2002 study, the median
related to surgical expenditures.79 Thus, it is likely that in a cost- period between the time when a patient was scheduled for surgery
conscious, competitive environment, the OR will be a major and the day of the operation ranged from 2 to 27 days, depending
focus of change. Surgical costs are related to OR utilization, on the subspecialty.83 Whereas ophthalmologic surgeons might
inventory levels, operative volume, supply usage, and equipment schedule outpatient cases weeks beforehand, cardiac or thoracic
purchase, rental, and maintenance. Facility design also affects surgeons might book cases the day before the operation.
efficiency and thus the ability to reduce costs. All of these issues Consequently, it would not be logical to release allocated OR time
must be evaluated and monitored to ensure quality care at the for all services the same prespecified number of days before
lowest feasible cost.80 surgery.84 A better approach would be to predict, as soon as a case
Once good data are available, the issue then becomes how prac- is scheduled, which surgical service is likely to have the most
tices and procedures should change as a result. Although new underutilized OR time on the scheduled day of surgery. In prac-
information, by itself, can often affect behavior, true behavior tice, the OR information system would perform the forecasting
modification in the OR requires effective leadership from the and provide a recommendation to the OR scheduler. To produce
chiefs of surgery, anesthesia, and nursing, all of whom should reliable results, forecasting should be based on the previous 6
receive monthly performance reports. months of OR performance, with allowances made for vacations
and meeting-related down time.
DATA ACQUISITION
Perioperative costs can be reduced if cases are scheduled so that
The necessary data must be not only available but also acces- the workload evenly matches staffing schedules. Specifically, to
sible in a rapid and convenient manner. Total automation of minimize the cost per case, down time must be minimized.
OR data management is critical for ascertaining patterns, man- Appropriate choice of the day on which a patient will undergo
aging productivity and resources, and providing solid informa- surgery is the most important decision affecting OR labor costs.84
tional bases for future decisions. Only through automation
QUALITY IMPROVEMENT
tools can relevant, timely, and accurate statistical data be gen-
erated to facilitate problem solving, trend spotting, forecasting, The key to increased OR efficiency is increased productivity.
and revisioning.81 Standardization and streamlining of internal procedures reduces
A long-standing question in OR utilization was how many his- bottlenecks, and computerization speeds the flow of information
torical data points were necessary or ideal to make appropri- so that continuous improvement of the system becomes possible.
ate decisions regarding OR staffing via statistical methods. In a Before a desired improvement can be implemented, the proposed
2002 study, statistical analysis of 30 workdays of data yielded change must be tested quickly so that its effect can be determined.
staffing solutions that had, on average, 30% lower staffing costs This is accomplished by means of a collaborative effort, in which
and 27% higher staffing productivity than the existing staffing the group involved in the change learns how to plan, do, check
plans.82 The productivity achieved in this way was 80%, and this and act—the so-called PDCA cycle, which is a classic quality ini-
figure was not significantly improved by increasing the number tiative method. During the PDCA cycle, teams are encouraged to
of workdays of data beyond 180. These findings suggest that in share ideas and talk about various solutions. A change is tested
most OR environments, statistical methods of data acquisition quickly, and if it works, implementation is expanded and tested
and analysis can identify cost-lowering and productivity-enhanc- further. The importance of the changes that can be implemented
ing staffing solutions by using 30 days of OR and anesthesia is often secondary to the progress made in building collaboration
data. with fellow physicians and other health care professionals.84
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(HRS-M-HF) 84-1. US Department of Health and 1973 15. Beck WC: Choosing surgical illumination. Am J
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I BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 2 PREVENTION OF POSTOPERATIVE INFECTION — 1
2 PREVENTION OF POSTOPERATIVE
INFECTION
Jonathan L. Meakins, M.D., D.Sc., F.A.C.S., and Byron J. Masterson, M.D., F.A.C.S.
Epidemiology of Surgical Site Infection

Standardization in reporting will permit more effective sur-
Historically, the control of wound infection depended on anti- veillance and improve results, as well as offer a painless way of
septic and aseptic techniques directed at coping with the infecting achieving quality assurance.The natural tendency to deny that a
organism. In the 19th century and the early part of the 20th cen- surgical site has become infected contributes to the difficulty of
tury, wound infections had devastating consequences and a mea- defining SSI in a way that is both accurate and acceptable to sur-
surable mortality. Even in the 1960s, before the correct use of geons. The surgical view of SSI recalls one judge’s (probably
antibiotics and the advent of modern preoperative and postopera- apocryphal) remark about pornography: “It is hard to define, but
tive care, as much as one quarter of a surgical ward might have I know it when I see it.” SSIs are usually easy to identify.
been occupied by patients with wound complications. As a result, Nevertheless, there is a critical need for definitions of SSI that
wound management, in itself, became an important component of can be applied in different institutions for use as performance
ward care and of medical education. It is fortunate that many fac- indicators.4 The criteria on which such definitions must be based
tors have intervened so that the so-called wound rounds have are more detailed than the simple apocryphal remark just cited;
become a practice of the past. The epidemiology of wound infec- they are outlined more fully elsewhere [see 1:1 Preparation of the
tion has changed as surgeons have learned to control bacteria and Operating Room].
the inoculum as well as to focus increasingly on the patient (the
STRATIFICATION OF RISK FOR SSI
host) for measures that will continue to provide improved results.
The following three factors are the determinants of any infec- The National Academy of Sciences–National Research Council
tious process: classification of wounds [see Table 1], published in 1964, was a
landmark in the field.5 This report provided incontrovertible data
1. The infecting organism (in surgical patients, usually bacteria). to show that wounds could be classified as a function of probabil-
2. The environment in which the infection takes place (the local ity of bacterial contamination (usually endogenous) in a consistent
response). manner. Thus, wound infection rates could be validly compared
3. The host defense mechanisms, which deal systemically with the from month to month, between services, and between hospitals.
infectious process.1 As surgery became more complex in the following decades, how-
Wounds are particularly appropriate for analysis of infection ever, antibiotic use became more standardized and other risk vari-
with respect to these three determinants. Because many compo- ables began to assume greater prominence. In the early 1980s, the
nents of the bacterial contribution to wound infection now are Study on the Efficacy of Nosocomial Infection Control (SENIC)
clearly understood and measures to control bacteria have been study identified three risk factors in addition to wound class: loca-
implemented, the host factors become more apparent. In addition of operation (abdomen or chest), duration of operation, and
tion, interactions between the three determinants play a critical
role, and with limited exceptions (e.g., massive contamination),
few infections will be the result of only one factor [see Figure 1].
Definition of Surgical Site Infection

HOST
Wound infections have traditionally been thought of as infec- BACTERIA DEFENSE
tions in a surgical wound occurring between the skin and the deep MECHANISMS
soft tissues—a view that fails to consider the operative site as a
whole. As prevention of these wound infections has become more
effective, it has become apparent that definitions of operation-
related infection must take the entire operative field into account;
obvious examples include sternal and mediastinal infections, vas- SURGICAL
cular graft infections, and infections associated with implants (if SITE
occurring within 1 year of the procedure and apparently related to
it). Accordingly, the Centers for Disease Control and Prevention
currently prefers to use the term surgical site infection (SSI). SSIs
can be classified into three categories: superficial incisional SSIs
(involving only skin and subcutaneous tissue), deep incisional Figure 1 In a homeostatic, normal state, the determinants of
SSIs (involving deep soft tissue), and organ/space SSIs (involving any infectious process—bacteria, the surgical site, and host
anatomic areas other than the incision itself that are opened or defense mechanisms (represented by three circles)—intersect at a
manipulated in the course of the procedure) [see Figure 2].2,3 point indicating zero probability of sepsis.
Epidemiology of Surgical Site Infection
Surgical site infection is caused by exogenous or endogenous

bacteria; infection is influenced not only by the source of the infecting
inoculum but also by the bacterial characteristics.
Ensure that prophylactic antibiotics, if indicated, are present in tissue

in adequate concentrations at beginning of operation.
Endogenous factors Bacterial characteristics of importance Exogenous factors

or sources of bacteria (virulence and antibiotic resistance) or sources of bacteria
Remote sites of Skin Bowel Nature and site Size of Operating Operating
infection of operation inoculum team–related room–related
required to
Postpone elective Is the operation produce • Comportment • Traffic control
operation if possible. • Clean infection • Use of • Cleaning
Treat remote infection • Clean- impermeable • Air
appropriately. contaminated Varies in drapes and
• Contaminated different gowns
• Dirty or clinical • Surgical scrub
infected situations.
Surveillance and quality assurance
Preventive measures to control bacteria
• Decontamination of patient's skin [see Sidebar Preoperative

Preparation of the Operative Site]
• Additional antibiotics if indicated, depending on likelihood
of contamination and on bacterial inoculum and properties
[see Sidebar Antibiotic Prophylaxis of Infection]
HOST
DEFENSE
BACTERIA MECHANISMS
Factors contributing to dysfunction of host defense mechanisms

can be related to surgical disease, to events surrounding the operation,
to the patient’s underlying disease, and to anesthetic management.
SURGICAL
SITE
Surgeon-related Patient-related Anesthesiologist-related

Factors influenced by the Patient-related factors • Normothermia
surgeon include include • Normovolemia
• Preoperative decisions • Presence of ≥ 3 • Pain control
• Timing of operation concomitant diagnoses • Tissue oxygenation
• Surgical technique • Underlying disease • Glucose control
• Transfusion • Age • Sterility of drugs
• Blood loss • Drug use
• Duration and extent • Preoperative nutritional
of operation status
• Glucose control • Smoking
• Tissue oxygenation
(mask)
Local factors influence the susceptibility of the wound environment by

affecting the size of the inoculum required to produce infection.
Operating team–related factors

Patient-related
include
Patient-related
Factors influenced by the surgeon and operating team include • Age

• Duration of operation • PaO2
• Maintenance of hemostasis and perfusion • Abdominal procedure
• Avoidance of seroma, hematoma, necrotic tissue, wound • Tissue perfusion
drains • Presence of foreign body
• Tissue handling • Barrier function
• Cautery use • Diabetes

CONTROL OF SOURCES OF
BACTERIA
Endogenous bacteria are
Skin a more important cause of
SSI than exogenous bacte-
ria. In clean-contaminated,
Superficial contaminated, and dirty-
Subcutaneous
Incisional infected operations, the
Tissue
SSI
source and the amount of bacteria are functions of the patient’s
disease and the specific organs being operated on.
Operations classified as infected are those in which infected tis-
Deep Soft Tissue sue and pus are removed or drained, providing a guaranteed
(Fascia and Muscle) Deep Incisional
SSI
inoculum to the surgical site.The inoculum may be as high as 1010
bacteria/ml, some of which may already be producing an infec-
tion. In addition, some bacteria could be in the growth phase
Organ/Space Organ/Space rather than the dormant or the lag phase and thus could be more
SSI pathogenic.The heavily contaminated wound is best managed by
delayed primary closure. This type of management ensures that
the wound is not closed over a bacterial inoculum that is almost
Figure 2 Surgical site infections are classified into three cate-
gories, depending on which anatomic areas are affected.3 certain to cause a wound infection, with attendant early and late
consequences.
Patients should not have elective surgery in the presence of
remote infection, which is associated with an increased incidence
patient clinical status (three or more diagnoses on discharge).6
of wound infection.5 In patients with urinary tract infections,
The National Nosocomial Infection Surveillance (NNIS) study
wounds frequently become infected with the same organism.
reduced these four risk factors to three: wound classification,
Remote infections should be treated appropriately, and the oper-
duration of operation, and American Society of Anesthesiologists
ation should proceed only under the best conditions possible. If
(ASA) class III, IV or V.7,8 Both risk assessments integrate the
operation cannot be appropriately delayed, the use of prophylac-
three determinants of infection: bacteria (wound class), local envi-
tic and therapeutic antibiotics should be considered [see Sidebar
ronment (duration), and systemic host defenses (one definition of
Antibiotic Prophylaxis of Infection and Tables 2 through 4].
patient health status), and they have been shown to be applicable
Preoperative techniques of reducing patient flora, especially
outside the United States.9 However, the SENIC and NNIS
endogenous bacteria, are of great concern. Bowel preparation,
assessments do not integrate other known risk variables, such as
antimicrobial showers or baths, and preoperative skin decontami-
smoking, tissue oxygen tension, glucose control, shock, and main-
tenance of normothermia, all of which are relevant for clinicians
(though often hard to monitor and to fit into a manageable risk
assessment). Table 1 National Research Council
Classification of Operative Wounds 5
Bacteria
Nontraumatic
Clearly, without an No inflammation encountered
infecting agent, no infection Clean (class I) No break in technique
will result. Accordingly, Respiratory, alimentary, or genitourinary tract not
most of what is known entered
about bacteria is put to use Gastrointestinal or respiratory tract entered without
in major efforts directed at significant spillage
reducing their numbers by means of asepsis and antisepsis. The Appendectomy
principal concept is based on the size of the bacterial inoculum. Clean- Oropharynx entered
contaminated
Wounds are traditionally classified according to whether the (class II) Vagina entered
wound inoculum of bacteria is likely to be large enough to over- Genitourinary tract entered in absence of infected urine
whelm local and systemic host defense mechanisms and produce Biliary tract entered in absence of infected bile
an infection [see Table 1]. One study showed that the most impor- Minor break in technique
tant factor in the development of a wound infection was the num- Major break in technique
ber of bacteria present in the wound at the end of an operative Gross spillage from gastrointestinal tract
procedure.10 Another study quantitated this relation and provided Contaminated
(class III) Traumatic wound, fresh
insight into how local environmental factors might be integrated Entrance of genitourinary or biliary tracts in presence
into an understanding of the problem [see Figure 3].11 In the years of infected urine or bile
before prophylactic antibiotics, as well as during the early phases Acute bacterial inflammation encountered, without pus
of their use, there was a very clear relation between the classifica- Transection of “clean” tissue for the purpose of surgical
tion of the operation (which is related to the probability of a sig- Dirty and infected access to a collection of pus
nificant inoculum) and the rate of wound infection.5,12 This rela- (class IV) Traumatic wound with retained devitalized tissue, for-
tion is now less dominant than it once was; therefore, other fac- eign bodies, fecal contamination, or delayed treat-
ment, or all of these; or from dirty source
tors have come to play a significant role.6,13
50
ondary to the trauma of the shave and the inevitable small areas of
inflammation and infection. If hair removal is required,14,15 clip-
ping is preferable and should be done in the OR or the prepara-
tion room just before the operative procedure. Shaving, if ever per-
Clinical Wound Infection Rate (%)
40
formed, should not be done the night before operation.
In the past few years, the role of the classic bowel preparation [see
Table 5] has been questioned [see Discussion, Infection Prevention
30
in Bowel Surgery, below].16-20 The suggestion has been made that
selective gut decontamination (SGD) may be useful in major elec-
tive procedures involving the upper GI tract and perhaps in other
20 settings. At present, SGD for prevention of infection cannot be rec-
ommended in either the preoperative or the postoperative period.
When infection develops after clean operations, particularly
those in which foreign bodies were implanted, endogenous infect-
10
ing organisms are involved but the skin is the primary source of the
infecting bacteria. The air in the operating room and other OR
sources occasionally become significant in clean cases; the degree
0 of endogenous contamination can be surpassed by that of exoge-
0 1 2 3 4 5 6
nous contamination. Thus, both the operating team—surgeon,
Leg Wound Bacteria assistants, nurses, and anesthetists—and OR air have been report-
ed as significant sources of bacteria [see 1:1 Preparation of the
Dry Wound; Cephaloridine > 10 µg/ml
Operating Room]. In fact, personnel are the most important source
Dry Wound; Placebo of exogenous bacteria.21-23 In the classic 1964 study by the National
Academy of Sciences–National Research Council, ultraviolet light
Wet Wound;
Wound Fluid Hematocrit > 8%; Placebo (UVL) was efficacious only in the limited situations of clean and
ultraclean cases.5 There were minimal numbers of endogenous
Figure 3 The wound infection rate is shown here as a function of
bacteria, and UVL controlled one of the exogenous sources.
bacterial inoculum in three different situations: a dry wound with
an adequate concentration of antibiotic (cephaloridine > 10 µg/ml),
Clean air systems have very strong advocates, but they also have
a dry wound with no antibiotic (placebo), and a wet wound with no equally vociferous critics. It is possible to obtain excellent results
antibiotic (placebo, wound fluid hematocrit > 8%).11 in clean cases with implants without using these systems.
However, clean air systems are here to stay. Nevertheless, the pres-
ence of a clean air system does not mean that basic principles of
nation have been proposed frequently. These techniques, particu- asepsis and antisepsis should be abandoned, because endogenous
larly preoperative skin decontamination [see Sidebar Preoperative bacteria must still be controlled.
Preparation of the Operative Site], may have specific roles in The use of impermeable drapes and gowns has received con-
selected patients during epidemics or in units with high infection siderable attention. If bacteria can penetrate gown and drapes,
rates. As a routine for all patients, however, these techniques are they can gain access to the wound.The use of impermeable drapes
unnecessary, time-consuming, and costly in institutions or units may therefore be of clinical importance.24,25 When wet, drapes of
where infection rates are low. 140-thread-count cotton are permeable to bacteria. It is clear that
The preoperative shave is a technique in need of reassessment. some operations are wetter than others, but generally, much can
It is now clear that shaving the evening before an operation is asso- be done to make drapes and gowns impermeable to bacteria. For
ciated with an increased wound infection rate.This increase is sec- example, drapes of 270-thread-count cotton that have been water-
Table 2 Parenteral Antibiotics Recommended

for Prophylaxis of Surgical Site Infection
Route of
Antibiotic Dose
Administration
For coverage against aerobic gram-positive and Cefazolin 1g I.V. or I.M.

gram-negative organisms (I.V. preferred)
If patient is allergic to cephalosporins or if methicillin- Vancomycin 1g I.V.
resistant organisms are present
Clindamycin 600 mg I.V.

or
Metronidazole 500 mg I.V.
Combination regimens for coverage against
gram-negative aerobes and anaerobes plus
Tobramycin 1.5 mg/kg I.V. or I.M.
(or equivalent (I.V. preferred
aminoglycoside) for first dose)
For single-agent coverage against Cefoxitin 1–2 g I.V.

gram-negative aerobes and anaerobes Cefotetan 1–2 g I.V.
Antibiotic Prophylaxis of Infection

Selection diac, vascular, or orthopedic patients who receive prostheses.
Catheters for dialysis or nutrition, pacemakers, and shunts of vari-
Spectrum. The antibiotic chosen should be active against the most
ous sorts are prone to infection mostly for technical reasons, and pro-
likely pathogens. Single-agent therapy is almost always effective ex-
phylaxis is not usually required. Meta-analysis indicates, however, that
cept in colorectal operations, small-bowel procedures with stasis,
antimicrobial prophylaxis reduces the infection rate in CSF shunts by
emergency abdominal operations in the presence of polymicrobial flo-
50%.109 Beneficial results may also be achievable for other perma-
ra, and penetrating trauma; in such cases, a combination of antibiotics
nently implanted shunts (e.g., peritoneovenous) and devices (e.g.,
is usually used because anaerobic coverage is required.
long-term venous access catheters and pacemakers); however, the
Pharmacokinetics. The half-life of the antibiotic selected must be long
studies needed to confirm this possibility will never be done, because
enough to maintain adequate tissue levels throughout the operation.
the infection rates are low and the sample sizes would have to be pro-
Administration hibitively large. The placement of such foreign bodies is a clean oper-
ation, and the use of antibiotics should be based on local experience.
Dosage, route, and timing. A single preoperative dose that is of the
same strength as a full therapeutic dose is adequate in most instanc- CLEAN-CONTAMINATED CASES
es. The single dose should be given I.V. immediately before skin inci-
Abdominal procedures. In biliary tract procedures (open or laparo-
sion. Administration by the anesthetist is most effective and efficient.
scopic), prophylaxis is required only for patients at high risk: those
Duration. A second dose is warranted if the duration of the operation
whose common bile duct is likely to be explored (because of jaundice,
exceeds either 3 hours or twice the half-life of the antibiotic. No addi-
bile duct obstruction, stones in the common bile duct, or a reoperative
tional benefit has been demonstrated in continuing prophylaxis beyond
biliary procedure); those with acute cholecystitis; and those older than
the day of the operation, and mounting data suggest that the preopera-
70 years. A single dose of cefazolin is adequate. In hepatobiliary and
tive dose is sufficient. When massive hemorrhage has occurred (i.e.,
pancreatic procedures, antibiotic prophylaxis is always warranted be-
blood loss equal to or greater than blood volume), a second dose is
cause these operations are clean-contaminated, because they are long,
warranted. Even in emergency or trauma cases, prolonged courses of
because they are abdominal, or for all of these reasons. Prophylaxis is
antibiotics are not justified unless they are therapeutic.77,108
also warranted for therapeutic endoscopic retrograde cholangiopancre-
Indications atography. In gastroduodenal procedures, patients whose gastric acidi-
ty is normal or high and in whom bleeding, cancer, gastric ulcer, and ob-
CLEAN CASES
struction are absent are at low risk for infection and require no
Prophylactic antibiotics are not indicated in clean operations if the prophylaxis; all other patients are at high risk and require prophylaxis.
patient has no host risk factors or if the operation does not involve Patients undergoing operation for morbid obesity should receive double
placement of prosthetic materials. Open heart operation and opera- the usual prophylactic dose110; cefazolin is an effective agent.
tions involving the aorta of the vessels in the groin require prophylaxis. Operations on the head and neck (including the esophagus). Pa-
Patients in whom host factors suggest the need for prophylaxis in- tients whose operation is of significance (i.e., involve entry into the oral
clude those who have more than three concomitant diagnoses, those cavity, the pharynx, or the esophagus) require prophylaxis.
whose operations are expected to last longer than 2 hours, and those Gynecologic procedures. Patients whose operation is either high-
whose operations are abdominal.6 A patient who meets any two of risk cesarean section, abortion, or vaginal or abdominal hysterectomy
these criteria is highly likely to benefit from prophylaxis. When host fac- will benefit from cefazolin. Aqueous penicillin G or doxycycline may be
tors suggest that the probability of a surgical site infection is signifi- preferable for first-trimester abortions in patients with a history of pelvic
cant, administration of cefazolin at induction of anesthesia is appropri- inflammatory disease. In patients with cephalosporin allergy, doxycy-
ate prophylaxis. Vancomycin should be substituted in patients who are cline is effective for those having hysterectomies and metronidazole for
allergic to cephalosporins or who are susceptible to major immediate those having cesarean sections. Women delivering by cesarean sec-
hypersensitivity reactions to penicillin. tion should be given the antibiotic immediately after cord clamping.
When certain prostheses (e.g., heart valves, vascular grafts, and Urologic procedures. In principle, antibiotics are not required in pa-
orthopedic hardware) are used, prophylaxis is justified when viewed tients with sterile urine. Patients with positive cultures should be treat-
in the light of the cost of a surgical site infection to the patient’s health. ed. If an operative procedure is performed, a single dose of the appro-
Prophylaxis with either cefazolin or vancomycin is appropriate for car- priate antibiotic will suffice.
(continued )
proofed are impermeable, but they can be washed only 75 times. with possible contamination. A longer duration, even of a clean
Economics plays a role in the choice of drape fabric because operation, represents increased time at risk for contamination.
entirely disposable drapes are expensive. Local institutional factors These points, in addition to pharmacologic considerations, sug-
may be significant in the role of a specific type of drape in the pre- gest that the surgeon should be alert to the need for a second dose
vention of SSI. of prophylactic antibiotics [see Sidebar Antibiotic Prophylaxis of
Infection].
PROBABILITY OF CONTAMINATION
Abdominal operation is another risk factor not found in the
The probability of contamination is largely defined by the NNIS risk assessment.6,8 Significant disease and age are addition-
nature of the operation [see Table 1]. However, other factors con- al factors that play a role in outcome; however, because the major
tribute to the probability of contamination; the most obvious is the concentrations of endogenous bacteria are located in the
expected duration of the operative procedure, which, whenever abdomen, abdominal operations are more likely to involve bacter-
examined, has been significantly correlated with the wound infec- ial contamination.
tion rate.6,10,12 The longer the procedure lasts, the more bacteria For some years, postoperative contamination of the wound has
accumulate in a wound; the sources of bacteria include the been considered unlikely. However, one report of SSI in sternal
patient, the operating team (gowns, gloves with holes, wet drapes), incisions cleaned and redressed 4 hours postoperatively clearly
the OR, and the equipment. In addition, the patient undergoing a shows that wounds can be contaminated and become infected in
longer operation is likely to be older, to have other diseases, and to the postoperative period.26 Accordingly, use of a dry dressing for
have cancer of—or to be undergoing operation on—a structure 24 hours seems prudent.
Antibiotic Prophylaxis of Infection (continued )

CONTAMINATED CASES sulting from trauma, contamination and tissue destruction are usually
so extensive that the wounds must be left open for delayed primary or
Abdominal procedures. In colorectal procedures, antibiotics active
secondary closure. Appropriate timing of wound closure is judged at
against both aerobes and anaerobes are recommended. In appen-
the time of debridement. Antibiotics should be administered as part of
dectomy, SSI prophylaxis requires an agent or combination of agents
resuscitation. Administration of antibiotics for 24 hours is probably ad-
active against both aerobes and anaerobes; a single dose of cefoxitin,
equate if infection is absent at the outset. However, a therapeutic
2 g I.V., or, in patients who are allergic to β-lactam antibiotics, metroni-
course of antibiotics is warranted if infection is present from the outset
dazole, 500 mg I.V., is effective. A combination of an aminoglycoside
or if more than 6 hours elapsed before treatment of the wounds was
and clindamycin is effective if the appendix is perforated; a therapeu-
initiated.
tic course of 3 to 5 days is appropriate but does not seem warranted
unless the patient is particularly ill. A laparotomy without a precise di- Prophylaxis of Endocarditis
agnosis is usually an emergency procedure and demands preopera-
tive prophylaxis. If the preoperative diagnosis is a ruptured viscus Studies of the incidence of endocarditis associated with dental
(e.g., the colon or the small bowel), both an agent active against aer- procedures, endoscopy, or operations that may result in transient
obes and an agent active against anaerobes are required. Depending bacteremia are lacking. Nevertheless, the consensus is that patients
on operative findings, prophylaxis may be sufficient or may have to be with specific cardiac and vascular conditions are at risk for endo-
supplemented with postoperative antibiotic therapy. carditis or vascular prosthetic infection when undergoing certain pro-
Trauma. The proper duration of antibiotic prophylaxis for trauma pa- cedures; these patients should receive prophylactic antibiotics.111-113
tients is a confusing issue—24 hours or less of prophylaxis is probably A variety of organisms are dangerous, but viridans streptococci are
adequate, and more than 48 hours is certainly unwarranted. When la- most common after dental or oral procedures, and enterococci are
parotomy is performed for nonpenetrating injuries, prophylaxis should most common if the portal of entry is the GU or GI tract. Oral amoxi-
be administered. Coverage of both aerobes and anaerobes is manda- cillin now replaces penicillin V or ampicillin because of superior ab-
tory. The duration of prophylaxis should be less than 24 hours. In cas- sorption and better serum levels. In penicillin-allergic patients, clin-
es of penetrating abdominal injury, prophylaxis with either cefoxitin or damycin is recommended; alternatives include cephalexin, cef-
a combination of agents active against anaerobic and aerobic organ- adroxil, azithromycin, and clarithromycin. When there is a risk of ex-
isms is required. The duration of prophylaxis should be less than 24 posure to bowel flora or enterococci, oral amoxicillin may be given. If
hours, and in many cases, perioperative doses will be adequate. For an I.V. regimen is indicated, ampicillin may be given, with gentamicin
open fractures, management should proceed as if a therapeutic added if the patient is at high risk for endocarditis. In patients allergic
course were required. For grade I or II injuries, a first-generation to penicillin, vancomycin is appropriate, with gentamicin added in
cephalosporin will suffice, whereas for grade III injuries, combination high-risk patients. These parenteral regimens should be reserved for
therapy is warranted; duration may vary. For operative repair of frac- high-risk patients undergoing procedures with a significant probabili-
tures, a single dose of cefazolin may be given preoperatively, with a ty of bacteremia.
second dose added if the procedure is long. Patients with major soft In patients receiving penicillin-based prophylaxis because of a
tissue injury with a danger of spreading infection will benefit from cefa- history of rheumatic fever, erythromycin rather than amoxicillin
zolin, 1 g I.V. every 8 hours for 1 to 3 days. should be used to protect against endocarditis.111 There is consen-
sus concerning prophylaxis for orthopedic prostheses and acquired
DIRTY OR INFECTED CASES
infection after transient bacteremia. In major procedures, where the
Infected cases require therapeutic courses of antibiotics; prophylax- risk of bacteremia is significant, the above recommendations are
is is not appropriate in this context. In dirty cases, particularly those re- pertinent.
BACTERIAL PROPERTIES various complications, and a degree of illness that radically

changes the host’s ability to deal with an inoculum, however small.
Not only is the size of the Therefore, multiple factors combine to transform the hospitalized
bacterial inoculum impor- preoperative patient into a susceptible host. Same-day admission
tant; the bacterial proper- should eliminate any bacterial impact associated with the preop-
ties of virulence and patho- erative hospital stay.
genicity are also significant. Bacteria with multiple antibiotic resistance (e.g., methi-
The most obvious patho- cillin-resistant S. aureus [MRSA], S. epidermidis, and van-
genic bacteria in surgical patients are gram-positive cocci (e.g., comycin-resistant enterococci [VRE]) can be associated with
Staphylococcus aureus and streptococci). With modern hygienic significant SSI problems. In particular, staphylococci, with
practice, it would be expected that S. aureus would be found their natural virulence, present an important hazard if inap-
mostly in clean cases, with a wound infection incidence of 1% to propriate prophylaxis is used.
2%; however, it is in fact an increasingly common pathogen in Many surgeons consider it inappropriate or unnecessary to
SSIs. Surveillance can be very useful in identifying either wards obtain good culture and sensitivity data on SSIs; instead of con-
or surgeons with increased rates. Operative procedures in infect- ducting sensitivity testing, they simply drain infected wounds,
ed areas have an increased infection rate because of the high believing that the wounds will heal. However, there have been a
inoculum with actively pathogenic bacteria. number of reports of SSIs caused by unusual organisms23,26,27;
The preoperative hospital stay has frequently been found to these findings underscore the usefulness of culturing pus or
make an important contribution to wound infection rates.12 The fluid when an infection is being drained. SSIs caused by antibi-
usual explanation is that during this stay, either more endogenous otic-resistant organisms or unusual pathogens call for specific
bacteria are present or commensal flora is replaced by hospital prophylaxis, perhaps other infection control efforts, and, if the
flora. More likely, the patient’s clinical picture is a complex one, problem persists, a search for a possible carrier or a common
often entailing exhaustive workup of more than one organ system, source.21-23,26,27
SURGEONS AND BACTERIA

example, such data can be useful in identifying problems (e.g., the
The surgeon’s periopera- presence of MRSA, a high SSI incidence, or clusters), maintain-
tive rituals are designed to ing quality assurance, and allowing comparison with accepted
reduce or eliminate bacteria standards.
from the operative field.
Many old habits are obso-
lete [see 1:1 Preparation of Environment: Local
the Operating Room and Factors
Discussion, Hand Washing, below]. Nonetheless, it is clear that sur- Local factors influence
geons can influence SSI rates.13 The refusal to use delayed prima- SSI development because
ry closure or secondary closure is an example. Careful attention to they affect the size of the
the concepts of asepsis and antisepsis in the preparation and con- bacterial inoculum that is
duct of the operation is important. Although no single step in the required to produce an
ritual of preparing a patient for the operative procedure is indis- infection: in a susceptible
pensable, it is likely that certain critical standards of behavior must wound, a smaller inoculum produces infection [see Figure 2].
be maintained to achieve good results.
THE SURGEON’S INFLUENCE
The measurement and publication of data about individuals or
hospitals with high SSI rates have been associated with a diminu- Most of the local factors that make a surgical site favorable to
tion of those rates [see Table 6].12,13,28 It is uncertain by what bacteria are under the control of the surgeon. Although Halsted
process the diffusion of these data relates to the observed improve- usually receives, deservedly so, the credit for having established the
ments. Although surveillance has unpleasant connotations, it pro- importance of technical excellence in the OR in preventing infec-
vides objective data that individual surgeons are often too busy to tion, individual surgeons in the distant past achieved remarkable
acquire but that can contribute to improved patient care. For results by careful attention to cleanliness and technique.29 The
Halstedian principles dealt with hemostasis, sharp dissection, fine
sutures, anatomic dissection, and the gentle handling of tissues.
Mass ligatures, large or braided nonabsorbable sutures, necrotic
tissue, and the creation of hematomas or seromas must be avoid-
Table 3 Conditions and Procedures ed, and foreign materials must be judiciously used because these
That Require Antibiotic Prophylaxis techniques and materials change the size of the inoculum required
against Endocarditis111,112 to initiate an infectious process. Logarithmically fewer bacteria are
required to produce infection in the presence of a foreign body
CONDITIONS (e.g., suture, graft, metal, or pacemaker) or necrotic tissue (e.g.,
Cardiac
that caused by gross hemostasis or injudicious use of electro-
Prosthetic cardiac valves (including biosynthetic valves)
cautery devices).
Most congenital cardiac malformations
The differences in inoculum required to produce wound infec-
Surgically constructed systemic-pulmonary shunts
tions can be seen in a model in which the two variables are the
Rheumatic and other acquired valvular dysfunction
Idiopathic hypertrophic subaortic stenosis
wound hematocrit and the presence of antibiotic [see Figure 3]. In
History of bacterial endocarditis
the absence of an antibiotic and in the presence of wound fluid
Mitral valve prolapse causing mitral insufficiency with a hematocrit of more than 8%, 10 bacteria yield a wound
Surgically repaired intracardiac lesions with residual hemodynamic infection rate of 20%. In a technically good wound with no antibi-
abnormality or < 6 mo after operation otic, however, 1,000 bacteria produce a wound infection rate of
Vascular 20%.11 In the presence of an antibiotic, 105 to 106 bacteria are
Synthetic vascular grafts required.
PROCEDURES Drains
Dental or oropharyngeal
Procedures that may induce bleeding
The use of drains varies widely and is very subjective. All sur-
Procedures that involve incision of the mucosa geons are certain that they understand when to use a drain.
However, certain points are worth noting. It is now recognized
Respiratory
that a simple Penrose drain may function as a drainage route but
Rigid bronchoscopy
is also an access route by which pathogens can reach the patient.30
Incision and drainage or debridement of sites of infection It is important that the operative site not be drained through the
Urologic wound.The use of a closed suction drain reduces the potential for
Cystoscopy with urethral dilatation contamination and infection.
Urinary tract procedures Many operations on the GI tract can be performed safely with-
Catheterization in the presence of infected urine out employing prophylactic drainage.31 A review and meta-analy-
Gynecologic sis from 2004 concluded that (1) after hepatic, colonic, or rectal
Vaginal hysterectomy resection with primary anastomosis and after appendectomy for
Vaginal delivery in the presence of infection any stage of appendicitis, drains should be omitted (recommenda-
Gastrointestinal tion grade A), and (2) after esophageal resection and total gas-
Procedures that involve incision or resection of mucosa trectomy, drains should be used (recommendation grade D).
Endoscopy that involves manipulation (e.g., biopsy, dilatation, Additional randomized, controlled trials will be required to deter-
or sclerotherapy) or ERCP mine the value of prophylactic drainage for other GI procedures,
especially those involving the upper GI tract.
Table 4 Antibiotics for Prevention of Endocarditis 55,111

Prophylactic Regimen*
Manipulative Procedure
Usual In Patients with Penicillin Allergy
Oral Oral
Amoxicillin, 2.0 g 1 hr before procedure Clindamycin, 600 mg 1 hr before procedure
or
Dental procedures likely to cause Cephalexin or cefadroxil,† 2.0 g 1 hr before procedure
gingival bleeding; operations or
or instrumentation of the upper Azithromycin or clarithromycin, 500 mg 1 hr before procedure
respiratory tract Parenteral Parenteral
Ampicillin, 2.0 g I.M. or I.V. 30 min before procedure Clindamycin, 600 mg I.V. within 30 min before procedure
or
Cefazolin, 1.0 g I.M. or I.V. within 30 min before procedure
Oral
Amoxicillin, 2.0 g 1 hr before procedure
Vancomycin, 1.0 g I.V. infused slowly over 1 hr, beginning 1 hr
Gastrointestinal or genitourinary Parenteral before procedure; if risk of endocarditis is considered high,
operation; abscess drainage Ampicillin, 2.0 g I.M. or I.V. within 30 min before proce- add gentamicin, 1.5 mg/kg (to maximum of 120 mg) I.M. or
dure; if risk of endocarditis is considered high, add I.V. 30 min before procedure‡
gentamicin, 1.5 mg/kg (to maximum of 120 mg) I.M.
or I.V. 30 min before procedure‡
*Pediatric dosages are as follows: oral amoxicillin, 50 mg/kg; oral or parenteral clindamycin, 20 mg/kg; oral cephalexin or cefadroxil, 50 mg/kg; oral azithromycin or clarithromycin, 15 mg/kg;
parenteral ampicillin, 50 mg/kg; parenteral cefazolin, 25 mg/kg; parenteral gentamicin, 2 mg/kg; parenteral vancomycin, 20 mg/kg. Total pediatric dose should not exceed total adult dose.
†
Patients with a history of immediate-type sensitivity to penicillin should not receive these agents.
‡
High-risk patients should also receive ampicillin, 1.0 g I.M. or I.V., or amoxicillin, 1.0 g p.o., 6 hr after procedure.
Duration of Operation
lead to a reduced SSI rate, probably as a consequence of increased
In most studies,6,10,12 contamination certainly increases with tissue oxygen tension,33 though the value of this practice has been
time (see above).Wound edges can dry out, become macerated, or questioned.34 If the patient is not intubated, a mask, not nasal
in other ways be made more susceptible to infection (i.e., requir- prongs, is required.35
ing fewer bacteria for development of infection). Speed and poor
technique are not suitable approaches; expeditious operation is Barrier Function
appropriate. Inadequate perfusion may also affect the function of other
organs, and the resulting dysfunction will, in turn, influence the
Electrocautery patient’s susceptibility to infection. For example, ischemia-reper-
The use of electrocautery devices has been clearly associated fusion injury to the intestinal tract is a frequent consequence of
with an increase in the incidence of superficial SSIs. However, hypovolemic shock and bloodstream infection. Inadequate perfu-
when such devices are properly used to provide pinpoint coagu- sion of the GI tract may also occur during states of fluid and elec-
lation (for which the bleeding vessels are best held by fine for- trolyte imbalance or when cardiac output is marginal. In experi-
ceps) or to divide tissues under tension, there is minimal tissue mental studies, altered blood flow has been found to be associat-
destruction, no charring, and no change in the wound infection ed with the breakdown of bowel barrier function—that is, the
rate.30 inability of the intestinal tract to prevent bacteria, their toxins, or
both from moving from the gut lumen into tissue at a rate too
PATIENT FACTORS
fast to permit clearance by the usual protective mechanisms. A
variety of experimental approaches aimed at enhancing bowel
Local Blood Flow barrier function have been studied; at present, however, the most
Local perfusion can clinically applicable method of bowel protection is initiation of
greatly influence the devel- enteral feeding (even if the quantity of nutrients provided does
opment of infection, as is not satisfy all the nutrient requirements) and administration of
seen most easily in the ten- the amino acid glutamine [see 8:23 Nutritional Support].
dency of the patient with Glutamine is a specific fuel for enterocytes and colonocytes and
peripheral vascular disease to acquire infection of an extremity. As has been found to aid recovery of damaged intestinal mucosa and
a local problem, inadequate perfusion reduces the number of bac- enhance barrier function when administered either enterally or
teria required for infection, in part because inadequate perfusion parenterally.
leads to decreased tissue levels of oxygen. Shock, by reducing local
perfusion, also greatly enhances susceptibility to infection. Fewer Advanced Age
organisms are required to produce infection during or immediate- Aging is associated with structural and functional changes that
ly after shock [see Figure 4]. render the skin and subcutaneous tissues more susceptible to
To counter these effects, the arterial oxygen tension (PaO2) must infection. These changes are immutable; however, they must be
be translated into an adequate subcutaneous oxygen level (deter- evaluated in advance and addressed by excellent surgical tech-
mined by measuring transcutaneous oxygen tension)32; this, nique and, on occasion, prophylactic antibiotics [see Sidebar
together with adequate perfusion, will provide local protection by Antibiotic Prophylaxis of Infection]. SSI rates increase with aging
increasing the number of bacteria required to produce infection. until the age of 65 years, after which point the incidence appears
Provision of supplemental oxygen in the perioperative period may to decline.36
when appropriate, attempts should be made to modify the host.

Preoperative Preparation of the Operative Site The surgeon and the operation are both capable of reducing
immunologic efficacy; hence, the operative procedure should be
The sole reason for preparing the patient's skin before an opera- carried out in as judicious a manner as possible. Minimal blood
tion is to reduce the risk of wound infection. A preoperative anti- loss, avoidance of shock, and maintenance of blood volume, tissue
septic bath is not necessary for most surgical patients, but their perfusion, and tissue oxygenation all will minimize trauma and will
personal hygiene must be assessed and preoperative cleanliness reduce the secondary, unintended immunologic effects of major
established. Multiple preoperative baths may prevent postopera-
tive infection in selected patient groups, such as those who carry
procedures.
Staphylococcus aureus on their skin or who have infectious le- Diabetes has long been recognized as a risk factor for infection
sions. Chlorhexidine gluconate is the recommended agent for and for SSI in particular. Three studies from the past decade
such baths.114 demonstrated the importance of glucose control for reducing SSI
Hair should not be removed from the operative site unless it rates in both diabetic and nondiabetic patients who underwent
physically interferes with accurate anatomic approximation of the operation,37,38 as well as in critically ill ICU patients.39 Glucose
wound edges.115 If hair must be removed, it should be clipped in
control is required throughout the entire perioperative period.The
the OR.14 Shaving hair from the operative site, particularly on the
evening before operation or immediately before wound incision in beneficial effect appears to lie in the enhancement of host defens-
the OR, increases the risk of wound infection. Depilatories are not es. The surgical team must also ensure maintenance of adequate
recommended, because they cause serious irritation and rashes in tissue oxygen tension32,33 and maintenance of normothermia.40
a significant number of patients, especially when used near the When abnormalities in host defenses are secondary to surgical
eyes and the genitalia.116 disease, the timing of the operation is crucial to outcome. With
In emergency procedures, obvious dirt, grime, and dried blood acute and subacute inflammatory processes, early operation helps
should be mechanically cleansed from the operative site by using
sufficient friction. In one study, cleansing of contaminated wounds
restore normal immune function. Deferral of definitive therapy
by means of ultrasound debridement was compared with high- frequently compounds problems.
pressure irrigation and soaking. The experimental wounds were
contaminated with a colloidal clay that potentiates infection 1,000- PATIENT FACTORS
fold. The investigators irrigated wounds at pressures of 8 to 10 psi, Surgeons have always
a level obtained by using a 30 ml syringe with a 1.5 in. long known that the patient is a
19-gauge needle and 300 ml of 0.85% sterile saline solution. High-
pressure irrigation removed slightly more particulate matter (59%)
significant variable in the
than ultrasound debridement (48%), and both of these methods outcome of operation.
removed more matter than soaking (26%).117 Both ultrasound de- Various clinical states are
bridement and high-pressure irrigation were also effective in re- associated with altered
ducing the wound infection rate in experimental wounds contami- resistance to infection. In all
nated with a subinfective dose of S. aureus. patients, but particularly those at high risk, SSI creates not only
For nonemergency procedures, the necessary reduction in mi-
wound complications but also significant morbidity (e.g., reoper-
croorganisms can be achieved by using povidone-iodine (10%
available povidone-iodine and 1% available iodine) or chlorhexi- ation, incisional hernia, secondary infection, impaired mobility,
dine gluconate both for mechanical cleansing of the intertriginous increased hospitalization, delayed rehabilitation, or permanent
folds and the umbilicus and for painting the operative site. Which disability) and occasional mortality.22 SENIC has proposed that
skin antiseptic is optimal is unclear. The best option appears to be the risk of wound infection be assessed not only in terms of prob-
chlorhexidine gluconate or an iodophor.118 The patient should be
assessed for evidence of sensitivity to the antiseptic (particularly if
the agent contains iodine) to minimize the risk of an allergic reac-
tion. What some patients report as iodine allergies are actually io-
dine burns. Iodine in alcohol or in water is associated with an in- Table 5 Parenteral Antibiotics Commonly
creased risk of skin irritation,90 particularly at the edges of the Used for Broad-Spectrum Coverage of
operative field, where the iodine concentrates as the alcohol evap-
orates. Iodine should therefore be removed after sufficient contact
Colonic Microflora
time with the skin, especially at the edges. Iodophors do not irritate
the skin and thus need not be removed. COMBINATION THERAPY OR PROPHYLAXIS
Aerobic Coverage
(to be combined with a drug having anaerobic activity)
Amikacin Ciprofloxacin
Aztreonam Gentamicin
Host Defense Ceftriaxone Tobramycin
Mechanisms Anaerobic Coverage
(to be combined with a drug having aerobic activity)
The systemic response is Chloramphenicol Metronidazole
designed to control and Clindamycin
eradicate infection. Many
factors can inhibit systemic SINGLE-DRUG THERAPY OR PROPHYLAXIS
host defense mechanisms; Aerobic-Anaerobic Coverage
some are related to the sur- Ampicillin-sulbactam Imipenem-cilastatin*
Cefotetan Piperacillin-tazobactam
gical disease, others to the patient’s underlying disease or diseases Cefoxitin Ticarcillin-clavulanate
and the events surrounding the operation. Ceftizoxime
SURGEON-RELATED FACTORS *This agent should be used only for therapeutic purposes; it should not be used
for prophylaxis.
There are a limited number of ways in which the surgeon can
improve a patient’s systemic responses to surgery. Nevertheless,
Table 6 Effect of Surveillance and Feedback Shock has an influence on the incidence of wound infection [see
on Wound Infection Rates in Two Hospitals28 Figure 4]. This influence is most obvious in cases of trauma, but
there are significant implications for all patients in regard to main-
Period 1 Period 2* tenance of blood volume, hemostasis, and oxygen-carrying capac-
ity. The effect of shock on the risk of infection appears to be not
Number of wounds 1,500 1,447 only immediate (i.e., its effect on local perfusion) but also late
Hospital A
Wound infection rate 8.4% 3.7% because systemic responses are blunted as local factors return to
normal.
Number of wounds 1,746 1,939
Hospital B Advanced age, transfusion, and the use of steroids and other
Wound infection rate 5.7% 3.7%
immunosuppressive drugs, including chemotherapeutic agents,
*Periods 1 and 2 were separated by an interval during which feedback on wound infection are associated with an increased risk of SSI.41,42 Often, these fac-
rates was analyzed.
tors cannot be altered; however, the proper choice of operation,
the appropriate use of prophylaxis, and meticulous surgical tech-
ability of contamination but also in relation to host factors.6,7,9 nique can reduce the risk of such infection by maintaining patient
According to this study, patients most clearly at risk for wound homeostasis, reducing the size of any infecting microbial inocu-
infection are those with three or more concomitant diagnoses; lum, and creating a wound that is likely to heal primarily.
other patients who are clearly at risk are those undergoing a clean- Smoking is associated with a striking increase in SSI incidence.
contaminated or contaminated abdominal procedure and those As little as 1 week of abstinence from smoking will make a posi-
undergoing any procedure expected to last longer than 2 hours. tive difference.43
These last two risk groups are affected by a bacterial component, Pharmacologic therapy can affect host response as well.
but all those patients who are undergoing major abdominal pro- Nonsteroidal anti-inflammatory drugs that attenuate the pro-
cedures or lengthy operations generally have a significant prima- duction of certain eicosanoids can greatly alter the adverse
ry pathologic condition and are usually older, with an increased effects of infection by modifying fever and cardiovascular effects.
frequency of concomitant conditions. The NNIS system uses Operative procedures involving inhalational anesthetics result in
most of the same concepts but expresses them differently. In the an immediate rise in plasma cortisol concentrations.The steroid
NNIS study, host factors in the large study are evaluated in terms response and the associated immunomodulation can be modi-
of the ASA score. Duration of operation is measured differently fied by using high epidural anesthesia as the method of choice;
as well, with a lengthy operation being defined by the NNIS as pituitary adrenal activation will be greatly attenuated. Some
one that is at or above the 75th percentile for operating time. drugs that inhibit steroid elaboration (e.g., etomidate) have also
Bacterial contamination remains a risk factor, but operative site is been shown to be capable of modifying perioperative immune
eliminated.8 responses.
No Antibiotic Antibiotic
100
80
Wound Infection Rate (%)
60
40
20
0
Control 1 Hr Day 1 3 5 Control 1 Hr Day 1 3 5
Time of Inoculation
108 Bacteria/ml 107 Bacteria/ml 106 Bacteria/ml
Figure 4 Animals exposed to hemorrhagic shock followed by resuscitation show an early

decreased resistance to wound infection. There is also a persistent influence of shock on the
development of wound infection at different times of inoculation after shock. The impor-
tance of inoculum size (106/ml to 108/ml) and the effect of antibiotic on infection rates are
evident at all times of inoculation.103
Table 7 Determinants of Infection and Factors

That Influence Wound Infection Rates
Determinant of Infection
Wound Host Defense

Variable
Bacteria Environment Mechanisms
(Local Factors) (Systemic Factors)
Bacterial numbers in wound10 A

Potential contamination6,10,12 A
Preoperative shave12 A
Presence of 3 or more diagnoses6 C
Age10,12 B C
Duration of operation6,10,12 A B C
Abdominal operation6 A B C
ASA class III, IV, or V8 C
O2 tension32 B
Glucose control37,38 C
Normothermia40 B C
Shock103 B C
Smoking43 B C
ANESTHESIOLOGIST- terial contamination has come to be generally well managed, the

RELATED FACTORS importance of all members of the surgical team in the prevention
A 2000 commentary in of SSI has become increasingly apparent. The crux of Buggy’s
The Lancet by Donal Buggy commentary may be expressed as follows: details make a differ-
considered the question of ence, and all of the participants in a patient’s surgical journey can
whether anesthetic manage- contribute to a continuing decrease in SSI. It is a systems issue.
ment could influence surgi-
cal wound healing.44 In INTEGRATION OF DETERMINANTS
addition to the surgeon- and patient-related factors already dis- As operative infection rates slowly fall, despite the performance
cussed (see above), Buggy cogently identified a number of anes- of increasingly complex operations in patients at greater risk, sur-
thesiologist-related factors that could contribute to better wound geons are approaching the control of infection with a broader view
healing and reduced wound infection. Some of these factors (e.g., than simply that of asepsis and antisepsis. This new, broader view
pain control, epidural anesthesia, and autologous transfusion) are must take into account many variables, of which some have no re-
unproven but nonetheless make sense and should certainly be test- lation to bacteria but all play a role in SSI [see Table 7 and Figure 1].
ed. Others (e.g., tissue perfusion, intravascular volume, and—sig- To estimate risk, one must integrate the various determinants of
nificantly—maintenance of normal perioperative body tempera- infection in such a way that they can be applied to patient care.
ture) have undergone formal evaluation. Very good studies have Much of this exercise is vague. In reality, the day-to-day practice of
shown that dramatic reductions in SSI rates can be achieved surgery includes a risk assessment that is essentially a form of logis-
through careful avoidance of hypothermia.40,45 Patient-controlled tic regression, though not recognized as such. Each surgeon’s
analgesia pumps are known to be associated with increased SSI assessment of the probability of whether an SSI will occur takes
rates, through a mechanism that is currently unknown.46 Infection into account the determining variables:
control practices are required of all practitioners; contamination of
anesthetic drugs by bacteria has resulted in numerous small out- Probability of SSI =
breaks of SSI.47,48 x + a (bacteria) + b (environment: local factors)
As modern surgical practice has evolved and the variable of bac- + c (host defense mechanisms: systemic factors)
Discussion
Antibiotic Prophylaxis of Surgical Site Infection
1950s to profound skepticism about prophylactic antibiotic use in
It is difficult to understand why antibiotics have not always pre- any operation.
vented SSI successfully. Certainly, surgeons were quick to appreci- The principal reason for the apparent inefficacy was inadequate
ate the possibilities of antibiotics; nevertheless, the efficacy of understanding of the biology of SSIs. Fruitful study of antibiotics
antibiotic prophylaxis was not proved until the late 1960s.11 and how they should be used began after physiologic ground-
Studies before then had major design flaws—principally, the work established the importance of local blood flow, maintenance
administration of the antibiotic some time after the start of the of local immune defenses, adjuvants, and local and systemic
operation, often in the recovery room. The failure of studies to perfusion.49
demonstrate efficacy and the occasional finding that prophylactic The key antibiotic study, which was conducted in guinea pigs,
antibiotics worsened rather than improved outcome led in the late unequivocally proved the following about antibiotics:
1. They are most effective when given before inoculation of bacte- use, anesthesia, and surveillance have reduced SSI rates in all cat-
ria. egories that were established by this classification [see Table
2. They are ineffective if given 3 hours after inoculation. 8].6,12,13,51
3. They are of intermediate effectiveness when given in between In 1960, after years of negative studies, it was said, “Nearly all
these times [see Figure 5].50 surgeons now agree that the routine use of prophylaxis in clean
operations is unnecessary and undesirable.”57 Since then, much
Although efficacy with a complicated regimen was demonstrat- has changed: there are now many clean operations for which no
ed in 1964,51 the correct approach was not defined until 1969.11 competent surgeon would omit the use of prophylactic antibiotics,
Established by these studies are the philosophical and practical particularly as procedures become increasingly complex and pros-
bases of the principles of antibiotic prophylaxis of SSI in all surgi- thetic materials are used in patients who are older, sicker, or
cal arenas11,50: that prophylactic antibiotics must be given preoper- immunocompromised.
atively within 2 hours of the incision, in full dosage, paren- A separate risk assessment that integrates host and bacterial
terally, and for a very limited period. These principles remain variables (i.e., whether the operation is dirty or contaminated, is
essentially unchanged despite minor modifications from innumer- longer than 2 hours, or is an abdominal procedure and whether the
able subsequent studies.52-56 Prophylaxis for colorectal operations patient has three or more concomitant diagnoses) segregates more
is discussed elsewhere [see Infection Prevention in Bowel Surgery, effectively those patients who are prone to an increased incidence
below]. of SSI [see Integration of Determinants of Infection, below]. This
approach enables the surgeon to identify those patients who are
PRINCIPLES OF PATIENT SELECTION
likely to require preventive measures, particularly in clean cases, in
Patients must be selected for prophylaxis on the basis of either which antibiotics would normally not be used.6
their risk for SSI or the cost to their health if an SSI develops (e.g., The prototypical clean operation is an inguinal hernia repair.
after implantation of a cardiac valve or another prosthesis). The Technical approaches have changed dramatically over the past 10
most important criterion is the degree of bacterial contamination years, and most primary and recurrent hernias are now treated
expected to occur during the operation. The traditional classifica- with a tension-free mesh-based repair. The use of antibiotics has
tion of such contamination was defined in 1964 by the historic become controversial. In the era of repairs under tension, there was
National Academy of Sciences–National Research Council study.5 some evidence to suggest that a perioperative antibiotic (in a sin-
The important features of the classification are its simplicity, ease gle preoperative dose) was beneficial.58 Current studies, however,
of understanding, ease of coding, and reliability. Classification is do not support antibiotic use in tension-free mesh-based inguinal
dependent on only one variable—the bacterial inoculum—and the hernia repairs.59,60 On the other hand, if surveillance indicates that
effects of this variable are now controllable by antimicrobial pro- there is a local or regional problem61 with SSI after hernia surgery,
phylaxis. Advances in operative technique, general care, antibiotic antibiotic prophylaxis (again in the form of single preoperative
dose) is appropriate. Without significantly more supportive data,
prophylaxis for clean cases cannot be recommended unless specif-
ic risk factors are present.
Data suggest that prophylactic use of antibiotics may contribute
Staphylococcal Lesions
to secondary Clostridium difficile disease; accordingly, caution
10
should be exercised when widening the indications for prophylax-
is is under consideration.62 If local results are poor, surgical prac-
Mean 24-Hour Lesion Diameter (mm)
tice should be reassessed before antibiotics are prescribed.

ANTIBIOTIC SELECTION AND ADMINISTRATION
When antibiotics are given more than 2 hours before operation,

Staphylococcal Lesions + Antibiotic the risk of infection is increased.52,54 I.V. administration in the OR
or the preanesthetic room guarantees appropriate levels at the time
of incision.The organisms likely to be present dictate the choice of
5 antibiotic for prophylaxis. The cephalosporins are ideally suited to
prophylaxis: their features include a broad spectrum of activity, an
excellent ratio of therapeutic to toxic dosages, a low rate of allergic
responses, ease of administration, and attractive cost advantages.
Mild allergic reactions to penicillin are not contraindications for
the use of a cephalosporin.
Physicians like new drugs and often tend to prescribe newer,
Killed Staphylococcal Lesions more expensive antibiotics for simple tasks. First-generation
cephalosporins (e.g., cefazolin) are ideal agents for prophylaxis.
Third-generation cephalosporins are not: they cost more, are not
–1 0 1 2 3 4 5 6
more effective, and promote emergence of resistant strains.63,64
The most important first-generation cephalosporin for surgical
Lesion Age at Time of Penicillin Injection (hr)
patients continues to be cefazolin. Administered I.V. in the OR at
Figure 5 In a pioneer study of antibiotic prophylaxis,50 the diam- the time of skin incision, it provides adequate tissue levels through-
eter of lesions induced by staphylococcal inoculation 24 hours ear- out most of the operation. A second dose administered in the OR
lier was observed to be critically affected by the timing of peni- after 3 hours will be beneficial if the procedure lasts longer than
cillin administration with respect to bacterial inoculation. that. Data on all operative site infections are imprecise, but SSIs
Table 8 Historical Rates of Wound Infection

Infection Rate (%)
Wound
51 12
Classification 1960–1962 1967–1977 1975–19766 1977–198113 1982–1986107
(15,613 patients) (62,937 patients) (59,353 patients) (20,193 patients) (20,703 patients)
Clean 5.1 1.5 2.9 1.8 1.3

Clean-contaminated 10.8 7.7 3.9 2.9 2.5
Contaminated 16.3 15.2 8.5 9.9 7.1
Dirty-infected 28.0 40.0 12.6 — —
Overall 7.4 4.7 4.1 2.8 2.2
can clearly be reduced by this regimen. No data suggest that fur- meager, resistant microbes have developed in every other situation
ther doses are required for prophylaxis. in which antibiotics have been utilized, and it is reasonable to
Fortunately, cefazolin is effective against both gram-positive expect that prophylaxis in any ecosystem will have the same result,
and gram-negative bacteria of importance, unless significant particularly if selection of patients is poor, if prophylaxis lasts too
anaerobic organisms are encountered.The significance of anaero- long, or if too many late-generation agents are used.
bic flora has been disputed, but for elective colorectal surgery,65 A rare but important complication of antibiotic use is
abdominal trauma,66,67 appendicitis,68 or other circumstances in pseudomembranous enterocolitis, which is induced most com-
which penicillin-resistant anaerobic bacteria are likely to be monly by clindamycin, the cephalosporins, and ampicillin [see 8:16
encountered, coverage against both aerobic and anaerobic gram- Nosocomial Infection].62 The common denominator among differ-
negative organisms is strongly recommended and supported by ent cases of pseudomembranous enterocolitis is hard to identify.
the data. Diarrhea and fever can develop after administration of single doses
Despite several decades of studies, prophylaxis is not always of prophylactic antibiotics. The condition is rare, but difficulties
properly implemented.52,54,68,69 Unfortunately, didactic education occur because of failure to make a rapid diagnosis.
is not always the best way to change behavior. Preprinted order
CURRENT ISSUES
forms70 and a reminder sticker from the pharmacy71 have proved
to be effective methods of ensuring correct utilization. The most significant questions concerning prophylaxis of SSIs
The commonly heard decision “This case was tough, let’s give already have been answered. An important remaining issue is the
an antibiotic for 3 to 5 days” has no data to support it and should proper duration of prophylaxis in complicated cases, in the setting
be abandoned. Differentiation between prophylaxis and therapeu- of trauma, and in the presence of foreign bodies. No change in the
sis is important. A therapeutic course for perforated diverticulitis criteria for antibiotic prophylaxis is required in laparoscopic pro-
or other types of peritoneal infection is appropriate. Data on casu- cedures; the risk of infection is lower in such cases.78,79 Cost fac-
al contamination associated with trauma or with operative proce- tors are important and may justify the endless succession of stud-
dures suggest that 24 hours of prophylaxis or less is quite ade- ies that compare new drugs in competition for appropriate clinical
quate.72-74 Mounting evidence suggests that a single preoperative niches.
dose is good care and that additional doses are not required. Further advances in patient selection may take place but will
require analysis of data from large numbers of patients and a dis-
Trauma Patients tinction between approaches to infection of the wound, which is
The efficacy of antibiotic administration on arrival in the emer- only a part of the operative field, and approaches to infections
gency department as an integral part of resuscitation has been directly related to the operative site. These developments will
clearly demonstrated.66 The most common regimens have been define more clearly the prophylaxis requirements of patients
(1) a combination of an aminoglycoside and clindamycin and (2) whose operations are clean but whose risk of wound or operative
cefoxitin alone. These two regimens or variations thereof have site infection is increased.
been compared in a number of studies.40,67,75 They appear to be A current issue of some concern is potential loss of infection
equally effective, and either regimen can be recommended with surveillance capability. Infection control units have been shown to
confidence. For prophylaxis, there appears to be a trend toward offer a number of benefits in the institutional setting, such as the
using a single drug: cefoxitin or cefotetan.55 If therapy is required following:
because of either a delay in surgery, terrible injury, or prolonged
1. Identifying epidemics caused by common or uncommon
shock, the combination of an agent that is effective against anaer-
organisms.23,26,56
obes with an aminoglycoside seems to be favored. Because amino-
2. Establishing correct use of prophylaxis (timing, dose, duration,
glycosides are nephrotoxic, they must be used with care in the
and choice).52,55,72
presence of shock.
3. Documenting costs, risk factors, and readmission rates.80,81
In many of the trauma studies just cited, antibiotic prophylaxis
4. Monitoring postdischarge infections and secondary conse-
lasted for 48 hours or longer. Subsequent studies, however, indi-
quences of infections.82-84
cated that prophylaxis lasting less than 24 hours is appropri-
5. Ensuring patient safety.85
ate.73,74,76 Single-dose prophylaxis is appropriate for patients with
6. Managing MRSA and VRE.86
closed fractures.77
S. aureus—in particular, MRSA—is a major cause of SSI.86
COMPLICATIONS
Cross-infection problems are a concern, in a manner reminiscent
Complications of antibiotic prophylaxis are few. Although data of the preantibiotic era. Hand washing (see below) is coming back
linking prophylaxis to the development of resistant organisms are into fashion, consistent with the professional behavior toward
cross-infection characteristic of that era. At present, hard evidence tion in bacterial counts on clean skin.90 All variables considered,
is lacking, but clinical observation suggests that S. aureus SSIs are chlorhexidine gluconate followed by an iodophor appears to be
especially troublesome and destructive of local tissue and require the best option [see Table 9].
a longer time to heal than other SSIs do. When S. aureus SSIs The purpose of washing the hands after surgery is to remove
occur after cardiac surgery, thoracotomy, or joint replacement, microorganisms that are resident, that flourished in the warm, wet
their consequences are significant. Prevention in these settings is environment created by wearing gloves, or that reached the hands
important. When nasal carriage of S. aureus has been identified, by entering through puncture holes in the gloves. On the ward,
mupirocin may be administered intranasally to reduce the inci- even minimal contact with colonized patients has been demon-
dence of S. aureus SSIs.87 strated to transfer microorganisms.91 As many as 1,000 organisms
The benefits of infection surveillance notwithstanding, as the were transferred by simply touching the patient’s hand, taking a
business of hospital care has become more expensive and finan- pulse, or lifting the patient. The organisms survived for 20 to 150
cial control more rigid, the infection control unit is a hospital com- minutes, making their transfer to the next patient clearly possible.
ponent that many administrators have come to consider a luxury A return to the ancient practice of washing hands between each
and therefore expendable. Consequently, surveillance as a quality patient contact is warranted. Nosocomial spread of numerous
control and patient safety mechanism has been diminished. organisms—including C. difficile; MRSA, VRE, and other antibi-
It is apparent that SSIs have huge clinical and financial impli- otic-resistant bacteria; and viruses—is a constant threat.
cations. Patients with infections tend to be sicker and to undergo Hand washing on the ward is complicated by the fact that over-
more complex operations. Therefore, higher infection rates trans- washing may actually increase bacterial counts. Dry, damaged
late into higher morbidity and mortality as well as higher cost to skin harbors many more bacteria than healthy skin and is almost
the hospital, the patient, and society as a whole.With increasingly impossible to render even close to bacteria free. Although little is
early discharge becoming the norm, delayed diagnosis of postdis- known about the physiologic changes in skin that result from fre-
charge SSI and the complications thereof is a growing prob- quent washings, the bacterial flora is certainly modified by alter-
lem.82-84 Effective use of institutional databases may contribute ations in the lipid or water content of the skin. The so-called dry
greatly to identification of this problem.83 hand syndrome was the impetus behind the development of the
Clearly, the development of effective mechanisms for identify- alcohol-based gels now available.These preparations make it easy
ing and controlling SSIs is in the interests of all associated with the for surgeons to clean their hands after every patient encounter
delivery of health care.85 The identification of problems by means with minimal damage to their skin.
of surveillance and feedback can make a substantial contribution
to reducing SSI rates [see Table 6].12,85
Infection Prevention in Bowel Surgery
Hand Washing At present, the best method of preventing SSIs after bowel
surgery is, once again, a subject of debate. There have been three
The purpose of cleansing the surgeon’s hands is to reduce the
principal approaches to this issue, involving mechanical bowel
numbers of resident flora and transient contaminants, thereby
preparation in conjunction with one of the following three antibi-
decreasing the risk of transmitting infection. Although the proper
otic regimens55,92-97:
duration of the hand scrub is still subject to debate, evidence sug-
1. Oral antibiotics (usually neomycin and erythromycin),20,96
gests that a 120-second scrub is sufficient, provided that a brush
2. Intravenous antibiotics covering aerobic and anaerobic bowel
is used to remove the bacteria residing in the skin folds around the
flora,16,20,55,94,95 or
nails.88 The nail folds, the nails, and the fingertips should receive
3. A combination of regimens 1 and 2 (meta-analysis suggests that
the most attention because most bacteria are located around the
the combination of oral and parenteral antibiotics is best).97
nail folds and most glove punctures occur at the fingertips.
Friction is required to remove resident microorganisms which are The present controversy, triggered by a clinical trial,16 a
attached by adhesion or adsorption, whereas transient bacteria are review,20 and three meta-analyses, relates to the need for mechan-
easily removed by simple hand washing. ical bowel preparation,17-19 which has been a surgical dogma since
Solutions containing either chlorhexidine gluconate or one of the early 1970s.The increased SSI and leak rates noted have been
the iodophors are the most effective surgical scrub preparations attributed to the complications associated with vigorous bowel
and have the fewest problems with stability, contamination, and preparation, leading to dehydration, overhydration, or electrolyte
toxicity.89 Alcohols applied to the skin are among the safest known abnormalities.
antiseptics, and they produce the greatest and most rapid reduc- An observational study reported a 26% SSI rate in colorectal
Table 9 Characteristics of Three Topical Antimicrobial Agents Effective against

Both Gram-Positive and Gram-Negative Bacteria90
Antifungal
Agent Mode of Action Comments
Activity
Chlorhexidine Cell wall disruption Fair Poor activity against tuberculosis-causing organisms; can
cause ototoxicity and eye irritation
Iodine/iodophors Oxidation and substitution by free iodine Good Broad antibacterial spectrum; minimal skin residual activi-
ty; possible absorption toxicity and skin irritation
Alcohols Denaturation of protein Good Rapid action but little residual activity; flammable
Table 10 Comparison of Wound

Classification Systems 6
Simplified Risk Index
Traditional Wound Low Medium High All from

Classification System Risk Risk Risk Traditional
0 1 2 3 4 Classification
Clean 1.1 3.9 8.4 15.8 2.9
Clean-contaminated 0.6 2.8 8.4 17.7 3.9
Contaminated 4.5 8.3 11.0 23.9 8.5
Dirty-infected 6.7 10.9 18.8 27.4 12.6
All from SENIC index 1.0 3.6 8.9 17.2 27.0 4.1
SENIC—Study of the Efficacy of Nosocomial Infection Control
surgery patients.98 Intraoperative hypotension and body mass have a major influence on outcome.
index were the only independent predictive variables. All patients One investigation demonstrated that silk sutures decrease the
underwent mechanical bowel preparation the day before operation number of bacteria required for infection.101 Other investigators
and received oral antibiotics and perioperative I.V. antibiotics. Half used a suture as the key adjuvant in studies of host manipula-
of the SSIs were discovered after discharge. Most would agree that tion,102 whereas a separate study demonstrated persistent suscep-
the protocol was standard. These and other results suggest that a tibility to wound infection days after shock.103 The common vari-
fresh look at the infectious complications of surgery—and of bowel able is the number of bacteria. This relation may be termed the
surgery in particular—is required. inoculum effect, and it has great relevance in all aspects of infec-
The recommended antibiotic regimen for bowel surgery con- tion control. Applying knowledge of this effect in practical terms
sists of oral plus systemic agents (see above).55 The approach to involves the following three steps:
mechanical bowel preparation, however, is open. Intuition would
1. Keeping the bacterial contamination as low as possible via asep-
suggest that the presence of less liquid and stool in the colon might
sis and antisepsis, preoperative preparation of patient and sur-
be beneficial and perhaps that a preoperative phosphate enema
geon, and antibiotic prophylaxis.
with 24 hours of fluid might make sense. It is hard to throw out
2. Maintaining local factors in such a way that they can prevent
30 years of apparent evidence on the basis of these three meta-
the lodgment of bacteria and thereby provide a locally unrecep-
analyses. These studies do, however, present data that cannot be
tive environment.
ignored. Protocols for bowel surgery in the modern era of same-
3. Maintaining systemic responses at such a level that they can
day admission, fast track surgery, and rapid discharge will require
control the bacteria that become established.
further study and clinical trials.
These three steps are related to the determinants of infection
and their applicability to daily practice.Year-by-year reductions in
Integration of Determinants of Infection wound infection rates, when closely followed, indicate that it is
The significant advances in the control of wound infection dur- possible for surgeons to continue improving results by attention to
ing the past several decades are linked to a better understanding of quality of clinical care and surgical technique, despite increasingly
the biology of wound infection, and this link has permitted the complex operations.5,13,28-30 In particular, the measures involved in
advance to the concept of SSI.2 In all tissues at any time, there will the first step (control of bacteria) have been progressively refined
be a critical inoculum of bacteria that would cause an infectious and are now well established.
process [see Figure 3].The standard definition of infection in urine The integration of determinants has significant effects [see Figures
and sputum has been 105 organisms/ml. In a clean dry wound, 105 3 and 4]. When wound closure was effected with a wound hemat-
bacteria produce a wound infection rate of 50% [see Figure 3].11 ocrit of 8% or more, the inoculum required to produce a wound
Effective use of antibiotics reduces the infection rate to 10% with infection rate of 40% was 100 bacteria [see Figure 3]. Ten bacteria
the same number of bacteria and thereby permits the wound to produced a wound infection rate of 20%. The shift in the number
tolerate a much larger number of bacteria. of organisms required to produce clinical infection is significant. It
All of the clinical activities described are intended either to is obvious that this inoculum effect can be changed dramatically
reduce the inoculum or to permit the host to manage the number by good surgical technique and further altered by use of prophylac-
of bacteria that would otherwise be pathologic. One study in tic antibiotics. If the inoculum is always slightly smaller than the
guinea pigs showed how manipulation of local blood flow, shock, number of organisms required to produce infection in any given set-
the local immune response, and foreign material can enhance the ting, results are excellent. There is clearly a relation between the
development of infection.99 This study and two others defined an number of bacteria and the local environment.The local effect can
early decisive period of host antimicrobial activity that lasts for 3 also be seen secondary to systemic physiologic change, specifically
to 6 hours after contamination.50,99,100 Bacteria that remain after shock. One study showed the low local perfusion in shock to be
this period are the infecting inoculum. Processes that interfere important in the development of an infection.99,100
with this early response (e.g., shock, altered perfusion, adjuvants, One investigation has shown that shock can alter infection rates
or foreign material) or support it (e.g., antibiotics or total care) immediately after its occurrence [see Figure 4].103 Furthermore, if
the inoculum is large enough, antibiotics will not control bacteria. normal homeostasis in patients at risk is one of the great advances
In addition, there is a late augmentation of infection lasting up to of surgical critical care.104 The clearest improvements in this
3 days after restoration of blood volume. These early and late regard have come in maintenance of blood volume, oxygenation,
effects indicate that systemic determinants come into play after and oxygen delivery.
local effects are resolved.These observations call for further study, One group demonstrated the importance of oxygen delivery,
but obviously, it is the combined abnormalities that alter outcome. tissue perfusion, and PaO2 in the development of wound infec-
Systemic host responses are important for the control of infection.105 Oxygen can have as powerful a negative influence on the
tion. The patient has been clearly implicated as one of the four development of SSI as antibiotics can.106 The influence is very
critical variables in the development of wound infection.6 In addi- similar to that seen in other investigations. Whereas a PaO2 equiv-
tion, the bacterial inoculum, the location of the procedure and its alent to a true fractional concentration of oxygen in inspired gas
duration, and the coexistence of three or more diagnoses were (FIO2) of 45% is not feasible, maintenance, when appropriate, of
found to give a more accurate prediction of the risk of wound an increased FIO2 in the postoperative period may prove an ele-
infection. The spread of risk is defined better with the SENIC mentary and effective tool in managing the inoculum effect.
index (1% to 27%) than it is with the traditional classification Modern surgical practice has reduced the rate of wound infec-
(2.9% to 12.6%) [see Table 10].The importance of the number of tion significantly. Consequently, it is more useful to think in terms
bacteria is lessened if the other factors are considered in addition of SSI, which is not limited to the incision but may occur any-
to inoculum. The inoculum effect has to be considered with where in the operative field; this concept provides a global objec-
respect to both the number of organisms and the local and sys- tive for control of infections associated with a surgical procedure.
temic host factors that are in play. Certain variables were found to Surveillance is of great importance for quality assurance. Reports
be significantly related to the risk of wound infection in three of recognized pathogens (e.g., S. epidermidis and group A strepto-
important prospective studies [see Table 10].6,10,12 It is apparent cocci) as well as unusual organisms (e.g., Rhodococcus [Gordona]
that the problem of SSI cannot be examined only with respect to bronchialis, Mycoplasma hominis, and Legionella dumoffii) in SSIs
the management of bacteria. Host factors have become much highlight the importance of infection control and epidemiology for
more significant now that the bacterial inoculum can be main- quality assurance in surgical departments.21-23,26,27 (Although
tained at low levels by means of asepsis, antisepsis, technique, and these reports use the term wound infection, they are really
prophylactic antibiotics.104 addressing what we now call SSI.) The importance of surgeon-
Important host variables include the maintenance of normal specific and service-specific SSI reports should be clear [see Table
homeostasis (physiology) and immune response. Maintenance of 6],12,13,107 and their value in quality assurance evident.
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Acknowledgment
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 3 Perioperative Considerations for Anesthesia — 1
3 PERIOPERATIVE CONSIDERATIONS
FOR ANESTHESIA
Steven B. Backman, M.D.C.M., Ph.D., Richard M. Bondy, M.D.C.M., Alain Deschamps, M.D., Ph.D., Anne Moore, M.D.,
and Thomas Schricker, M.D., Ph.D.
Ongoing advancements in modern surgical care are being comple- medications that may result in withdrawal or rebound phenome-
mented by alterations in anesthetic management aimed at provid- na (e.g., beta blockers, alpha agonists, barbiturates, and opioids).
ing maximum patient benefit. Since the early 1990s, anesthesia With some medications (e.g., oral hypoglycemics, insulin, and cor-
practice has changed enormously—through the proliferation of ticosteroids), perioperative dosage adjustments may be necessary
airway devices, the routine employment of patient-controlled anal- [see 8:10 Endocrine Problems]. Angiotensin-converting enzyme
gesia (PCA), the wider popularity of thoracic epidural anesthesia, (ACE) inhibitors have been associated with intraoperative
the development of computer-controlled devices for infusing hypotension and may be withheld at the discretion of the anesthe-
short-acting drugs, the growing use of quickly reversible inhala- siologist.3 Drugs that should be discontinued preoperatively
tional drugs and muscle relaxants, the availability of online moni- include monoamine oxidase inhibitors (MAOIs) and oral antico-
toring of CNS function, and the increased application of trans- agulants [see Table 1].
esophageal echocardiography, to name but a few examples. Our Many surgical patients are taking antiplatelet drugs. Careful
aim in this chapter is to offer surgeons a current perspective on consideration should be given to the withdrawal of these agents in
perioperative considerations for anesthesia so as to facilitate dia- the perioperative period [see Table 1] because of the possibility that
logue between the surgeon and the anesthesiologist and thereby discontinuance may lead to an acute coronary syndrome. If
help minimize patient risk. The primary focus is on the adult increased bleeding is a significant risk, longer-acting agents (e.g.,
patient: the special issues involved in pediatric anesthesia are aspirin, clopidogrel, and ticlopidine) can be replaced with non-
beyond the scope of our review. In addition, the ensuing discus- steroidal anti-inflammatory drugs (NSAIDs) that have shorter
sion is necessarily selective; more comprehensive discussions may half-lives. Typically, these shorter-acting drugs are given for 10
be found elsewhere.1,2 days, stopped on the day of surgery, and then restarted 6 hours
after operation. Platelet transfusion should be considered only in
the presence of significant medical bleeding.4
Perioperative Patient Management The increasing use of herbal and alternative medicines has led
Preoperative medical evaluation is an essential component of to significant morbidity and mortality as a consequence of unex-
preoperative assessment for anesthesia. Of particular importance pected interactions with traditional drugs. Because many patients
to the anesthesiologist is any history of personal or family prob- fail to mention such agents as part of their medication regimen
lems with anesthesia. Information should be sought concerning during the preoperative assessment, it is advisable to question all
difficulty with airway management or intubation, drug allergy, patients directly about their use. Particular attention should be
delayed awakening, significant postoperative nausea or vomiting given to Chinese herbal teas, which include organic compounds
(PONV), unexpected hospital or ICU admission, and post–dural and toxic contaminants that may produce renal fibrosis or failure,
puncture headache (PDPH). Previous anesthetic records may be cholestasis, hepatitis, and thrombocytopenia. Specific recommen-
requested. dations for discontinuance for many of these agents have been
The airway must be carefully examined to identify patients at developed [see Table 1].
risk for difficult ventilation or intubation [see Special Scenarios,
Difficult Airway, below], with particular attention paid to teeth,
caps, crowns, dentures, and bridges. Patients must be informed Inpatient versus Outpatient Surgery
about the risk of trauma associated with intubation and airway An ever-increasing number of operations are performed on an
management. Anesthetic options [see Choice of Anesthesia, below] ambulatory basis [see ECP:5 Outpatient Surgery]. Operations con-
should be discussed, including the likelihood of postoperative ven- sidered appropriate for an ambulatory setting are associated with
tilation and admission to the hospital or the intensive care unit. minimal physiologic trespass, low anesthetic complexity, and
When relevant, the possibility of blood product administration uncomplicated recovery.5,6 The design of the ambulatory facility
should be raised [see 1:4 Bleeding and Transfusion], and the patient’s may impose limitations on the types of operations or patients that
acceptance or refusal of transfusion should be carefully document- can be considered for ambulatory surgery. Such limitations may
ed. Postoperative pain management [see 1:5 Postoperative Pain] be secondary to availability of equipment, recovery room nursing
should be addressed, particularly when a major procedure is expertise and access to consultants, and availability of ICU beds
planned. The risks associated with general or regional anesthesia or hospital beds. Patients who are in class I or class II of the
should be discussed in an informative and reassuring manner; a American Society of Anesthesiologists (ASA) physical status scale
well-conducted preoperative anesthesia interview plays an impor- are ideally suited for ambulatory surgery; however, a subset of
tant role in alleviating anxiety. ASA class III patients may be at increased risk for prolonged
The medications the patient is taking can have a substantial recovery and hospital admission [see Table 2].
impact on anesthetic management. Generally, patients should Premedication to produce anxiolysis, sedation, analgesia, amne-
continue to take their regular medication up to the time of the sia, and reduction of PONV and aspiration may be considered for
operation. It is especially important not to abruptly discontinue patients undergoing outpatient procedures, as it may for those
Table 1 Recommendations for Preoperative Discontinuance of Drugs and Medicines51-64
Type of Drug Agent Pharmacologic Effects Adverse Effects Discontinuance Recommendations
Potentiation of sympathomimetic
amines, possible hypertensive crisis
May prolong and intensify effects of Elective surgery: discontinue at least 2 wk in
Isocarboxazid Irreversible inhibition of mono- other CNS depressants advance; consider potential for suicidal
Phenelzine amine oxidase with the resultant Severe idiopathic hyperpyrexic reaction tendency—mental health specialist should
MAOIs Pargyline increase in serotonin, norepineph- with meperidine and possibly other be involved
Tranylcypromine rine, epinephrine, dopamine, and narcotics Emergency surgery: avoid meperidine;
octamine neurotransmitters
Selegiline Potential catastrophic interaction with consider regional anesthesia
tricyclic antidepressants, characterized
by high fever and excessive cerebral
excitation and hypertension
Inhibition of vitamin K–dependent Elective surgery: discontinue 5–7 days in

Oral anticoagulants Warfarin Bleeding advance; replace with heparin if necessary
clotting factors II, VII, IX, X
Aspirin and NSAIDs

Aspirin
Fenoprofen Primary hemostasis normalizes in 48 hr in
Ibuprofen healthy persons; platelet activity fully
May increase intraoperative and post- recovered in 8–10 days
Sodium Inhibition of thromboxane A2 operative bleeding, but not transfusion
meclofenamate 80% of platelets must be requirement Patients on long-term aspirin therapy for
Tolmetin inhibited for therapeutic effect coronary or cerebrovascular pathology
Perioperative hemorrhagic complications should not discontinue drug in periopera-
Indomethacin Susceptibility to aspirin varies increase with increasing half-life of tive period unless hemorrhagic complica-
Ketoprofen between patients drug tions of procedure outweigh risk of acute
Diflunisal thrombotic event
Naproxen
Sulindac
Piroxicam
Antiplatelet agents Discontinue ticlopidine 2 wk in advance;

discontinue clopidogrel 7–10 days in
advance
Thienopyridines Inhibition of platelet aggregation
Synergistic antithrombotic effect with Patients with coronary artery stents must
Ticlopidine Inhibition of platelet ADP–induced aspirin receive aspirin plus ticlopidine for 2–4 wk
amplification after angioplasty; stopping therapy con-
Clopidogrel
siderably increases risk of coronary throm-
bosis; elective surgery should be delayed
for 1–3 mo
Competitive inhibition of GPIIb/IIIa

Antiglycoprotein receptors to prevent platelet Literature (mainly from cardiac surgery)
agents aggregation shows increased hemorrhagic risk if
Discontinue at least 12 hr in advance
Eptifibatide surgery undertaken < 12 hr after
Rapid onset of action Transfuse platelets only if needed to correct
discontinuance of abciximab
Tirofiban Short half-lives clinically significant bleeding
Individual variability in recovery time of
Abciximab Often combined with aspirin and/ platelet function
or heparin
(continued )
undergoing inpatient procedures. Such premedication should not induction agent are required to blunt the hypertension and tachy-
delay discharge. Fasting guidelines [see Table 3] and intraoperative cardia associated with its insertion; in addition, it is associated
monitoring standards for ambulatory surgery are identical to with a decreased incidence of sore throat and does not require
those for inpatient procedures [see Patient Monitoring, below]. muscle paralysis for insertion. On the other hand, an LMA may
A number of currently used anesthetics (e.g., propofol and des- not protect as well against aspiration.5,9,10
flurane), narcotics (e.g., alfentanil, fentanyl, sufentanil, and The benefits of regional anesthesia [see Regional Anesthesia
remifentanil), and muscle relaxants (e.g., atracurium, mivacuri- Techniques, below] may include decreases in the incidence of aspi-
um, and rocuronium) demonstrate rapid recovery profiles. ration, nausea, dizziness, and disorientation. Spinal and epidural
Nitrous oxide also has desirable pharmacokinetic properties, but anesthesia may be associated with PDPH and backache.
it may be associated with increased PONV. Titration of anesthet- Compared with spinal anesthesia, epidural anesthesia takes more
ics to indices of CNS activity (e.g., the bispectral index) may result time to perform, has a slower onset of action, and may not pro-
in decreased drug dosages, faster recovery from anesthesia, and duce as profound a block; however, the duration of an epidural
fewer complications.7,8 Multimodal analgesia (involving the use of block can readily be extended intraoperatively or postoperatively if
local anesthetics, ketamine, α2-adrenergic agonists, beta blockers, necessary. Care should be exercised in choosing a local anesthetic
acetaminophen, or NSAIDs) may reduce intraoperative and post- for neuraxial blockade: spinal lidocaine may be associated with a
operative opioid requirements and accelerate patient discharge. transient radicular irritation, and bupivacaine may be associated
Use of a laryngeal mask airway (LMA) rather than an endotra- with prolonged motor block; narcotics may produce pruritus, uri-
cheal tube is ideal in the outpatient setting because lower doses of nary retention, nausea and vomiting, and respiratory depression.
Table 1 (continued)
Type of Drug Agent Pharmacologic Effects Adverse Effects Discontinuance Recommendations
Garlic (Allium Irreversible dose-dependent Increased bleeding

sativum) Discontinue at least 7 days in advance
inhibition of platelet aggregation May potentiate other platelet inhibitors
Inhibition of platelet-activating
Ginkgo (Ginkgo factor Increased bleeding
biloba) Discontinue at least 36 hr in advance
Modulation of neurotransmitter May potentiate other platelet inhibitors
receptor activity
Increased bleeding
Ginger (Zingiber Potent inhibitor of thromboxane Discontinue at least 36 hr in advance
May potentiate effects of other
officinale) synthase
anticoagulants
Prolonged PT and PTT

Inhibition of platelet aggregation, Hypoglycemia
possibly irreversibly
Ginseng (Panax Reduced anticoagulation effect of
Antioxidant action Discontinue at least 7 days in advance
ginseng) warfarin
Antihyperglycemic action Possible additive effect with other
“Steroid hormone”–like activity stimulants, with resultant hypertension
and tachycardia
Dose-dependent increase in HR and BP,

with potential for serious cardiac and
Noncatecholamine sympatho- CNS complications
Ephedra/ma huang mimetic agent with α1, β1, and Possible adverse drug reactions: MAOIs
β2 activity; both direct and Discontinue at least 24 hr in advance
(Ephedra sinica) (life-threatening hypertension, hyper-
Herbal medicines indirect release of endogenous pyrexia, coma), oxytocin (hypertension),
catecholamines digoxin and volatile anesthetics
(dysrhythmias), guanethedine
(hypertension, tachycardia)
Echinacea Discontinue as far in advance as possible in

Hepatotoxicity any patient with hepatic dysfunction or
(Echinacea Immunostimulatory effect
purpurea) Allergic potential surgery with possible hepatic blood flow
compromise
Hypertension
Hypokalemia
Licorice (Glycyrrhiza
Edema
glabra)
Contraindicated in chronic liver and renal
insufficiency
Dose-dependent potentiation of Potentiation of sedative anesthetics,

Kava (Piper GABA-inhibitory neurotransmitter including barbiturates and benzodi-
methysticum) with sedative, anxiolytic, and azepines
antiepileptic effects Possible potentiation of ethanol effects
Dose-dependent modulation of Possible potentiation of sedative

Valerian (Valeriana anesthetics, including barbiturates and
GABA neurotransmitter and Discontinue at least 24 hr in advance
officinalis) benzodiazepines
receptor function
Inhibits reuptake of serotonin, Possible interaction with MAOIs Discontinue on day of surgery; abrupt with-
St. John’s wort norepinephrine, and dopamine Evidence for reduced activity of drawal in physically dependent patients
(Hypericum by neurons cyclosporine, warfarin, calcium chan- may produce benzodiazepine-like with-
perforatum) Increases metabolism of some P- nel blockers, lidocaine, midazolam, drawal syndrome
450 isoforms alfentanil, and NSAIDs
ADP—adenosine diphosphate ETOH—ethyl alcohol GABA—γ-aminobutyric acid GP—glycoprotein MAOIs—monoamine oxidase inhibitors NSAIDs—nonsteroidal anti-inflammatory drugs
PT—prothrombin time PTT—partial thromboplastin time
Various dosing regimens, including minidose spinal techniques, room have been established [see Table 4]. Recovery of normal mus-
have been proposed as means of minimizing these side effects.11-14 cle strength and sensation (including proprioception of the lower
Monitored anesthesia care [see Choice of Anesthesia, below] extremity, autonomic function, and ability to void) should be
achieves minimal CNS depression, so that the airway and sponta- demonstrated after spinal or epidural anesthesia. Delays in dis-
neous ventilation are maintained and the patient is able to respond charge are usually the result of pain, PONV, hypotension, dizzi-
to verbal commands. Meticulous attention to monitoring is ness, unsteady gait, or lack of an escort.15
required to guard against airway obstruction, arterial desaturation,
and pulmonary aspiration.
In the recovery room, the anesthetic plan is continued until dis- Elective versus Emergency Surgery
charge. Shorter-acting narcotics and NSAIDs are administered for Surgical procedures performed on an emergency basis may
pain relief, and any of several agents may be given for control of range from relatively low priority (e.g., a previously cancelled case
nausea and vomiting. Criteria for discharge from the recovery that was originally elective) to highly urgent (e.g., a case of
Table 2—Association between Preexisting controlled ventilation: the need for abdominal muscle paralysis,
Medical Conditions and Adverse Outcomes65 lung isolation, and hyperventilation; the presence of serious car-
diorespiratory instability; and the lack of sufficient time to perform
regional anesthesia. Alternatives to general anesthesia should be
Medical Condition Associated Adverse Outcome
considered for patients who are susceptible to malignant hyper-
Congestive heart failure 12% prolongation of postoperative stay thermia (MH), for those in whom intubation is likely to prove dif-
Hypertension Twofold increase in risk of intraoperative ficult or the risk of aspiration is high, and for those with pulmonary
cardiovascular events compromise that may worsen after intubation and positive pres-
Asthma Fivefold increase in risk of postoperative sure ventilation.
respiratory events
Regional anesthesia is achieved by interfering with afferent or
Smoking Fourfold increase in risk of postoperative
respiratory events efferent neural signaling at the level either of the spinal cord (neu-
Obesity Fourfold increase in risk of intraoperative raxial blockade) or of the peripheral nerves. Neuraxial anesthesia
and postoperative respiratory events (i.e., epidural or spinal administration of local anesthetics) is com-
Reflux Eightfold increase in risk of intubation- monly employed as the sole anesthetic technique for procedures
related adverse events involving the lower abdomen and the lower extremities; it also pro-
vides effective pain relief after intraperitoneal and intrathoracic
procedures. Combining regional and general anesthesia has
impending airway obstruction). For trauma, specific evaluation become increasingly popular.16 Currently, some physicians are
and resuscitation sequences have been established to facilitate using neuraxial blockade as the sole anesthetic technique for pro-
patient management [see 7:1 Initial Management of Life-Threatening cedures such as thoracotomy and coronary artery bypass grafting,
Trauma].The urgency of the situation dictates how much time can which are traditionally thought to require general anesthesia and
be allotted to preoperative patient assessment and optimization. endotracheal intubation.17
When it is not possible to communicate with the patient, informa- Neuraxial blockade has several advantages over general anes-
tion obtained from family members and paramedics may be cru- thesia, including better dynamic pain control, shorter duration of
cial. Information should be sought concerning allergies, current paralytic ileus, reduced risk of pulmonary complications, and
medications, significant past medical illnesses, nihil per os (NPO) decreased transfusion requirements; it is also associated with a
status, personal or family problems with anesthesia, and recent decreased incidence of renal failure and myocardial infarction [see
ingestion of alcohol or drugs. Any factor that may complicate air- 1:5 Postoperative Pain].18-21 Contrary to conventional thinking,
way management should be noted (e.g., trauma to the face or the however, the type of anesthesia used (general or neuraxial) is not
neck, a beard, a short and thick neck, obesity, or a full stomach). an independent risk factor for long-term cognitive dysfunction.22
When appropriate, blood samples should be obtained as soon as Neuraxial blockade is an essential component of multimodal reha-
possible for typing and crossmatching, as well as routine blood bilitation programs aimed at optimization of perioperative care
chemistries and a complete blood count. Arrangements for post- and acceleration of recovery [see ECP:6 Fast Track Surgery].23,24
operative ICU monitoring, if appropriate, should be instituted For short, superficial procedures, a wide variety of peripheral
early. nerve blocks may be considered.25 For procedures on the upper or
Clear communication must be established between the surgical lower extremity, an I.V. regional (Bier) block with diluted lidocaine
team and anesthesia personnel so that an appropriate anesthetic is often useful. Anesthesia of the upper extremity and shoulder
management plan can be formulated and any specialized equip- may be achieved with brachial plexus blocks. Anesthesia of the
ment required can be mobilized in the OR.The induction of anes- lower extremity may be achieved by blocking the femoral, obtura-
thesia may coincide with resuscitation. Accordingly, the surgical tor, and lateral femoral cutaneous nerves (for knee surgery) or the
team must be immediately available to help with difficult I.V. ankle and popliteal sciatic nerves (for foot surgery). Anesthesia of
access, emergency tracheostomy, and cardiopulmonary resuscita- the thorax may be achieved with intercostal or intrapleural nerve
tion. Patients in shock may not tolerate standard anesthetics, blocks. Anesthesia of the abdomen may be achieved with celiac
which characteristically blunt sympathetic outflow.The anesthetic
dose must be judiciously titrated, and definitive surgical treatment
must not be unduly delayed by attempts to “get a line.” Table 3—Fasting Recommendations* to
Reduce Risk of Pulmonary Aspiration66
Choice of Anesthesia
Ingested Material Minimum Fasting Period† (hr)
Anesthesia may be classified into three broad categories: (1)
general anesthesia, (2) regional anesthesia, and (3) monitored Clear liquids‡ 2
anesthesia care. General anesthesia can be defined as a state of Breast milk 4
insensibility characterized by loss of consciousness, amnesia, anal- Infant formula 6
gesia, and muscle relaxation. This state may be achieved either Nonhuman milk§ 6
with a single anesthetic or, in a more balanced fashion, with a Light meal¶ 8
combination of several drugs that specifically induce hypnosis, *These recommendations apply to healthy patients undergoing elective procedures; they
analgesia, amnesia, and paralysis. are not intended for women in labor. Following the guidelines does not guarantee complete
gastric emptying.
There is, at present, no consensus as to which general anesthet- †
These fasting periods apply to all ages.
ic regimen best preserves organ function. General anesthesia is ‡
Examples of clear liquids include water, fruit juices without pulp, carbonated beverages,
clear tea, and black coffee.
employed when contraindications to regional anesthesia are pres- §
Because nonhuman milk is similar to solids in gastric emptying time, amount ingested
ent or when regional anesthesia or monitored anesthesia care fails must be considered in determining appropriate fasting period.
¶
A light meal typically consists of toast and clear liquids. Meals that include fried or fatty
to provide adequate intraoperative analgesia. In addition, there are foods or meat may prolong gastric emptying time. Both amount and type of foods ingested
a few situations that specifically mandate general anesthesia and must be considered in determining appropriate fasting period.
Table 4—Postanesthetic Discharge Patient Monitoring

Scoring System (PADSS)67 Patient monitoring is central to the practice of anesthesia. A
trained, experienced physician is the only truly indispensable
Category Score* Explanation monitor; mechanical and electronic monitors, though useful, are,
at most, aids to vigilance.Wherever anesthesia is administered, the
2 Within 20% of preoperative value proper equipment for pulse oximetry, blood pressure measure-
Vital signs 1 Within 20% to 40% of preoperative value ment, electrocardiography, and capnography should be available.
0 Within 40% of preoperative value At each anesthesia workstation, equipment for measuring temper-
2 Oriented and steady gait
ature, a peripheral nerve stimulator, a stethoscope, and appropri-
Activity, mental 1 Oriented or steady gait
ate lighting must be immediately available. A spirometer must be
status
0 Neither available without undue delay.
Additional monitoring may be indicated, depending on the
2 Minimal patient’s health, the type of procedure to be performed, and the
Pain, nausea, 1 Moderate
vomiting characteristics of the practice setting. Cardiovascular monitoring,
0 Severe
including measurement of systemic arterial, central venous, pul-
2 Minimal monary arterial, and wedge pressures, is covered in detail else-
Surgical bleeding 1 Moderate where [see 8:26 Cardiovascular Monitoring]. Additional information
0 Severe about the cardiovascular system may be obtained by means of
2 Oral fluid intake and voiding
transesophageal echocardiography.26 Practice guidelines for this
Intake/output 1 Oral fluid intake or voiding modality have been developed.27 It may be particularly useful in
0 Neither patients who are undergoing valvular repair or who have persistent
severe hypotension of unknown etiology.
*Total possible score is 10; patients scoring ≥ 9 are considered fit for discharge home.
The effects of anesthesia and surgery on the CNS may be moni-
tored by recording processed electroencephalographic activity, as
plexus and paravertebral blocks. Anesthesia of the head and neck in the bispectral index or the Patient State Index. These indices
may be achieved by blocking the trigeminal, supraorbital, supra- are used as measures of hypnosis to guide the administration of
trochlear, infraorbitral, and mental nerves and the cervical plexus. anesthetics.28,29
Local infiltration of the operative site may provide intraoperative
as well as postoperative analgesia.
Unlike the data on neuraxial blockade, the data on peripheral General Anesthesia Techniques
nerve blockade neither support nor discourage its use as a substi- An ever-expanding armamentarium of drugs is available for
tute for general anesthesia. Generally, however, we favor regional premedication and for induction and maintenance of anesthesia.
techniques when appropriate: such approaches maintain con- Selection of one agent over another is influenced by the patient’s
sciousness and spontaneous breathing while causing only mini- baseline condition, the procedure, and the predicted duration of
mal depression of the CNS and the cardiorespiratory system, and hospitalization.
they yield improved pain control in the immediate postoperative
period. PREMEDICATION
Monitored anesthesia care involves the use of I.V. drugs to Preoperative medications are given primarily to decrease anxi-
reduce anxiety, provide analgesia, and alleviate the discomfort of ety, to reduce the incidence of nausea and vomiting, and to pre-
immobilization.This approach may be combined with local infiltra- vent aspiration. Other benefits include sedation, amnesia, analge-
tion analgesia provided by the surgeon. Monitored anesthesia care sia, drying of oral secretions, and blunting of undesirable auto-
requires monitoring of vital signs and the presence of an anesthesi- nomic reflexes.
ologist who is prepared to convert to general anesthesia if neces-
sary. Its benefits are substantially similar to those of regional anes- Sedatives and Analgesics
thesia.These benefits are lost when attempts are made to overcome Benzodiazepines produce anxiolysis, sedation, hypnosis, amne-
surgical pain with excessive doses of sedatives and analgesics. sia, and muscle relaxation; they do not produce analgesia. They
may be classified as short-acting (midazolam), intermediate-acting
Table 5 Benzodiazepines: Doses (lorazepam), or long-acting (diazepam). Adverse effects [see Table
5] may be marked in debilitated patients.Their central effects may
and Duration of Action68 be antagonized with flumazenil.
Dose (for Elimination Muscarinic antagonists (e.g., scopolamine and atropine) were
Benzodiazepine Comments commonly administered at one time; this practice is not as popu-
Sedation) Half-life
lar today. They produce, to varying degrees, sedation, amnesia,
Respiratory depression, lowered anesthetic requirements, diminished nausea and vomit-
excessive sedation, hy-
Midazolam 0.5–1.0 mg, 1.7–2.6 hr potension, bradycardia, ing, reduced oral secretions, and decreased gastric hydrogen ion
repeated withdrawal secretion. They blunt the cardiac parasympathetic reflex respons-
Anticonvulsant activity es that may occur during certain procedures (e.g., ocular surgery,
See midazolam traction on the mesentery, and manipulation of the carotid body).
Lorazepam 0.25 mg, 11–22 hr
repeated Venous thrombosis Adverse effects include tachycardia, heat intolerance, inhibition of
GI motility and micturition, and mydriasis.
Diazepam 2.0 mg, 20–50 hr See midazolam and Opioids are used when analgesia, in addition to sedation and
repeated lorazepam
anxiolysis, is required.With morphine and meperidine, the time of
Table 6 Opioids: Doses and Duration of Action69
Relative Dose Time to Peak Duration of

Agent Analgesic Effect Action Comments
Potency Induction Maintenance
Respiratory depression, nausea, vomiting, pruritus,

constipation, urinary retention, biliary spasm,
For perioperative neuroexcitation ± seizure, tolerance
Morphine 1 1 mg/kg analgesia: 0.1 mg/kg 5–20 min 2–7 hr Cough suppression, relief of dyspnea-induced anxiety
I.V., I.M. (common to all opioids)
Histamine release, orthostatic hypotension, prolonged emergence
See morphine
For perioperative Orthostatic hypotension, myocardial depression, dry mouth,
Meperidine analgesia: 0.5– 2 hr (oral); 1 hr 2–4 hr mild tachycardia, mydriasis, histamine release
0.1 NA 1.5 mg/kg I.V., (s.c., I.M.)
I.M., s.c. Attenuates shivering; to be avoided with MAOIs
Local anesthetic–like effect
See morphine
Remifentanil 250–300 1 μg/kg 0.25–0.4 μg/kg/min 3–5 min 5–10 min Awareness, bradycardia, muscle rigidity
Ideal for infusion; fast recovery, no postoperative analgesia
See morphine
Alfentanil 7.5–25 50–300 μg/kg 1.25–8.0 μg/kg/min 1–2 min 10–15 min Awareness, bradycardia, muscle rigidity
Fentanyl 75–125 5–30 μg/kg 0.25–0.5 μg/kg/min 5–15 min 30–60 min See morphine and alfentanil
See morphine and alfentanil

Sufentanil 525–625 2–20 μg/kg 0.05–0.1 μg/kg/min 3–5 min 20–45 min
Ideal for prolonged infusion
onset of action and the peak effect are unpredictable. Fentanyl has Fasting helps reduce the risk of this complication [see Table 3].
a rapid onset and a predictable time course, which make it more When the likelihood of aspiration is high, pharmacologic treat-
suitable for premedication immediately before operation. Adverse ment may be helpful [see Table 7]. H2-receptor antagonists (e.g.,
effects [see Table 6] can be reversed with full (naloxone) or partial cimetidine, ranitidine, and famotidine) and proton pump
(e.g., nalbuphine) antagonists. inhibitors (e.g., omeprazole) reduce gastric acid secretion, thereby
The α2-adrenergic agonists clonidine and dexmedetomidine are raising gastric pH without affecting gastric volume or emptying
sympatholytic drugs that also exert sedative, anxiolytic, and anal- time. Nonparticulate antacids (e.g., sodium citrate) neutralize the
gesic effects. They reduce intraoperative anesthetic requirements, acidity of gastric contents. Metoclopramide promotes gastric emp-
thus allowing faster recovery, and attenuate sympathetic activation tying (by stimulating propulsive GI motility) and decreases reflux
secondary to intubation and surgery, thus improving intraopera- (by increasing the tone of the esophagogastric sphincter); it may
tive hemodynamic stability. Major drawbacks are hypotension and also possess antiemetic properties.
bradycardia; rebound hypertensive crises may be precipitated by In all patients at risk for aspiration who require general anesthe-
their discontinuance.30,31 sia, a rapid sequence induction is essential.This is achieved through
adequate preoxygenation, administration of drugs to produce rapid
Prevention of Aspiration
loss of consciousness and paralysis, and exertion of pressure on the
Aspiration of gastric contents is an extremely serious complica- cricoid cartilage (the Sellick maneuver) as loss of consciousness
tion that is associated with significant morbidity and mortality. occurs to occlude the esophagus and so limit reflux of gastric con-
Table 7 Pharmacologic Prevention of Aspiration70,71
Timing of
Agent Dose Administration Comments
before Operation
H2 receptor 1–3 hr
antagonists
Cimetidine 300 mg, p.o. Hypotension, bradycardia, heart block, increased airway resistance,
CNS dysfunction, reduced hepatic metabolism of certain drugs
Ranitidine 50 mg I.V. Bradycardia
Famotidine 20 mg I.V. Rare CNS dysfunction
Sodium citrate 30 ml p.o. 20–30 min Increased gastric fluid volume
Omeprazole 40 mg I.V. 40 min Possible alteration of GI drug absorption, hepatic metabolism
Extrapyramidal reactions, agitation, restlessness (large doses); to

Metoclopramide 10 mg I.V. 15–30 min be avoided with MAOIs, pheochromocytoma, bowel obstruction
Table 8 Induction Agents: Doses and Duration of Action68
Time to Peak Duration of Comments

Agent Induction Dose
Effect (sec) Action (min)
Hypotension, apnea, antiemetic (low dose), sexual fantasies and hallucinations, convulsions
Propofol 1.0–2.5 mg/kg 90–100 5–10 ± seizures (rare), pain on injection, thrombophlebitis
Hypotension, apnea, emergence delirium, prolonged somnolence, anaphylactoid reaction,

injection pain, hyperalgesia
Thiopental 2.5–4.5 mg/kg 60 5–8
Anticonvulsant effect
Contraindicated with porphyria
Analgesia; increased BP, HR, CO; lacrimation and salivation; bronchial dilatation; elevated ICP
Ketamine 0.5–2 mg/kg 30 10–15 Dreaming, illusions, excitement
Preservation of respiration (apnea possible with high doses)
Minor effects on BP, HR, CO

Etomidate 0.2–0.6 mg/kg 60 4–10
Adrenocortical suppression, injection pain and thrombophlebitis, myoclonus, nausea and vomiting
CO—cardiac output
tents into the pharynx. An alternative is the so-called modified profile during induction and operation [see Table 6].
rapid sequence induction, which permits gentle mask ventilation Volatile agents [see Table 9] may be employed for induction of
during the application of cricoid pressure (thereby potentially general anesthesia when maintenance of spontaneous ventilation
reducing or abolishing insufflation of gas into the stomach). The is of paramount importance (e.g., with a difficult airway) or when
advantages of the modified approach are that there is less risk of bronchodilation is required (e.g., with severe hyperreactive airway
hypoxia and that there is more time to treat cardiovascular respons- disease). Inhalation induction is also popular for ambulatory
es to induction agents before intubation. Regardless of which tech- surgery when paralysis is not required. Sevoflurane is well suited
nique is used, consideration should be given to emptying the stom- for this application because it is not irritating on inhalation, as
ach via an orogastric or nasogastric tube before induction. most other volatile agents are, and it produces rapid loss of con-
sciousness. Sevoflurane has mostly replaced halothane as the agent
INDUCTION
of choice for inhalation induction because it is less likely to cause
Induction of general anesthesia is produced by administering dysrhythmias and is not hepatotoxic.
drugs to render the patient unconscious and secure the airway. It
MAINTENANCE
is one of the most crucial and potentially dangerous moments for
the patient during general anesthesia. Various agents can be used Balanced general anesthesia is produced with a variety of drugs
for this purpose; the choice depends on the patient’s baseline med- to maintain unconsciousness, prevent recall, and provide analge-
ical condition and fasting status, the state of the airway, the surgi- sia. Various combinations of volatile and I.V. agents may be
cal procedure, and the expected length of the hospital stay. The employed to achieve these goals. The volatile agents isoflurane,
agents most commonly employed for induction are propofol, sodi- desflurane, and sevoflurane are commonly used for maintenance
um thiopental, ketamine, and etomidate [see Table 8]. The opioids [see Table 9]. Nitrous oxide is a strong analgesic and a weak anes-
alfentanil, fentanyl, sufentanil, and remifentanil are also used for thetic agent that possesses favorable pharmacokinetic properties.
this purpose; they are associated with a very stable hemodynamic It cannot be used as the sole anesthetic agent unless it is adminis-
Table 9—Volatile Drugs72,73
Oil/Gas MAC† (atm) Blood/Gas Rank Order

Agent
Coefficient* Coefficient‡ (FA/FI)§
Halothane 224 0.0074 2.5 6
Enflurane 96.5 0.0168 1.8 5
Isoflurane 90.8 0.0115 1.4 4
Desflurane 18.7 0.060 0.45 2
Sevoflurane 47.2 0.0236 0.65 3
Nitrous oxide 1.4 1.04 0.47 1
*Lipid solubility correlates closely with anesthetic potency (Meyer-Overton rule).

†
Correlates closely with lipid solubility.
‡
Relative affinity of an anesthetic for blood compared to gas at equilibrium. The larger the coefficient, the greater the
affinity of the drug for blood and hence the greater the quantity of drug contained in the blood.
§
Rise in alveolar anesthetic concentration towards the inspired concentration is most rapid with the least soluble drugs
and slowest with the most soluble.
FA/FI—alveolar concentration of gas/inspired concentration MAC—minimum alveolar concentration to abolish pur-
poseful movement in response to noxious stimulation in 50% of patients
Table 10 Neuromuscular Blocking Agents: Doses and Duration of Action74
Dose Duration of Comments

Agent Metabolism Elimination
(mg/kg) Action1 (min)
Fasciculations, elevation of serum potassium, increased

Succinylcholine
0.7–2.5 5–10 Plasma cholinesterase Renal < 2%, hepatic 0% ICP, bradycardia, MH trigger; prolonged effect in
chloride
presence of atypical pseudocholinesterase
0.04–0.1 Muscarinic antagonist (vagolytic), prolonged paralysis

Pancuronium 60–120 Hepatic 10%–20% Renal 85%, hepatic 15%
(long-term use)
Rocuronium 0.6–1.2 35–75 None Renal < 10%, hepatic > 70% Minimal histamine release
Vecuronium 0.08–0.1 45–90 Hepatic 30%–40% Renal 40%, hepatic 60% Prolonged paralysis (long-term use)
Hoffman elimination, Histamine release; laudanosine metabolite (a CNS

Atracurium 0.3–0.5 30–45 nonspecific ester Renal 10%–40%, hepatic 0% stimulant)
hydrolysis
Cisatracurium 0.15–0.2 40–75 Hoffman elimination Renal 16%, hepatic 0% Negligible histamine release; laudanosine metabolite
Histamine release; prolonged effect in presence of

Mivacurium 0.15–0.2 15–20 Plasma cholinesterase Renal < 5%, hepatic 0%
atypical pseudocholinesterase
tered in a hyperbaric chamber; it is usually administered with at rocuronium, vecuronium, atracurium, cisatracurium, and miva-
least 30% oxygen to prevent hypoxia. Nitrous oxide is commonly curium) and may be further differentiated on the basis of chemi-
used in combination with other volatile agents. All of the volatile cal structure and duration of action [see Table 10]. The blocking
agents can trigger malignant hyperthermia in susceptible patients. effect of nondepolarizing muscle relaxants is enhanced by volatile
The I.V. drugs currently used to maintain general anesthesia, drugs, hypothermia, acidosis, certain antibiotics, magnesium sul-
whether partially or entirely, feature a short context-sensitive elim- fate, and local anesthetics and is reduced by phenytoin and carba-
ination half-life; thus, pharmacologically significant drug accumu- mazepine. Patients with weakness secondary to neuromuscular
lation during prolonged infusion is avoided. Such agents (includ- disorders (e.g., myasthenia gravis and Eaton-Lambert syndrome)
ing propofol, midazolam, sufentanil, and remifentanil) are typical- may be particularly sensitive to nondepolarizing muscle relaxants.
ly administered via computer-controlled infusion pumps that use
EMERGENCE
population-based pharmacokinetic data to establish stable plasma
(and CNS effector site) concentrations. Because of the extremely General anesthesia is terminated by cessation of drug adminis-
rapid hydrolysis of remifentanil, its administration may be labor tration, reversal of paralysis, and extubation. During this period,
intensive, necessitating frequent administration of boluses and close scrutiny of the patient is essential, and all OR personnel must
constant vigilance. Its short half-life also limits its usefulness as an coordinate their efforts to help ensure a smooth and safe emer-
analgesic in the postoperative period and may even contribute to gence. In this phase, patients may demonstrate hemodynamic
acute opioid intolerance. To help circumvent these problems, var- instability, retching and vomiting, respiratory compromise, and,
ious dosing regimens have been proposed in which the patient is occasionally, uncooperative or aggressive behavior.
switched from remifentanil to a longer-acting narcotic. Reversal of neuromuscular blockade is achieved by administer-
ing anticholinesterases such as neostigmine and edrophonium.
NEUROMUSCULAR BLOCKADE
These drugs should be given in conjunction with a muscarinic
The reversible paralysis produced by neuromuscular blockade antagonist (atropine or glycopyrrolate) to block their unwanted
improves conditions for endotracheal intubation and facilitates parasympathomimetic side effects. Neostigmine is more potent
surgery. Neuromuscular blocking agents are classified as either than edrophonium in reversing profound neuromuscular block-
depolarizing (succinylcholine) or nondepolarizing (pancuronium, ade. It is imperative that paralysis be sufficiently reversed before
Table 11 Pharmacology of Anticoagulant Agents
Coagulation Tests Time to Normal

Drug Time to Peak Hemostasis after
INR PTT Effect Discontinuance
Heparin
I.V. ⇔ ⇑ min 4–6 hr
s.c. ⇔ ↑ 1 hr 4–6 hr
LMWH ⇔ ⇔ 2–4 hr 12 hr
Warfarin ⇑ ⇔ 2–6 days 4–6 days
Aspirin ⇔ ⇔ hr 5–8 days
Thrombolytic agents (t-PA, streptokinase) ⇔ ⇑ min 1–2 days
⇑ —clinically significant increase ↑—possibly clinically significant increase ⇔—clinically insignificant increase or no effect
LMWH—low-molecular-weight heparin t-PA—tissue plasminogen activator
extubation to ensure that spontaneous respiration is adequate and Antiplatelet Agents

that the airway can be protected. Reversal can be clinically verified
There is no universally accepted test that can guide antiplatelet
by confirming the patient’s ability to lift the head for 5 seconds.
therapy. Antiplatelet agents can be divided into four major classes:
Reversal can also be assessed by measuring muscle contraction in
(1) aspirin and related cyclooxygenase inhibitors (nonsteroidal
response to electrical nerve stimulation.
anti-inflammatory drugs, or NSAIDs); (2) ticlopidine and selec-
Causes of failure to emerge from anesthesia include residual tive adenosine diphosphate antagonists; (3) direct thrombin
neuromuscular blockade, a benzodiazepine or opioid overdose, the inhibitors (e.g., hirudin); and (4) glycoprotein IIb/IIIa inhibitors.
central anticholinergic syndrome, an intraoperative cerebrovascular Only with aspirin is there sufficient experience to suggest that it
accident, preexisting pathophysiologic conditions (e.g., CNS disor- does not increase the risk of spinal hematoma when given at clin-
ders, hepatic insufficiency, and drug or alcohol ingestion), electrolyte ical dosages.36 Caution should, however, be exercised when aspirin
abnormalities, acidosis, hypercarbia, hypoxia, hypothermia, and hypo- is used in conjunction with other anticoagulants.37
thyroidism. As noted, the effects of narcotics and benzodiazepines
can be reversed with naloxone and flumazenil, respectively. Physo- Oral Anticoagulants
stigmine may be given to reverse the reduction in consciousness Therapeutic anticoagulation with warfarin is a contraindication
level produced by general anesthetics. Electrolyte, glucose, blood urea to regional anesthesia.38 If regional anesthesia is planned, oral war-
nitrogen, and creatinine levels should be measured; liver and thy- farin can be replaced with I.V. heparin (see below).
roid function tests should be performed; and arterial blood gas val- Heparin
ues should be obtained. Patients should be normothermic.
Unexplained failure to emerge from general anesthesia warrants There does not seem to be an increased risk of spinal bleeding
immediate consultation with a neurologist. in patients receiving subcutaneous low-dose (5,000 U) unfraction-
ated heparin [see 6:6 Venous Thromboembolism] if the interval
between administration of the drug and initiation of the procedure
Regional Anesthesia Techniques is greater than 4 hours.39 Higher doses, however, are associated
Neuraxial (central) anesthesia techniques involve continuous or with increased risk. If neuraxial anesthesia or epidural catheter
intermittent injection of drugs into the epidural or intrathecal removal is planned, heparin infusion must be discontinued for at
least 6 hours, and the partial thromboplastin time (PTT) should
space to produce sensory analgesia, motor blockade, and inhibi-
be measured. Recommendations for standard heparin cannot be
tion of sympathetic outflow. Peripheral nerve blockade involves
extrapolated to low-molecular-weight heparin (LMWH), because
inhibition of conduction in fibers of a single peripheral nerve or
the biologic actions of LMWH are different and the effects cannot
plexus (cervical, brachial, or lumbar) in the periphery. Intravenous be monitored by conventional coagulation measurements. After
regional anesthesia involves I.V. administration of a local anesthet- the release of LMWH for general use in the United States in 1993,
ic into a tourniquet-occluded extremity. Perioperative pain control more than 40 spinal hematomas were reported during a 5-year
may be facilitated by administering local anesthetics, either infil- period. LMWH should be stopped at least 24 hours before region-
trated into the wound or sprayed into the wound cavity.32,33 Pro- al blockade, and the first postoperative dose should be given no
cedures performed solely under infiltration may be associated with sooner than 24 hours afterward.37
patient dissatisfaction caused by intraoperative anxiety and pain.34
COMPLICATIONS
CONTRAINDICATIONS
Drug Toxicity
Strong contraindications to regional (particularly neuraxial)
anesthesia include patient refusal or inability to cooperate during Systemic toxic reactions to local anesthetics primarily involve
the procedure, elevated intracranial pressure, anticoagulation, vas- the CNS and the cardiovascular system [see Table 12]. The initial
cular malformation or infection at the needle insertion site, severe symptoms are light-headedness and dizziness, followed by visual
hemodynamic instability, and sepsis. Preexisting neurologic dis- and auditory disturbances. Convulsions and respiratory arrest
ease is a relative contraindication. may ensue and necessitate treatment and resuscitation.
The use of neuraxial analgesic adjuncts (e.g., opioids, clonidine,
ANTICOAGULATION AND BLEEDING RISK epinephrine, and neostigmine) decreases the dose of local anes-
Although hemorrhagic complications can occur after any thetic required, speeds recovery, and improves the quality of anal-
regional technique, bleeding associated with neuraxial blockade is gesia.The side effects of such adjuncts include respiratory depres-
the most serious possibility because of its devastating conse- sion (with morphine), tachycardia (with epinephrine), hypoten-
sion (with clonidine), and nausea and vomiting (with neostigmine
quences. Spinal hematoma may occur as a result of vascular trau-
and morphine).
ma from placement of a needle or catheter into the subarachnoid
or epidural space. Spinal hematoma may also occur spontaneous- Neurologic Complications
ly, even in the absence of antiplatelet or anticoagulant therapy.The The incidence of neurologic complications ranges from
actual incidence of spinal cord injury resulting from hemorrhagic 2/10,000 to 12/10,000 with epidural anesthesia and from
complications is unknown; the reported incidence is estimated to 0.3/10,000 to 70/10,000 with spinal anesthesia.40 The most com-
be less than 1/150,000 for epidural anesthesia and 1/220,000 for mon serious complication is neuropathy, followed by cranial nerve
spinal anesthesia.35 With such low incidences, it is difficult to palsy, epidural abscess, epidural hematoma, anterior spinal artery
determine whether any increased risk can be attributed to antico- syndrome, and cranial subdural hematoma.Vigilance and routine
agulant use [see Table 11] without data from millions of patients, neurologic testing of sensory and motor function are of para-
which are not currently available. Much of our clinical practice is mount importance for early detection and treatment of these
based on small surveys and expert opinion. potentially disastrous complications.
Table 12 Local Anesthetics for Infiltration Anesthesia:

Maximum Doses* and Duration of Action
Without Epinephrine With Epinephrine (1:200,000)

Drug Maximum Dose
Maximum Dose Duration of Action Duration of Action
(mg) (min) (mg) (min)
Chloroprocaine 800 15–30 1,000 3–90
Lidocaine 300 30–60 500 120–360
Mepivacaine 300 45–90 500 120–360
Prilocaine 500 30–90 600 120–360
Bupivacaine 175 120–240 225 180–420
Etidocaine 300 120–180 400 180–420
*Recommended maximum dose can be given to healthy, middle-aged, normal-sized adults without toxicity.
Subsequent doses should not be given for at least 4 hr. Doses should be reduced during pregnancy.
Transient neurologic symptoms The term transient neu- Special Scenarios

rologic symptoms (TNS) refers to backache with pain radiating
into the buttocks or the lower extremities after spinal anesthesia. It DIFFICULT AIRWAY
occurs in 4% to 33% of patients, typically 12 to 36 hours after the Airway management is a pivotal component of patient care
resolution of spinal anesthesia, and lasts for 2 to 3 days.41 TNS has because failure to maintain airway patency can lead to permanent
been described after intrathecal use of all local anesthetics but is disability, brain injury, or death. The difficult airway should be
most commonly noted after administration of lidocaine, in the managed in accordance with contemporary airway guidelines,
ambulatory surgical setting, and with the patient in the lithotomy such as the protocols established by the ASA, to reduce the risk of
position during operation. Discomfort from TNS is self-limited adverse outcomes during attempts at ventilation and intubation.
and can be effectively treated with NSAIDs. (The ASA protocols may be accessed on the organization’s Web
Post–Dural Puncture Headache site: http://www.asahq.org/publicationsandservices/difficult%20air-
way.pdf.) The emphasis on preserving spontaneous ventilation
Use of small-gauge pencil-point needles for spinal anesthesia is
and the focus on awake intubation options are central themes
associated with a 1% incidence of PDPH.The incidence of PDPH
whose importance cannot be overemphasized.
after epidural analgesia varies substantially because the risk of
It is crucial that all patients who are undergoing difficult or pro-
inadvertent dural puncture with a Tuohy needle is directly depen-
longed airway instrumentation be appropriately treated with topi-
dent on the anesthesiologist’s training. PDPH is characteristically
cal anesthesia, sedation, and monitoring so as to ensure adequate
aggravated by upright posture and may be associated with photo-
phobia, neck stiffness, nausea, diplopia, and tinnitus. Meningitis ventilation and to attenuate, detect, and treat harmful neuroen-
should be considered in the differential diagnosis. Although docrine responses that can cause myocardial ischemia, bron-
PDPH is not life-threatening, it carries substantial morbidity in chospasm, and intracranial hypertension. Extubation is stressful as
the form of restricted activity. Medical treatment with bed rest, I.V. well and may be associated with intense mucosal stimulation and
fluids, NSAIDs, and caffeine is only moderately effective. An exaggerated glottic closure reflexes resulting in laryngospasm and,
epidural blood patch is the treatment of choice: the success rate is possibly, pulmonary edema secondary to vigorous inspiratory
approximately 70%. efforts against an obstructed airway. Laryngeal incompetence and
aspiration can also occur after extubation. Removal of an endotra-
cheal tube from a known or suspected difficult airway should ide-
Recovery ally be performed over a tube exchanger so as to facilitate emer-
Admission to the postanesthetic care unit (PACU) is appro- gency reintubation.
priate for patients whose vital signs are stable and whose pain is Alternatives to standard oral airways, masks, introducers,
adequately controlled after emergence from anesthesia. Patients exchangers, laryngoscopes, and endotracheal tubes now exist that
requiring hemodynamic or respiratory support may be admitted offer more options, greater safety, and better outcomes. It would
to the PACU if rapid improvement is expected and appropriate be naive to believe that any single practitioner could master every
monitoring and personnel are available. Hemodynamic instabil- new airway protocol and device. To keep up with technical and
ity, the need for prolonged respiratory support, and poor base- procedural advances, university hospital program directors should
line condition mandate admission to the ICU. Common compli- consider incorporating technical skill laboratories and simulator
cations encountered in the PACU include postoperative pul- training sessions into their curricula.
monary insufficiency, cardiovascular instability, acute pain, and
MORBID OBESITY
nausea and vomiting [see Table 13]. These complications are dis-
cussed in greater detail elsewhere [see 8:4 Pulmonary Insufficiency, Morbid obesity represents the extreme end of the overweight
8:2 Acute Cardiac Dysrhythmia, 1:5 Postoperative Pain, and ECP:5 spectrum and is usually defined as a body-mass index higher than
Outpatient Surgery]. 40 kg/m2 [see 5:7 Morbid Obesity].42 It poses a formidable challenge
to health care providers in the OR, the postoperative recovery reticulum calcium release channel in skeletal muscle has been
ward, and the ICU.The major concerns in the surgical setting are identified as a possible underlying cause.
the possibility of a difficult airway, the increased risk of known or In making the diagnosis of MH, it is important to consider
occult cardiorespiratory compromise, and various serious techni- other possible causes of postoperative temperature elevation. Such
cal problems related to positioning, monitoring, vascular access, causes include inadequate anesthesia, equipment problems (e.g.,
and transport. Additional concerns are the potential for underly- misuse or malfunction of heating devices, ventilators, or breathing
ing hepatic and endocrine disease and the effects of altered drug circuits), local or systemic inflammatory responses (either related
pharmacokinetics and pharmacodynamics. For the morbidly or unrelated to infection), transfusion reaction, hypermetabolic
obese patient, there is no such thing as minor surgery. endocrinopathy (e.g., thyroid storm or pheochromocytoma), neu-
Initial management should be based on the assumptions that rologic catastrophe (e.g., intracranial hemorrhage), and reaction to
(1) a difficult airway is likely, (2) the patient will be predisposed to or abuse of a drug.
hiatal hernia, reflux, and aspiration, and (3) rapid arterial desatu- Immediate recognition and treatment of a fulminant MH epi-
ration will occur with induction of anesthesia as a consequence of sode are essential for preventing morbidity and mortality.Therapy
decreased functional residual capacity and high basal oxygen con- consists of discontinuing all triggers, instituting aggressive cooling
sumption. Often, the safest option is an awake fiberoptic intuba- measures, giving dantrolene in an initial dose of 2.5 mg/kg, and
tion with appropriate topical anesthesia and light sedation.43 In administering 100% oxygen to compensate for the tremendous
expert hands, this technique is extremely well tolerated and can increase in oxygen utilization and carbon dioxide production. An
usually be performed in less than 10 minutes. Morbidly obese indwelling arterial line, central venous access, and bladder
patients often are hypoxemic at rest and have an abnormal alveo- catheterization are indispensable for monitoring and resuscitation.
lar-arterial oxygen gradient caused by ventilation-perfusion mis- Acidosis, hyperkalemia, and malignant dysrhythmias must be
matching. The combination of general anesthesia and the supine rapidly treated, with the caveat that calcium channel blockers are
position exacerbates alveolar collapse and airway closure. contraindicated in this setting. Maintenance of adequate urine
Mechanical ventilation, weaning, and extubation may be difficult output is of paramount importance and may be facilitated by the
and dangerous, especially in the presence of significant obstructive clinically significant amounts of mannitol contained in commer-
sleep apnea. Postoperative pulmonary complications (e.g., pneu- cial dantrolene preparations. When the patient is stable and the
monia, aspiration, atelectasis, and emboli) are common. surgical procedure is complete, monitoring and support are con-
Morbid obesity imposes unusual loading conditions on both tinued in the ICU, where repeat doses of dantrolene may be need-
sides of the heart and the circulation, leading to the progressive ed to prevent or treat recrudescence of the disease.
development of insulin resistance, atherogenic dyslipidemias, sys-
MASSIVE TRANSFUSION
temic and pulmonary hypertension, ventricular hypertrophy, and
a high risk of premature coronary artery disease and biventricular Massive blood transfusion, defined as the replacement of a pa-
heart failure. Perioperative cardiac morbidity and mortality are tient’s entire circulating blood volume in less than 24 hours, is as-
therefore significant problems. Untoward events can happen sud- sociated with significant morbidity and mortality. Management of
denly, and resuscitation is extremely difficult. Cardiorespiratory massive transfusion requires an organized multidisciplinary team
compromise may be attenuated by effective postoperative pain approach and a thorough understanding of associated hematolog-
control that permits early ambulation and effective ventilation. ic and biochemical abnormalities and subsequent treatment options.
Surgical site infection and dehiscence may result in difficult reop- Patients suffering from shock as a result of massive blood loss
eration and prolonged hospitalization. often require transfusions of packed red blood cells, platelets, fresh
frozen plasma, and cryoprecipitate to optimize oxygen-carrying
MALIGNANT HYPERTHERMIA
capacity and address dilutional and consumptive loss of platelets
MH is a rare but potentially fatal genetic condition character- and clotting factors [see 8:3 Shock and 1:4 Bleeding and Transfusion].
ized by life-threatening hypermetabolic reactions in susceptible Transfusion of large amounts of blood products into a critically ill
individuals after the administration of volatile anesthetics or depo- patient can lead to coagulopathies, hyperkalemia, acidosis, citrate
larizing muscle relaxants.44 Abnormal function of the sarcoplasmic intoxication, fluid overload, and hypothermia.45 Therapy should be
Table 13—Pharmacologic Treatment of PONV5
Agent Dose Comments
Propofol 10 mg I.V., repeated dose [See Table 8]
Ondansetron 4.0–8.0 mg I.V. Highly effective, costly; headache, constipation, transiently

increased LFTs
Dexamethasone 4.0–8.0 mg I.V. Adrenocortical suppression, delayed wound healing, fluid

retention, electrolyte disturbances, psychosis, osteoporosis
Droperidol 0.5–1.0 mg I.V. Sedation, restlessness, dysphoria, ?dysrhythmia
Metoclopramide 10–20 mg I.V. Avoid in bowel obstruction, extrapyramidal reactions
Scopolamine 0.1–0.6 mg s.c., I.M., I.V. Muscarinic side effects, somnolence
Dimenhydrinate 25–50 mg I.V. Drowsiness, dizziness

LFTs—liver function tests
guided by vital signs, urine output, pulse oximetry, electrocardiog- or efforts are being made to avoid fetal depression during cesarean
raphy, capnography, invasive hemodynamic monitoring, serial arte- section), the light level of anesthesia may have been intentionally
rial blood gases, biochemical profiles, and bedside coagulation chosen. Regardless of the cause, intraoperative awareness is a terri-
screens. Fluids should be administered through large-bore cannu- fying experience for the patient and has been associated with seri-
las connected to modern countercurrent warming devices. Shed ous long-term psychological sequelae.48 Prevention of awareness
blood should be salvaged and returned to the patient whenever depends on regular equipment maintenance, meticulous anesthet-
possible. In refractory cases, transcatheter angiographic emboliza- ic technique, and close observation of the patient’s movements and
tion techniques should be considered for control of bleeding. hemodynamic responses during operation. CNS monitoring may
Newer hemostatic agents, such as aprotinin and recombinant reduce the risk of intraoperative awareness.
factor VIIa, should also be considered [see 1:4 Bleeding and
ANAPHYLAXIS
Transfusion]. Aprotinin is a serine protease inhibitor with unique
antifibrinolytic and hemostatic properties. It is used during Allergic reactions range in severity from mild pruritus and
surgery to decrease blood loss and transfusion requirements as urticaria to anaphylactic shock and death. Inciting agents include
well as to attenuate potentially harmful inflammatory responses antibiotics, contrast agents, blood products, volume expanders,
and minimize reperfusion injury. Recombinant factor VIIa was protamine, aprotinin, narcotics, induction agents, muscle relax-
originally approved for hemophiliacs who developed antibodies ants, latex,49 and, rarely, local anesthetic solutions. Many drug
against either factor VIII or factor IX; it may prove useful for man- additives and preservatives have also been implicated.
aging uncontrolled hemorrhage deriving from trauma or surgery. True anaphylaxis presents shortly after exposure to an allergen
and is mediated by chemicals released from degranulated mast
HYPOTHERMIA
cells and basophils. Manifestations usually include dramatic hypo-
Significant decreases in core temperature are common during tension, tachycardia, bronchospasm, arterial oxygen desaturation,
anesthesia and surgery as a consequence of exposure to a cold OR and cutaneous changes. Laryngeal edema can occur within minutes,
environment and of disturbances in normal protective thermoreg- in which case the airway should be secured immediately. Anaphy-
ulatory responses. Patients lose heat through conduction, convec- laxis can mimic heart failure, asthma, pulmonary embolism, and
tion, radiation, and evaporation, especially from large wounds and tension pneumothorax.Treatment involves withdrawing the offend-
during major intracavitary procedures. Moreover, effective vaso- ing substance and administering oxygen, fluids, and epinephrine,
constrictive reflexes and both shivering and nonshivering thermo- followed by I.V. steroids, bronchodilators, and histamine antago-
genesis are severely blunted by anesthetics.46 Neonates and the nists. Prolonged intubation and ICU monitoring may be required
elderly are particularly vulnerable. until symptoms resolve. Appropriate skin and blood testing should
Hypothermia may confer some degree of organ preservation be done to identify the causative agent.
during ischemia and reperfusion. For example, in cardiac surgery,
PERIOPERATIVE DYSRHYTHMIAS
hypothermic cardiopulmonary bypass is a common strategy for
protecting the myocardium and the CNS. Intentional hypother- In 2005, current scientific developments in the acute treatment
mia has also been shown to improve neurologic outcome and sur- of cerebrovascular, cardiac, and pulmonary disease were merged
vival in comatose victims of cardiac arrest. Perioperative hypother- with the evolving discipline of evidence-based medicine to produce
mia can have significant deleterious effects as well, however, the most comprehensive set of resuscitation standards ever creat-
including myocardial ischemia, surgical site infection, increased ed: a 14-part document from the American Heart Association
blood loss and transfusion requirements, and prolonged anesthet- entitled “2005 American Heart Association Guidelines for
ic recovery and hospital stay. Cardiopulmonary Resuscitation and Emergency Cardiovascular
The sensation of cold is highly uncomfortable for the patient, Care.”50 This document addresses a wide array of key issues in
and shivering impedes monitoring, raises plasma catecholamine both in-hospital and out-of-hospital resuscitation, including a rec-
levels, and exacerbates imbalances between oxygen supply and ommendation for confirmation of tube position after endotracheal
demand by consuming valuable energy for involuntary muscular intubation and a warning about the danger associated with unin-
activity. It is therefore extremely important to measure the tentional massive auto-PEEP.
patient’s temperature and maintain thermoneutrality. Increasing As regards the impact the new guidelines have on the manage-
the ambient temperature of the OR and applying modern forced- ment of cardiopulmonary resuscitation, an increase in compres-
air warming systems are the most effective techniques available. In sion:ventilation ratios (to 30:2) and an emphasis on effective chest
addition, all I.V. and irrigation fluids should be heated. After the compressions (“push hard, push fast”) are suggested. In addition,
patient has been transferred from the OR, aggressive treatment of early chest compressions before defibrillation, a one-shock
hypothermia with these techniques should be continued as neces- sequence for defibrillation as opposed to a three-shock sequence,
sary. Shivering may also be reduced by means of drugs such as and avoidance of prolonged interruption of chest compressions
meperidine, nefopam, tramadol, physostigmine, ketamine, are recommended. For wide QRS dysrhythmias, amiodarone con-
methylphenidate, and doxapram.47 tinues to be the drug of choice. It may also be administered for
ventricular fibrillation or for pulseless ventricular tachycardia that
INTRAOPERATIVE AWARENESS
does not respond to cardiopulmonary resuscitation, cardioversion,
One of the goals of anesthesia is to produce a state of uncon- and a vasopressor.
sciousness during which the patient neither perceives nor recalls Amiodarone is a complex, powerful, and broad-spectrum agent
noxious surgical stimuli.When this objective is not met, awareness that inhibits almost all of the drug receptors and ion channels con-
occurs, and the patient will have explicit or implicit memory of ceivably responsible for the initiation and propagation of cardiac
intraoperative events. In some instances, intraoperative awareness ectopy, irrespective of underlying ejection fraction, accessory path-
develops because human error, machine malfunction, or technical way conduction, or anatomic substrate. It does, however, have
problems result in an inappropriately light level of anesthesia. In potential drawbacks, such as its relatively long half-life, its toxicity
others (e.g., when the patient is severely hemodynamically unstable to multiple organs, and its complicated administration scheme.
Furthermore, amiodarone is a potent noncompetitive alpha and boluses may be given similarly. A loading regimen is then initiated,
beta blocker, which has important implications for anesthetized, first at 1 mg/min for 6 hours and then at 0.5 mg/min for 18 hours.
mechanically ventilated patients who may be debilitated and expe- Vasopressin (antidiuretic hormone) continues to be listed as an
riencing volume depletion, abnormal vasodilation, myocardial alternative to epinephrine in the ventricular tachycardia/ventricular
depression, and fluid, electrolyte, and acid-base abnormalities. fibrillation protocol. Vasopressin is an integral component of the
That said, no other drug in its class has ever demonstrated a sig- hypothalamic-pituitary-adrenal axis and the neuroendocrine stress
nificant benefit in randomized trials addressing cardiac arrest in response.The recommended dose for an adult in fibrillatory arrest
humans. is 40 units in a single bolus. For vasodilatory shock states associat-
Amiodarone is effective in both children and adults, and it can ed with sepsis, hepatic failure, or vasomotor paralysis after cardio-
be used for prophylaxis as well as treatment. The recommended pulmonary bypass, infusion at a rate of 0.01 to 0.04 units/min may
cardiac arrest dose is a 300 mg I.V. bolus. In less acute situations be particularly useful. Vasopressin is neither recommended nor
(e.g., wide-complex tachycardia), an initial 150 mg dose should be forbidden in cases of pulseless electrical activity or asystolic arrest,
administered slowly over 10 minutes, and one or two additional and it may be substituted for epinephrine.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 4 BLEEDING AND TRANSFUSION — 1
4 BLEEDING AND TRANSFUSION

John T. Owings, M.D., F.A.C.S., Garth H. Utter, M.D., M.Sc., and Robert C. Gosselin, M.T.
Approach to the Patient with Ongoing Bleeding
A surgeon is often the first person to be called when a patient Even when a technical cause of bleeding has seemingly been
experiences ongoing bleeding.To treat such a patient appropriate- excluded, the possibility often must be reconsidered periodically
ly, the surgeon must identify the cause or source of the bleeding. throughout assessment. Patients who are either unresuscitated or
Causes fall into two main categories: (1) conditions leading to loss underresuscitated undergo vasospasm that results in decreased
of vascular integrity, as in a postoperative patient with an unligat- bleeding.1 As resuscitation proceeds, the catecholamine-induced
ed vessel that is bleeding or a trauma patient with a ruptured vasospasm subsides and the bleeding may recur. For this reason,
spleen, and (2) conditions leading to derangement of the hemo- repeated reassessment of the possibility of a technical cause of
static process. In this chapter, we focus on the latter category, bleeding is appropriate. Only when the surgeon is confident that a
which includes a broad spectrum of conditions, such as aspirin- missed injury or unligated vessel is not the cause of the bleeding
induced platelet dysfunction, von Willebrand disease (vWD), dis- should other potential causes be investigated.
seminated intravascular coagulation (DIC), and even hemophilia.
Coagulopathies are varied in their causes, treatments, and prog-
noses. Our aim is not to downplay the usefulness of the specialized Initial Assessment of
hematologic tests required for identification of rare congenital or Potential Coagulopathy
acquired clotting abnormalities but to outline effective manage- The first step in assess-
ment approaches to the coagulopathies surgeons see most fre- ment of a patient with a po-
quently. The vast majority of these coagulopathies can be diag- tential coagulopathy is to
nosed by means of a brief patient and family history, a review of draw a blood sample. The
medications, physical examination, and commonly used laborato- blood should be drawn into
ry studies—in particular, activated partial thromboplastin time a tube containing ethylene-
(aPTT), prothrombin time (PT, commonly expressed as an inter- diaminetetraacetic acid (EDTA) for a CBC and into a citrated
national normalized ratio [INR]), complete blood count (CBC), tube for coagulation analysis (at most centers, these tubes have
and D-dimer assay. purple and blue tops, respectively).
At the same time, the patient’s temperature should be noted.
Because coagulation is a chemical reaction, it slows with decreas-
Exclusion of Technical ing temperature.2 Thus, a patient with a temperature lower than
Causes of Bleeding 35° C (95° F) clots more slowly and less efficiently than one with
It is critical for the sur- a temperature of 37° C (98.6° F).3 The resulting coagulatory
geon to recognize that the abnormality is what is known as a hypothermic coagulopathy.
most common causes of Upon receipt of the drawn specimen, the laboratory warms the
postoperative bleeding are sample to 37° C to run the coagulation assays (aPTT and INR).
technical: an unligated ves- In a patient with a purely hypothermic coagulopathy, this step
sel or an unrecognized results in normal coagulation parameters. Hypothermic patients
injury is much more likely to be the cause of a falling hematocrit should be actively rewarmed.4 Typically, such patients cease to
than either a drug effect or an endogenous hemostatic defect. bleed after rewarming, and no further treatment is required. If the
Furthermore, if an unligated vessel is treated as though it were an patient is normothermic and exhibits normal coagulation values
endogenous hemostatic defect (i.e., with transfusions), the out- but bleeding continues, attention should again be focused on the
come is likely to be disastrous. For these reasons, in all cases of possibility of an unligated bleeding vessel or an uncontrolled
ongoing bleeding, the first consideration must always be to occult bleeding source (e.g., the GI tract).
exclude a surgically correctable cause. Ongoing bleeding in conjunction with abnormal coagulation
Ongoing bleeding may be surprisingly difficult to diagnose. parameters may have any of several underlying causes. In this set-
Healthy young patients can usually maintain a normal blood pres- ting, one of the most useful pieces of information to obtain is a
sure until their blood loss exceeds 40% of their blood volume personal and family history. A patient who has had dental extrac-
(roughly 2 L). If the bleeding is from a laceration to an extremity, tions without major problems or who had a normal adolescence
it will be obvious; however, if the bleeding is occurring internally without any history of bleeding dyscrasias is very unlikely to have
(e.g., from a ruptured spleen or an intraluminal GI source), there a congenital or hereditary bleeding disorder.5 If there is a person-
may be few physiologic signs [see 8:3 Shock]. For the purposes of al or family history of a specific bleeding disorder, appropriate
the ensuing discussion, we assume that bleeding is known to have steps should be taken to diagnose and treat the disorder [see
occurred or to be occurring. Discussion, Bleeding Disorders, below].
Patient experiences ongoing bleeding
First, consider possible technical cause (unligated

vessel after operation or unrecognized injury).
Patient has unligated vessel or unrecognized injury
Control bleeding vessel.
Approach to the Patient with Ongoing Bleeding
Patient has family history of

bleeding disorder
Initiate directed testing and therapy.
Patient has normal INR and aPTT Patient has normal INR and prolonged aPTT
Consider platelet dysfunction. Consider drug effects (heparin, lepirudin), acquired

Give platelets and initiate directed factor deficiency, and vWD.
therapy. Give protamine (to reverse heparin), replace factors, or
initiate directed therapy for vWD.
No technical cause of bleeding is apparent
Draw blood for laboratory tests.

Check T°.
T° is normal T° is low
Warm patient.
Bleeding continues Bleeding stops
Assess platelet status and

coagulation parameters.
Platelet status or coagulation parameters are abnormal Platelet status and coagulation parameters are normal
Look for family history of specific bleeding disorder. DIC is not present.
Reconsider possibility of unligated vessel [see above, left].
Patient has no family history of bleeding disorder
Continue evaluation guided by laboratory test results.
Patient has increased INR and normal aPTT Patient has increased INR and prolonged aPTT
Consider drug effects (warfarin), hepatic failure, and If D-dimer level is elevated, assume DIC and
malnutrition. treat accordingly.
Give I.V. vitamin K or FFP as appropriate; treat cirrhosis-related If D-dimer level is normal, consider end-stage
variceal bleeding surgically. renal disease and multifactor deficiency.
Give FFP, and initiate directed therapy.
Measurement of
may simply be related to reversal of a needed anticoagulant state).
Coagulation Parameters
Protamine should also be used with caution in diabetic patients.
These persons sometimes become sensitized to impurities in pro-
NORMAL INR, NORMAL tamine through their exposure to similar impurities in protamine-
aPTT containing insulin formulations, and this sensitization may result
Patients with a normal in an anaphylactic reaction.11
INR and aPTT who exhibit It should be remembered that the aPTT does not accurately
ongoing bleeding may have measure the anticoagulant activity of low-molecular-weight
impaired platelet activity. heparins (LMWHs). Because such heparins exert the greater pro-
Inadequate platelet activity is frequently manifested as persistent portion of their anticoagulant effect by potentiating antithrombin
oozing from wound edges or as low-volume bleeding. Such bleed- to inactivate factor Xa rather than factor IIa, an assay that mea-
ing is rarely the cause of exsanguinating hemorrhage, though it may sures anti-Xa activity is needed to measure the anticoagulant
be life-threatening on occasion, depending on its location (e.g., effect. This effect, however, unlike that of unfractionated heparin,
inside the cranium or the pericardium). Inadequate platelet activi- is not effectively reversed by protamine.
ty may be attributable either to an insufficient number of platelets It should also be noted that the anti-Xa laboratory assay does
or to platelet dysfunction. In the absence of a major surgical insult not truly measure the degree of anticoagulation in vivo; rather, it
or concomitant coagulopathy, a platelet count of 20,000/mm3 or measures only the LMWH concentration in plasma. Because
higher is usually adequate for normal coagulation.6,7 There is some heparins (including LMWHs) function almost exclusively by cat-
disagreement regarding the absolute level to which the platelet alyzing the activity of antithrombin, the therapeutic effect of
count must fall before platelet transfusion is justified in the absence heparin is critically dependent on adequate antithrombin levels;
of active bleeding. Patients undergoing procedures in which even acquired antithrombin deficiency (as occurs with trauma and
capillary oozing is potentially life-threatening (e.g., craniotomy) other critical illnesses) is the most common reason for LMWH to
should be maintained at a higher platelet count (i.e., > have an inadequate effect. The anti-Xa laboratory assay does not
20,000/mm3). Patients without ongoing bleeding who are not account for in vivo antithrombin levels, because it involves the
specifically at increased risk for major complications from low-vol- addition of antithrombin itself to the plasma sample as a reagent.
ume bleeding may be safely watched with platelet counts lower Consequently, the results of this assay cannot be taken as a reli-
than 20,000/mm3. able guide to the patient’s coagulation status. In effect, all the assay
Oozing in a patient who has an adequate platelet count and actually does is give the physician some idea of the concentration
normal coagulation parameters may be a signal of platelet dys- of circulating LMWH, which is dependent on the dosing, renal
function.The now-routine administration of aspirin to reduce the clearance, and the time since LMWH was last administered.
risk of myocardial infarction and stroke has led to a rise in the inci- An additional crucial point is that the administration of fresh
dence of aspirin-induced platelet dysfunction. Aspirin causes irre- frozen plasma (FFP) will not correct the anticoagulant effect of
versible platelet dysfunction through the cyclooxygenase pathway; either unfractionated heparin or LMWHs. In fact, given that plas-
the effect of aspirin can thus be expected to last for approximate- ma contains antithrombin and that both unfractionated heparin
ly 10 days. The platelet dysfunction caused by other nonsteroidal and LMWHs act by potentiating antithrombin, administration of
anti-inflammatory drugs (e.g., ibuprofen) is reversible and conse- FFP could actually enhance the heparins’ anticoagulant effect.
quently does not last as long as that caused by aspirin. Newer A variety of direct thrombin inhibitors (e.g., bivalirudin
platelet-blocking agents have been found to be effective in improv- [Hirulog], lepirudin, argatroban, and ximelagatran) are currently
ing outcome after coronary angioplasty.8 These drugs function available in Europe, Asia, and North America.12 Many of them
predominantly by blocking the platelet surface receptor glycopro- cause prolongation of the aPTT. One disadvantage shared by most
tein (GP) IIb-IIIa, which binds platelets to fibrinogen. of the direct thrombin inhibitors is that the effects are not reversible;
In patients with platelet dysfunction caused by an inhibitor of if thrombin inhibition is no longer desired, FFP must be given to
platelet function, such as an elevated blood urea nitrogen (BUN) correct the aPTT. Because the inhibitor that is circulating but not
level or aspirin, 1-desamino-8-D-arginine vasopressin (DDAVP) bound at the time of FFP administration will bind the prothrombin
is capable of significantly reversing the platelet dysfunction.9 in the FFP, the amount of FFP required to correct the aPTT may
Less common causes of bleeding in patients with a normal INR be greater than would be needed with a simple factor deficiency.
and a normal aPTT include factor XIII deficiency, hypofibrino- Von Willebrand disease is frequently, though not always, associ-
genemia or dysfibrinogenemia, and derangements in the fibri- ated with a slight prolongation of the aPTT. Its clinical expression
nolytic pathway [see Discussion, Mechanics of Hemostasis, below]. is variable. Confirmation of the diagnosis can be obtained by test-
ing for circulating factor levels. Platelet function analysis will also
NORMAL INR, PRO- show abnormal function. Correction is accomplished by adminis-
LONGED aPTT tering directed therapy (von Willebrand factor [vWF]) [see Dis-
Patients with a normal cussion, Bleeding Disorders, below], DDAVP, or cryoprecipitate.
INR and an abnormal Hemophilia may either cause spontaneous bleeding or lead to
aPTT are likely to have a prolonged bleeding after a surgical or traumatic insult. As noted,
drug-induced coagulation hemophilia is rare in the absence of a personal or family history of
defect. The agent most the disorder.The most common forms of hemophilia involve defi-
commonly responsible is ciencies of factors VIII, IX, and XI (hemophilia A, hemophilia B,
unfractionated heparin. and hemophilia C, respectively). In contrast to depletion of natur-
Reversal of the heparin effect, if desired, can be accomplished by al anticoagulants such as antithrombin and protein C [see 6:6
administering protamine sulfate. Protamine should be given with Venous Thromboembolism], depletion of procoagulant factors rarely
caution, however, because it has been reported to induce a hyper- gives rise to significant manifestations until it is relatively severe.
coagulable state10 (though many of the thrombotic complications Typically, no laboratory abnormalities result from depletion of
Table 1 Preparations Used in Directed Therapy for Hemophilia

Used to Compensate for Depletion of Factors
Product (Manufacturer) Origin
Factor VIII Factor IX vWF
Alphanate (Alpha Therapeutic) Plasma Yes — Yes
Monarc-M (American Red Cross) Plasma Yes — Yes
Hemofil M (Baxter Healthcare) Plasma Yes — Yes
Humate-P (Centeon) Plasma Yes — Yes

– te-HP (Bayer)
Koa Plasma Yes — Yes
Monoclate-P (Centeon) Plasma Yes — Yes
Recombinate (Baxter Healthcare) Recombinant Yes — —
Kogenate (Bayer) Recombinant Yes — —
Bioclate (Baxter Healthcare), Helixate (Centeon) Recombinant Yes — —
Hyate:C (Speywood) Porcine plasma Yes — —
Autoplex T (prothrombin complex concentrate) Plasma — Yes —

(NABI)
Feiba VH Immuno (prothrombin complex

concentrate) (Immuno-US) Plasma — Yes —
Mononine (Centeon) Plasma — Yes —
AlphaNine-SD (Alpha Therapeutic) Plasma — Yes —
Bebulin VH Immuno (Immuno-US) Plasma — Yes —
Proplex T (Baxter Healthcare) Plasma — Yes —

–ne 80 (Bayer)
Kony Plasma — Yes —
Profilnine SD (Alpha Therapeutic) Plasma — Yes —
BeneFix (Genetics Institute) Recombinant — Yes —
Novo Seven (Novo Nordisk) Recombinant Yes Yes —
procoagulant factors until factor activity levels fall below 40% of Cirrhosis is arguably the most serious of the causes of an elevat-
normal, and clinical abnormalities are frequently absent even ed INR. It is a major problem not so much because of the coagu-
when factor activity levels fall to only 10% of normal. This toler- lopathy itself but because of the associated deficits in wound heal-
ance for subcritical degrees of depletion is a reflection of the built- ing and immune function that result from the synthetic dysfunc-
in redundancies in the procoagulant pathways. tion and the loss of reticuloendothelial function. In all cases,
If hemophilia is suspected, specific factor analysis is indicated. factor replacement should be instituted with FFP. If the bleeding
Appropriate therapy involves administering the deficient factor or is a manifestation of the cirrhosis (as in variceal bleeding), emer-
factors [see Table 1]. Hemophiliac patients who have undergone gency portal decompression should be accomplished before the
extensive transfusion therapy may pose a particular challenge: coagulopathy worsens. Management of cirrhotic patients who
massive transfusions frequently lead to the development of anti- have sustained injuries is particularly troublesome because such
bodies that make subsequent transfusion or even directed therapy patients are at disproportionately high risk for subdural
impossible. Accordingly, several alternatives to transfusion or hematoma. The reason this risk is so high is that in addition to
directed factor therapy (e.g., recombinant activated factor VII their pathologic autoanticoagulation, these patients often have
[rVIIa]) have been developed for use in this population. some degree of cerebral atrophy as a result of one of the more fre-
quent causes of cirrhosis—namely, alcoholism. As a result, the
INCREASED INR, NORMAL
bridging intracranial veins are more vulnerable to tears and more
aPTT likely to bleed. For patients with life-threatening intracranial
An increased INR in bleeding and an elevated INR, off-label use of activated factor VII
association with a normal has become widespread. Although to date, no prospective ran-
aPTT is a more ominous domized studies have demonstrated that this practice confers a
finding in a patient with a survival advantage, the administration of activated factor VII, 20 to
coagulopathy. Any of a num- 40 μg/kg, does appear promising.13 Modest elevations of the INR
ber of causes, all centering in patients who are not actively bleeding, have not recently under-
on factor deficiency, may be gone operation, and are not specifically at increased risk for life-
responsible. threatening hemorrhage may be observed without correction.
An elevated INR with a normal aPTT may also be a conse- Table 2 Management of the Patient
quence of warfarin administration. Such a coagulopathy is the with an Increased INR14
result of a pure factor deficiency, and its degree is proportional to
the prolongation of the INR. Because warfarin acts by disrupting
Indication Recommended Treatment
vitamin K metabolism, the coagulopathy may be corrected by giv-
ing vitamin K [see Table 2].14 If the patient is actively bleeding, vi- INR above therapeutic range If no bleeding is present or surgery is
tamin K should still be given, but the primary corrective measure but < 5.0 indicated, lower or hold next dose
should be to administer FFP in an amount proportional to the INR > 5.0 but < 9.0
patient’s size and the relative increase in the INR.The INR should Patient has no significant In the absence of additional risk factors
subsequently be rechecked to ensure that replacement therapy is bleeding for bleeding, withhold next 1–2 doses;
adequate. Vitamin K replacement therapy has two main potential alternatively, withhold next dose and
give vitamin K, 1.0–2.5 mg (oral route
drawbacks: (1) if the patient is to be reanticoagulated with war- is acceptable)
farin in the near future, dosing will be difficult because the patient Rapid reduction of INR Give vitamin K, 2.0–4.0 mg p.o.; expected re-
will exhibit resistance to warfarin for a variable period; and (2) ana- is required duction of INR should occur within 24 hr
phylactic reactions have been reported when vitamin K is given I.V.
INR > 9.0
INCREASED INR, PRO- Patient has no significant Give vitamin K, 3.0–5.0 mg p.o.; expected re-
LONGED aPTT bleeding duction of INR should occur within 24 hr
Patient has serious bleeding Give vitamin K, 10 mg I.V., and FFP; further vi-
Increases in both the INR or is overly anticoagulated tamin K supplementation may be
and the aPTT may be the (INR > 20.0) required every 12 hr
most problematic finding of Patient has life-threatening Prothrombin complexes may be indicated,
bleeding or is seriously along with vitamin K, 10 mg I.V.
all. When both assays show overanticoagulated
increases, the patient is like-
ly to have multiple factor
deficiencies; possible causes and microthrombi are formed in the vascular space but are cleared
include DIC, severe hemodilution, and renal failure with severe effectively.Thus, mild DIC may be little more than an acceleration
nephrotic syndrome. However, when dramatic elevations of the of the clotting cascade that escapes recognition. In the moderate
aPTT and the INR are observed in a seemingly asymptomatic form of DIC, the microthrombi are ineffectively lysed and cause
patient, the problem may lie not in the patient’s condition but in occlusion of the microcirculation.This process is clinically manifes-
the laboratory analysis. If the tube in which the blood sample was ted in the lungs as the acute respiratory distress syndrome (ARDS),
drawn for these tests was not adequately filled, the results of the in the kidneys as renal failure, and in the liver as hepatic failure.
coagulation assays may be inaccurate. In such cases, the blood Neither mild DIC nor moderate DIC is what surgeons tradi-
sample should be redrawn and the tests repeated. tionally think of as DIC. Severe DIC arises when congestion of the
Hemodilution and nephrotic syndrome result in a coagulopathy microvasculature with thrombi occurs, resulting in large-scale acti-
that is attributable to decreased concentration of coagulation pro- vation of the fibrinolytic system to restore circulation. This fibri-
teins. Dilutional coagulopathy may occur when a patient who is nolytic activity results in breakdown of clot at previously hemostat-
given a large volume of packed red blood cell (RBC) units is not ic sites of microscopic injury (e.g., endothelial damage) and macro-
also given coagulation factors.15 Because of the tremendous scopic injury (e.g., I.V. catheter sites, fractures, or surgical wounds).
redundancy of the hemostatic process, pure dilutional coagulopa- Bleeding and reexposure to tissue factor stimulate activation of
thy is rare. It is considered an unlikely diagnosis until after one full factor VII with increased coagulation activity; thus, microthrombi
blood volume has been replaced (as when a patient requires 10
are formed, and the vicious circle continues. The ultimate mani-
units of packed RBCs to maintain a stable hematocrit). Nephrotic
festation of severe DIC is bleeding from (1) fibrinolysis and (2)
syndrome is associated with loss of protein (coagulation proteins
depletion (consumption) of coagulation factors.
as well as other body proteins) from the kidneys.
Several scoring systems have been devised to assess the severity
Both hemodilution and nephrotic syndrome should be distin-
of DIC. In the absence of any specific treatment for this condition,
guished from DIC (which is a consumptive rather than a dilution-
al process16), though on occasion this distinction is a difficult one these scoring systems are currently most useful for distinguishing
to make. A blood sample should be sent for D-dimer assay. If the DIC from other causes of coagulopathy (e.g., hypothermia, dilu-
D-dimer level is low (< 1,000 ng/ml), DIC is unlikely; if it is very tion, and drug effects) [see Table 3].17
high (> 2,000 ng/ml) and there is no other clear explanation (e.g., DIC is a diagnosis of exclusion, largely because none of the var-
a complex unstable pelvic fracture), the diagnosis of DIC rather ious treatment strategies tried to date have been particularly suc-
than dilution should be made.Treatment of dilutional coagulopa-
thy should be directed at replacement of lost factors. FFP should Table 3 Coagulopathy (DIC) Score
be given first, followed by cryoprecipitate, calcium, and platelets.
Transfusion should be continued until the coagulation parameters INR aPTT Platelets Fibrinogen D-dimer
are corrected and the bleeding stops. Score (sec) (sec) (1,000/mm3) (mg/dl) (ng/ml)
DIC is a diffuse, disorganized activation of the clotting cascade
within the vascular space. It may result either from intravascular 0 < 1.2 < 34 > 150 > 200 < 1,000
presentation of an overwhelming clotting stimulus (e.g., massive 1 > 1.2 > 34 < 150 < 200 < 2,000
crush injury, overwhelming infection, or transfusion reaction) or 2 > 1.4 > 39 < 100 < 150 < 4,000
from presentation of a moderate clotting stimulus in the context of 3 > 1.6 > 54 < 60 < 100 > 4,000
shock. Different degrees of severity have been described. In the aPTT—activated partial thromboplastin time DIC—disseminated intravascular
mildest form of DIC, acceleration of the clotting cascade is seen, coagulopathy INR—international normalized ratio
cessful. Heparin has been given in large doses in an attempt to

Patient is anemic
break the cycle by stopping the clotting, thus allowing clotting fac-
tor levels to return to normal. Antifibrinolytic agents (e.g., Transfuse only if specific indicator besides Hb
ε-aminocaproic acid) have also been tried in an attempt to reduce is present.
fibrinolytic activity and thus slow the bleeding that stimulates sub- Base decision to transfuse on patient's need for
sequent clot formation. Antithrombotics (e.g., antithrombin and additional O2-carrying capacity.
protein C) have been used as well; improvements have been noted
in laboratory measures of DIC but not in survival. At present,
interest is focused on activated factor VII, though as yet, the avail-
able data are insufficient to validate its use. Patient is actively Patient is not actively
Currently, the most appropriate way of treating a patient with bleeding bleeding
severe DIC is to follow a multifaceted approach. First, the clotting
Transfuse to an Hct of 30%. Look for significant coronary
stimulus, if still present, should be removed: dead or devitalized artery disease (CAD).
tissue should be debrided, abscesses drained, and suspect transfu-
sions discontinued. Second, hypothermia, of any degree of severi-
ty, should be corrected.Third, both blood loss (as measured by the
hematocrit) and clotting factor deficits (as measured by the INR)
Patient has significant Patient does not have
should be aggressively corrected (with blood and plasma, respec- CAD significant CAD
tively). This supportive approach is only modestly successful. For
certain groups of patients in whom DIC develops (e.g., those who Transfuse to an Hct of 30%. Look for symptoms of anemia.
have sustained head injuries), mortality approaches 100%. This
alarmingly high death rate is probably related more to the under-
lying pathology than to the hematologic derangement.
An increased INR with a prolonged aPTT may also be caused Patient is symptomatic Patient is asymptomatic
by various isolated factor deficiencies of the common pathway. with poor mobilization and can be mobilized
Congenital deficiencies of factors X, V, and prothrombin are very
rare. Acquired factor V deficiencies have been observed in patients Transfuse until clinical Observe patient.
improvement is achieved.
with autoimmune disorders. Acquired hypoprothrombinemia has
been documented in a small percentage of patients with lupus
Figure 1 Algorithm depicts decision-making process for transfu-
anticoagulants who exhibit abnormal bleeding. Factor X deficien-
sion in anemic patients.
cies have been noted in patients with amyloidosis.
Stabilized warfarin therapy will increase both the INR and the
aPTT. Several current rodenticides (e.g., brodifacoum) exert the
same effect on these parameters that warfarin does; however, transfusion protocol (aimed at maintaining a hemoglobin concen-
because they have a considerably longer half-life than warfarin, the tration of 7.0 to 9.0 g/dl) in place of a more traditional protocol
reversal of the anticoagulation effect with vitamin K or FFP may (aimed at maintaining a hemoglobin concentration of 10.0 to 12.0
be correspondingly longer.18 Animal venoms may also increase the g/dl) did not harm critically ill patients and even appeared to
INR and the aPTT. improve survival for younger or less severely ill patients.22 These
findings have encouraged a paradigm shift with respect to RBC
transfusion: whereas the traditional view was that anemia by itself
Management of Anemia and Indications for Transfusion was a sufficient indication for transfusion, the current consensus is
Anemia is common among hospitalized surgical patients. In that the threshold for transfusion should be determined by taking
two large prospective cohort studies, the average hemoglobin level into account additional clinical factors besides the hemoglobin
in surgical ICU patients was 11.0 g/dl,19 and 55% of surgical ICU concentration.23
patients received transfusions.20 Anemia results from at least three The decision whether to transfuse should be based on the
factors: (1) blood loss related to the primary condition or to the patient’s current and predicted need for additional oxygen-carry-
operation, (2) serial blood draws (totaling, on average, approxi- ing capacity [see Figure 1]. A major component of this decision is
mately 40 ml/day in the ICU),19 and (3) diminished erythropoiesis to determine as promptly as possible whether significant hypo-
related to the primary illness. volemia or active bleeding is present. In a hypovolemic or actively
Treatment of anemia has changed substantially since the early bleeding patient, liberal transfusion is indicated as a means of
1990s. Blood cell transfusions have been shown to have significant increasing intravascular volume and preventing the development
immunosuppressive potential, and transmission of fatal diseases of profound deficits in oxygen-carrying capacity. Coagulation fac-
through the blood supply has been extensively documented. tors must also be replaced as necessary [see Measurement of
Although the blood-banking community has systematically Coagulation Parameters, Increased INR, Prolonged aPTT, above].
reduced the risk of transmission of infection by restricting the eli- In a hemodynamically stable patient without evidence of active
gible donor pool and routinely testing blood products for serolog- hemorrhage, it is appropriate to take a more restrictive approach
ic and nucleic acid evidence of pathogens,21 comparatively little to transfusion, one that is tailored to the symptoms observed and
progress has been made in defining and controlling the immuno- to the specific anticipated risks.Thus, there is no specific hemoglo-
modulatory effects of transfusion [see Discussion, Mechanism and bin concentration or hematocrit (i.e., transfusion trigger) at which
Significance of Transfusion-Related Immunomodulation, below]. all patients should receive transfusions.
Moreover, at least one large trial, the Transfusion Requirements in There are two groups of patients for whom a more aggressive
Critical Care (TRICC) study, found that using a restrictive RBC RBC transfusion policy should be considered. Patients who are at
high risk for active bleeding and patients who have acute coronary eral transfusion approach does not seem to lead to earlier liber-
artery ischemic syndromes may benefit from a more liberal trans- ation from mechanical ventilation.27 Moreover, although some
fusion protocol than that applied to the general patient population. studies support the notion that transfusion speeds wound heal-
ing,28 others suggest that transfusion may also increase the inci-
HIGH RISK FOR ACTIVE BLEEDING
dence of infection and impaired wound healing.29 A major ran-
Patients who are at high risk for active bleeding (e.g., those with domized trial, the Functional Outcomes in Cardiovascular
a massive liver injury or recurrent GI hemorrhage) should receive Patients Undergoing Surgical hip fracture repair (FOCUS)
transfusions up to a level at which, should bleeding occur or recur, study, is currently being conducted to address the issue of func-
enough reserve oxygen-carrying capacity would be available to tional recovery. Its primary aim is to determine whether liberal
allow diagnosis and correction of the hemorrhage without signifi- transfusion improves walking ability among anemic patients with
cant compromise of oxygen delivery. In acute cases of major a history of cardiovascular disease who undergo operative repair
injury, we advocate an initial target hematocrit of 30%; however, of a hip fracture.30
this is not a fixed value but a rule-of-thumb figure that may be
OBSERVATION OF ANEMIA
increased or decreased as appropriate, depending on the individ-
ual patient’s reserves and the individual surgical team’s ability to It is now standard practice to observe patients with low hemo-
diagnose and correct the underlying problem. globin concentrations that in the past would have triggered trans-
fusion. For most acutely anemic patients, the data currently avail-
ACUTE CORONARY ARTERY ISCHEMIC SYNDROMES
able support this approach down to a hemoglobin concentration
Currently, there is no consensus on what the most appropriate of 6 to 7 g/dl; however, below 6 g/dl, the data suggest that the ben-
transfusion strategy is for patients with acute coronary artery efits of transfusion outweigh the risks.
ischemic syndromes, such as active myocardial infarction and For all patients, if the hemoglobin level drops low enough, cel-
unstable angina. The results of observational studies have been lular metabolism cannot be sustained and death becomes a cer-
mixed,24,25 and no clinical trial has yet addressed this specific sub- tainty. Followers of certain religious faiths have frequently
group of patients. Some distinction should be drawn between declined blood transfusion even when death is the probable or cer-
patients who have acute coronary artery ischemic syndromes and tain consequence. Such situations have challenged the medical
those who merely have a history of coronary artery or other ather- community to find techniques for supporting life at extremely low
osclerotic disease. Although the TRICC trial apparently did not hemoglobin concentrations, and they have helped to define the
enroll many patients with severe cardiovascular morbidity,22 it limits beyond which a restrictive transfusion protocol may be fatal.
included enough patients with cardiovascular disease to allow a Reviews of patients who have refused transfusion suggest that a
sizable subgroup analysis.26 This post hoc analysis suggested that hemoglobin below 5 g/dl results in substantial increases in mortal-
in patients with cardiovascular disease as a primary diagnosis or an ity, especially in elderly persons and patients with cardiovascular
important comorbid condition, survival was essentially the same disease.31
regardless of whether a liberal transfusion protocol or a restrictive When RBC transfusion is not possible (whether because the
one was followed. In patients with confirmed ischemic heart dis- patient declines transfusion or because compatible blood is
ease, however, a nonsignificant decrease in survival was noted, unavailable), there are a number of temporizing measures that can
generating some concern that adverse cardiovascular events (e.g., be used to support life. First, steps should be taken to minimize
myocardial infarction and stroke) might increase in frequency at additional iatrogenic blood loss. Laboratory tests should be re-
lower hematocrits. Consequently, a target hematocrit of 30% is stricted to those that are most likely to benefit the patient, and they
generally considered acceptable for patients with acute coronary should be conducted with the smallest amount of blood possible
artery ischemic syndromes or significant coronary artery disease. (e.g., the volume contained in pediatric specimen tubes). Non-
emergency operations that are likely to involve appreciable blood
NEUROLOGIC CONDITIONS
loss should be postponed if possible. Second, any impediments to
Some have argued that just as the heart may be sensitive to native erythropoiesis should be removed: iron should be supple-
decreases in oxygen-carrying capacity, the injured central nervous
system may be vulnerable to further damage from anemia because
anemia may limit the delivery of oxygen to damaged tissue.
According to this view, patients with traumatic brain injury, stroke, Table 4 Blood Substitutes 99
or spinal cord injury may be vulnerable to anemia-related damage;
however, as yet, the clinical evidence is insufficient either to sup- Product (Manufacturer) Source
port or to refute this notion. Pyridoxylated human hemoglobin conjugated to
PHP (Apex Bioscience)
polyoxyethylene
SYMPTOMATIC ANEMIA
PEG-hemoglobin (Enzon) Bovine hemoglobin conjugated to
An additional consideration in the decision to transfuse blood polyethylene glycol
is the oxygen-carrying capacity that is necessary to prevent
patient fatigue or discomfort. Typical symptoms of anemia PolyHeme (Northfield Glutaraldehyde-polymerized pyridoxylated
Laboratories) human hemoglobin
include light-headedness, tachycardia, and tachypnea either dur-
ing activity or at rest. Clearly, some degree of tachycardia is to be Glutaraldehyde-polymerized bovine
Hemopure (Biopure) hemoglobin
expected in any patient who has undergone a major operation or
sustained a serious injury. The key judgment to make in decid- Oxidized raffinose–cross-linked human
ing whether to treat symptomatic anemia with transfusion is Hemolink (Hemosol) hemoglobin from expired stored blood
whether the anemia is truly compromising the patient’s health or
Oxygent (Alliance
recovery. It is not always easy, however, to determine whether the Pharmaceutical)
Emulsified perflubron
patient will actually benefit from transfusion. For example, a lib-
mented orally if possible, and the administration of recombinant ferent substitutes are currently under investigation [see Table 4].32
erythropoietin should be considered.Third, in extreme cases, con- None have been approved for routine use by the United States
sideration should be given to decreasing oxygen demand. Oxygen Food and Drug Administration, but several have demonstrated
demand is directly proportional to metabolic activity; that is, as promise in clinical trials. Without modification, the hemoglobin
metabolic rate increases, so too does oxygen demand. Once the molecule is nephrotoxic. Accordingly, virtually all of the products
patient is immobile, respiration becomes a significant contributor now being studied depend on techniques for making an acellular
to metabolic requirements. Mechanical ventilation reduces the hemoglobin molecule nontoxic for I.V. administration.
work of breathing and with it the oxygen requirements of the res- Acellular blood substitutes clearly possess a number of advan-
piratory muscles. Respiratory efforts can be fully eliminated with tages, including greatly increased shelf life, reduced risk of viral
neuromuscular blocking agents, which will reduce oxygen transmission, availability that is not limited by donor supply,
demand in essentially all skeletal muscle, and the metabolic rate reduced or eliminated risk of incompatibility reactions, and poten-
can be further reduced by inducing hypothermia. tially greater acceptance among patients who decline blood trans-
A completely different approach to the issue of the unaccept- fusions.33 To what extent this approach is suited to the treatment
ability or unavailability of RBC transfusion involves the use of of anemia in surgical patients should be clarified when the results
RBC substitutes to augment oxygen-carrying capacity.Various dif- of the trials now under way are published.
Discussion
Mechanics of Hemostasis
down-regulators of thrombin formation. In the presence of throm-
Hemostasis is the term for the process by which cellular and bin, the endothelium responds by (1) releasing thrombomodulin,
plasma components interact in response to vessel injury in order to which forms a complex with thrombin to activate protein C; (2)
maintain vascular integrity and promote wound healing.The initial producing endothelium-derived relaxing factor (i.e., nitric oxide37)
response to vascular injury (primary hemostasis) involves the and prostacyclin, which have vasodilating and platelet aggrega-
recruitment and activation of platelets, which then adhere to the tion-inhibiting effects, respectively; and (3) releasing tissue plas-
site of injury. Subsequently, plasma proteins, in concert with cellu- minogen activator (t-PA) or urokinase-type plasminogen activator
lar components, begin to generate thrombin, which causes further (u-PA), either of which converts the zymogen plasminogen to an
activation of platelets and converts fibrinogen to fibrin monomers active form (i.e., plasmin) that degrades fibrin and fibrinogen.34,38
that polymerize into a fibrin clot. The final step is the release of Heparan sulfate, on the endothelium wall, forms a complex with
plasminogen activators that induce clot lysis and tissue repair. plasma antithrombin to neutralize thrombin. The endothelium is
The cellular components of hemostasis include endothelium, also the source of tissue factor pathway inhibitor (TFPI), which
white blood cells (WBCs), RBCs, and platelets.The plasma com- downregulates TF-VIIa-Xa complexes.
ponents include a number of procoagulant and regulatory proteins
Erythrocytes and Leukocytes
that, once activated, can accelerate or downregulate thrombin for-
mation or clot lysis to facilitate wound healing. In normal individ- The nonplatelet cellular components of blood play indirect
uals, these hemostatic components are in a regulatory balance; roles in hemostasis. RBCs contain thromboplastins that are potent
thus, any abnormality involving one or more of these components stimulators of various procoagulant proteins. In addition, the con-
can result in a pathologic state, whether of uncontrolled clot for- centration of RBCs within the bloodstream (expressed as the
mation (thrombosis) or of excessive bleeding (hemorrhage).These hematocrit) assists in primary hemostasis by physically forcing the
pathologies can result from either hereditary defects of protein platelets toward the endothelial surfaces. When the RBC count is
synthesis or acquired deficiencies attributable to metabolic causes. low enough, the absence of this force results in inadequate
endothelium-platelet interaction and a bleeding diathesis.
CELLULAR COMPONENTS Leukocytes have several functions in the hemostatic process.The
interaction between the adhesion molecules expressed on both
Endothelium
leukocytes and endothelium results in cytokine production, initia-
The endothelium has both procoagulant and anticoagulant prop- tion of inflammatory responses, and degradation of extracellular
erties. When vascular injury occurs, the endothelium serves as a matrix to facilitate tissue healing. In the presence of thrombin, mono-
nidus for recruitment of platelets, adhesion of platelets to the endo- cytes express TF, which is an integral procoagulant for thrombin
thelial surface, platelet aggregation, migration of platelets across the generation. Neutrophils and activated monocytes bind to stimulat-
endothelial surface, generation of fibrin, and expression of adhesion ed platelets and endothelial cells that express P-selectin. Adhesion
molecule receptors (E-selectin and P-selectin). Exposure of collagen and rolling of neutrophils, mediated by fibrinogen and selectins on
fibrils and release of vWF from the Weibel-Palade bodies cause the endothelium, appear to help restore vessel integrity but may
platelets to adhere to the cellular surface of the endothelium. The also lead to inflammatory responses.39,40 Lymphocytes also adhere
presence of interleukin-1β (IL-1β), tissue necrosis factor (TNF), to endothelium via adhesion molecule receptors and appear to be
interferon gamma (IFN-γ), and thrombin promotes expression of responsible for cytokine production and inflammatory responses.
tissue factor (TF) on the endothelium.34,35 TF activates factors X
Platelets
and VII, and these activated factors generate additional thrombin,
which increases both fibrin formation and platelet aggregation. The roles platelets play in hemostasis and subsequent fibrin for-
The endothelium also acts in numerous ways to downregulate mation rest on providing a phospholipid surface for localizing pro-
coagulation.36 Heparan sulfate and thrombomodulin are both coagulant activation. Activation of platelets by agonists such as
adenosine triphosphate (ATP), adenosine diphosphate (ADP), VIII, inducing platelet aggregation, inducing expression of TF on
epinephrine, thromboxane A2, collagen, and thrombin causes cell surfaces, and activating factor XIII. In cleaving fibrinogen,
platelets to undergo morphologic changes and degranulation. thrombin causes the release of fibrinopeptides A and B (fibrin
Degranulation of platelets results in the release of procoagulants monomer). The fibrin monomer undergoes conformational
that promote further platelet adhesion and aggregation (e.g., changes that expose the α and β chains of the molecule, which
thrombospondin, vWF, fibrinogen, ADP, ATP, and serotonin), then polymerize with other fibrin monomers to form a fibrin
and surface expression of P-selectin, which induces cellular adhe- mesh. Activated factor XIII cross-links the polymerized fibrin
sion. Platelet degranulation also results in the release of β-throm- (between the α chains and the γ chains) to stabilize the fibrin clot
boglobulin, platelet factor 4 (which has antiheparin properties), and delay fibrinolysis.
various growth factors, coagulation procoagulants, and calcium as
Fibrin(ogen)olysis
well as the formation of platelet microparticles. Plasminogen acti-
vator inhibitor-1 (PAI-1) released from degranulated platelets neu- Plasminogen is the primary fibrinolytic zymogen that circulates
tralizes the fibrinolytic pathway by forming a complex with t-PA. in plasma. In the presence of t-PA or u-PA (released from the
Upon exposure to vascular injury, platelets adhere to the endothelium), plasminogen is converted to the active form, plas-
exposed endothelium via binding of vWF to the GPIb-IX-V commin. Plasmin cleaves fibrin (or fibrinogen) between the molecule’s
plex.41 Conformational changes in the GPIIb-IIIa complex on the D and E domains, causing the formation of X,Y, D, and E frag-
activated platelet surface enhance fibrinogen binding, which ments. The secondary function of the fibrinolytic pathway is the
results in platelet-to-platelet interaction (i.e., complex morpholog- activation by u-PA of matrix metalloproteinases that degrade the
ic changes and aggregation). The phospholipid surface of the extracellular matrix.46
platelet membranes anchors activated IXa-VIIIa and Xa-Va com-
Regulatory Factors
plexes, thereby localizing thrombin generation.42
In persons with normal coagulation status, downregulation of
PLASMA COMPONENTS
hemostasis occurs simultaneously with the production of procoag-
ulants (e.g., activated plasma factors, stimulated endothelium, and
Procoagulants
stimulated platelets). In addition to their procoagulant activity,
Traditional diagrams of the coagulation cascade depict two dis- both thrombin and contact factors stimulate downregulation of
tinct pathways for thrombin generation: the intrinsic pathway and the the coagulation process. Thrombin forms a complex with
extrinsic pathway.The premise for the distinction between the two endothelium-bound thrombomodulin to activate protein C, which
is that the intrinsic pathway requires no extravascular source for initi- inhibits factors Va and VIIIa. The thrombin-thrombomodulin
ation, whereas the extrinsic pathway requires an extravascular com- complex also regulates the fibrinolytic pathway by activating a cir-
ponent (i.e.,TF).This traditional depiction is useful in interpreting culating plasma protein known as thrombin-activatable fibrinoly-
coagulation tests, but it is not an accurate reflection of the hemo- sis inhibitor (TAFI), which appears to suppress conversion of plas-
static process in vivo. Accordingly, our focus is not on this standard minogen to plasmin.47 Contact factors are known to be required
view but rather on the roles contact factors (within the intrinsic cas- for normal surface-dependent fibrinolysis, and there is some evi-
cade) and TF play in coagulation. As noted, circulating plasma dence that contact factor deficiencies can lead to thromboem-
vWF is necessary for normal adhesion of platelets to the endothe- bolism. Another plasma protein responsible for regulation of fibri-
lium. Plasma vWF also serves as the carrier protein for factor VIII, nolysis is α2-antiplasmin, which binds to circulating and bound
preventing its neutralization by the protein C regulatory pathway. plasmin to limit breakdown of fibrin.
Even in patients in whom laboratory tests strongly suggest a se- Circulating downregulating proteins include antithrombin (a
vere clotting abnormality (i.e., the aPTT is markedly prolonged), con- serine protease inhibitor of activated factors—especially factors
tact factors do not play a significant role in the generation of throm- IXa, Xa, and XIa—and thrombin45), proteins C and S (regulators
bin. However, contact factor activation does appear to play secon- of factors VIIIa and Va48), C1 inhibitor (a regulator of factor XIa),
dary roles that are essential to normal hemostasis and tissue repair. TFPI (a regulator of the TF-VIIa-Xa complex49), and α2-
Factor XII, prekallikrein, and high-molecular-weight kininogen are macroglobulin (a thrombin inhibitor—the primary thrombin
bound to the endothelium to activate the bradykinin (BK) path- inhibitor in neonates50). Limitation of platelet activation occurs
way. The BK pathway exerts profibrinolytic effects by stimulating secondarily as a result of decreased levels of circulating agonists
endothelial release of plasminogen activators. It also stimulates endo- and endothelial release of prostacyclin [see Figure 2].
thelial production of nitric oxide and prostacyclin, which play vital re-
gulatory roles in vasodilation and regulation of platelet activation.43
The key initiator of plasma procoagulant formation is the Bleeding Disorders
expression of TF on cell surfaces.35,44 TF activates factor VII and
INHERITED COAGULOPATHIES
binds with it to form the TF-VIIa complex, which activates factors
X and IX. Factor Xa also enhances its own production by activat- Numerous congenital abnormalities of the coagulation system
ing factor IX, which in turn activates factor X to form factor Xa. have been identified. In particular, various abnormalities involving
Factor Xa also produces minimal amounts of thrombin by cleav- plasma proteins (e.g., hemophilia and vWD), platelet receptors (e.g.,
ing the prothrombin molecule.The thrombin generated from this Glanzmann thrombasthenia and Bernard-Soulier syndrome), and
process cleaves the coagulation cofactors V and VIII to enhance endothelium (e.g., telangiectasia) have been described in detail.
production of the factor complexes IX-VIIIa (intrinsic tenase) and For the sake of brevity, we will refer to abnormal protein synthesis
Xa-Va (prothrombinase), which catalyze conversion of prothrom- resulting in a dysfunctional coagulation protein as a defect and to
bin to thrombin [see Figure 2].45 abnormal protein synthesis resulting in decreased protein produc-
Thrombin has numerous functions, including prothrombotic tion as a deficiency.
and regulatory functions. Its procoagulant properties include Most of the coagulation defects associated with endothelium
cleaving fibrinogen, activating the coagulation cofactors V and are closely related to thrombosis or atherosclerosis. Defects or
VII VIII
Platelet TF
Aggregation VIIIa
IXa
XIIIa V
VIII IXa AT
AT
TF-VIIa Va aPC
AT Xa
V
XIII TFPI Thrombomodulin
VIIIa PS
IX X
PC
Thrombin Thrombin
IXa Xa
Xa
Va Va
Fibrinogen II AT
II
Platelet
Fibrin Fibrin TAT

Polymer Monomer
Figure 2 Shown is a schematic representation of the procoagulant pathways.
deficiencies of thrombomodulin, TFPI, and t-PA, albeit rare, are Spontaneous bleeding may also occur, resulting in intracranial
associated with thrombosis.51,52 Vascular defects (e.g., hemorrhag- hemorrhage, large hematomas in the muscles of extremities,
ic telangiectasias) may carry an increased risk of bleeding as a con- hematuria, and GI bleeding. Factor XI deficiency is relatively
sequence of dysfunctional fibrinolysis, concomitant platelet dys- common in Jewish persons but rarely results in spontaneous
function, or coagulation factor deficiencies.53 bleeding.61,62 Such deficiency may result in bleeding after oral
Defects or deficiencies of RBCs and WBCs have other primary operations and trauma; however, there are a number of major pro-
clinical manifestations that are not related to hemostasis. cedures (e.g., cardiac bypass surgery) that do not result in postop-
Alterations in the physical properties of blood (e.g., decreased erative bleeding in this population.63
blood flow from increased viscosity, polycythemia vera, leukocyto- Inherited deficiencies of the other coagulation factors are very
sis, and sickle-cell anemia) have been reported to lead to throm- rare. Factor XIII deficiencies result in delayed postoperative or
bosis but usually not to major bleeding. posttraumatic bleeding. Congenital deficiencies of factor V, factor
Inherited platelet membrane receptor defects are relatively VII, factor X, prothrombin, and fibrinogen may become apparent
common. Of these, vWD is the one that most frequently causes in the neonatal period (presenting, for example, as umbilical
bleeding.54 The condition is characterized by vWF abnormalities, stump bleeding); later in life, they result in clinical presentations
which may take three forms: vWF may be present in a reduced such as epistaxis, intracranial bleeding, GI bleeding, deep and
concentration (type I vWD), dysfunctional (type II vWD), or superficial bruising, and menorrhagia.
absent altogether (type III). Diagnosis of vWD is based on a com- Defects or deficiencies in the fibrinolytic pathway are also rare
bination of the patient history (e.g., previous mucosal bleeding) and are most commonly associated with thromboembolic events.
and laboratory parameters [see Laboratory Assessment of α2-Antiplasmin deficiencies and primary fibrin(ogen)olysis are rare
Bleeding, below]. It is necessary to identify the correct type or sub- congenital coagulopathies with clinical presentations similar to
type of vWD: some treatments (e.g., DDAVP) are contraindicat- those of factor deficiencies. In primary fibrin(ogen)olysis, failure of
ed in patients with type IIb vWD.55 regulation of t-PA and u-PA leads to increases in circulating plasmin
Less common receptor defects include Glanzmann thrombas- levels, which result in rapid degradation of clot and fibrinogen.64,65
thenia (a defect in the GPIIb-IIIa complex), Bernard-Soulier
ACQUIRED COAGULOPATHIES
syndrome (a defect in the GPIb-IX complex), and Scott syn-
drome (a defect in the platelet’s activated surface that promotes A wide range of clinical conditions may cause deficiencies of the
thrombin formation); other agonist receptors on the platelet primary, secondary, or fibrinolytic pathways. Acquired coagu-
membrane may be affected as well.56,57 Intracellular platelet lopathies are very common, and most do not result in spontaneous
defects are relatively rare but do occur; examples are gray platelet bleeding. (DIC is an exception [see Disseminated Intravascular
syndromes (e.g., alpha granule defects), Hermansky-Pudlak syn- Coagulation, below].)
drome, dense granule defects, Wiskott-Aldrich syndrome, and As noted, coagulopathies related to the endothelium are pri-
various defects in intracellular production and signaling (involv- marily associated with thrombosis rather than bleeding.There are
ing defects of cyclooxygenase synthase and phospholipase C, a number of disorders that may cause vascular injury, including
respectively).57 sickle-cell anemia, hemolytic-uremic syndrome, and thrombotic
Numerous pathologic states are also associated with deficien- thrombocytopenic purpura.
cies or defects of plasma procoagulants. Inherited sex-linked defi- Acquired platelet abnormalities, both qualitative (i.e., dysfunc-
ciencies of factor VIII (i.e., hemophilia A) and factor IX (i.e., tion) and quantitative (i.e., decreases in absolute numbers), are
hemophilia B and Christmas disease) are relatively common.58-60 common occurrences. Many acquired thrombocytopathies are
The clinical presentations of hemophilia A and hemophilia B are attributable to either foods (e.g., fish oils, chocolate, red wine, gar-
similar: hemarthroses are the most common clinical manifesta- lic, and herbs) or drugs (e.g., aspirin, ibuprofen, other nonsteroidal
tions, ultimately leading to degenerative joint deformities. anti-inflammatory drugs, ticlopidine, various antibiotics, certain
antihistamines, and phenytoin).66-70 Direct anti–platelet receptor pathway and deposition of fibrin; the eventual consequence is the
drugs (e.g., abciximab and eptifibatide) block the GPIIb-IIIa com- multiple organ dysfunction syndrome (MODS).83 The activation
plex, thereby preventing platelet aggregation.71 Thrombocytopenia occurs at all levels (platelets, endothelium, and procoagulants),
can be primary or secondary to a number of clinical conditions. but it is not known whether this process is initiated by a local stim-
Primary bone disorders (e.g., myelodysplastic or myelophthisic ulus or a systemic one. It is crucial to emphasize that DIC is an
syndromes) and spontaneous bleeding may arise when platelet acquired disorder that occurs secondary to an underlying clinical
counts fall below 10,000/mm3. event (e.g., a complicated birth, severe gram-negative infection,
Thrombocytopenia can be associated with immune causes shock, major head injury, polytrauma, severe burns, or cancer). As
(e.g., immune thrombocytopenic purpura or thrombotic throm- noted [see Measurement of Coagulation Parameters, Increased
bocytopenic purpura) or can occur secondary to administration of INR, Prolonged aPTT, above], there is some controversy regard-
drugs (e.g., heparin). Acquired platelet dysfunction (e.g., acquired ing the best approach to therapy, but there is no doubt that treat-
vWD) that is not related to dietary or pharmacologic causes has ing the underlying cause of DIC is paramount to patient recovery.
been observed in patients with immune disorders or cancer. DIC is not always clinically evident: low-grade DIC may lack
Acquired plasma factor deficiencies are common as well. clinical symptoms altogether and manifest itself only through lab-
Patients with severe renal disease typically exhibit platelet dysfunc- oratory abnormalities, even when thrombin generation and fibrin
tion (from excessive amounts of uremic metabolites), factor defi- deposition are occurring. In an attempt to facilitate recognition of
ciencies associated with impaired synthesis or protein loss (as with DIC, the disorder has been divided into three phases, distin-
increased urinary excretion), or thrombocytopenia (from dimin- guished on the basis of clinical and laboratory evidence. In phase
ished thrombopoietin production).72,73 Patients with severe hepat- I DIC, there are no clinical symptoms, and the routine screening
ic disease commonly have impairment of coagulation factor syn- tests (i.e., INR, aPTT, fibrinogen level, and platelet count) are
thesis, increases in circulating levels of paraproteins, and splenic within normal limits.84 Secondary testing (i.e., measurement of
sequestration of platelets. antithrombin, prothrombin fragment, thrombin-antithrombin
Hemodilution from massive RBC transfusions can occur if more complex, and soluble fibrin levels) may reveal subtle changes
than 10 packed RBC units are given within a short period without indicative of thrombin generation. In phase II DIC, there are usu-
plasma supplementation. Immunologic reactions to ABO/Rh mis- ally clinical signs of bleeding around wounds, suture sites, I.V.
matches can induce immune-mediated hypercoagulation. Acquired sites, or venous puncture sites, and decreased function is noted in
multifactorial deficiencies associated with extracorporeal circuits specific organs (e.g., lung, liver, and kidneys). The INR is in-
(e.g., cardiopulmonary bypass, hemodialysis, and continuous ven- creased, the aPTT is prolonged, and the fibrinogen level and plate-
ovenous dialysis) can arise as a consequence of hemodilution from let count are decreased or decreasing. Other markers of thrombin
circuit priming fluid or activation of procoagulants after exposure generation and fibrinolysis (e.g., D-dimer level) show sizable ele-
to thrombogenic surfaces.74-76 Thrombocytopenia can result from vations. In phase III DIC, MODS is observed, the INR and the
platelet destruction and activation caused by circuit membrane ex- aPTT are markedly increased, the fibrinogen level is markedly
posure, or it can be secondary to the presence of heparin antibody. depressed, and the D-dimer level is dramatically increased. A
Animal venoms can be either procoagulant or prothrombotic. peripheral blood smear would show large numbers of schistocytes,
The majority of the poisonous snakes in the United States (rattle- indicating RBC shearing resulting from fibrin deposition.
snakes in particular) have venom that works by activating prothrom- The activation of the coagulation system seen in DIC appears
bin, but cross-breeding has produced a number of new venoms to be primarily caused by TF. The brain, the placenta, and solid
with different hemostatic consequences. The clinical presentation tumors are all rich sources of TF. Gram-negative endotoxins also
of coagulopathies associated with snakebites generally mimics that induce TF expression. The exposure of TF on cellular surfaces
of consumptive coagulopathies.77 causes activation of factors VII and IX, which ultimately leads to
Drug-induced factor deficiencies are common, particularly as thrombin generation. Circulating thrombin is rapidly cleared by
a result of anticoagulant therapy. The most commonly used antithrombin. Moreover, the coagulation pathway is downregulat-
anticoagulants are heparin and warfarin. Heparin does not ed by activated protein C and protein S. However, constant expo-
cause a factor deficiency; rather, it accelerates production of sure of TF (as a result of underlying disorders) results in constant
antithrombin, which inhibits factor IXa, factor Xa, and throm- generation of thrombin, and these regulator proteins are rapidly
bin, thereby prolonging clot formation.Warfarin reduces proco- consumed. TAFI and PAI also contribute to fibrin deposition by
agulant potential by inhibiting vitamin K synthesis, thereby re- restricting fibrinolysis and subsequent fibrin degradation and
ducing carboxylation of factor VII, factor IX, factor X, pro- clearance. Finally, it is likely that release of cytokines (e.g., IL-6,
thrombin, and proteins C and S. Newer drugs that may also IL-10, and TNF) may play some role in causing the sequelae of
cause factor deficiencies include direct thrombin inhibitors (e.g., DIC by modulating or activating the coagulation pathway.
lepirudin and bivalirudin78) and fibrinogen-degrading drugs
(e.g., ancrod79).
Isolated acquired factor deficiencies are relatively rare. Laboratory Assessment of Bleeding
Clinically, they present in exactly the same way as inherited factor Laboratory testing is an integral part of the diagnostic algorithm
deficiencies, except that there is no history of earlier bleeding. In used in assessing the bleeding patient. It may not be prudent to wait
most cases, there is a secondary disease (e.g., lymphoma or an for laboratory values before beginning treatment of acute bleeding,
autoimmune disorder) that results in the development of antibody but it is imperative that blood samples for coagulation testing be
to a procoagulant (e.g., factor V, factor VIII, factor IX, vWF, pro- drawn before therapy.The development of microprocessor technol-
thrombin, or fibrinogen).80-82 ogy has made it possible to perform diagnostic laboratory testing
outside the confines of the clinical laboratory (so-called near-care
Disseminated Intravascular Coagulation
testing). Whether near-care testing or clinical laboratory testing is
DIC is a complex coagulation process that involves activation of employed, it is important to recognize that valuable as such testing
the coagulation system with resultant activation of the fibrinolytic is, it does not provide all of the needed diagnostic information.
In particular, the value of a careful patient history must not be

Measurement of coagulation parameters
underestimated. Previous bleeding events and a familial history of
bleeding are both suggestive of a congenital coagulopathy. A thor- Determine INR and aPTT.
ough medication inventory is necessary to assess the possible
impact of drugs on laboratory and clinical presentations. In the
patient history query, it is advisable to ask explicitly about nonpre-
scription drugs—using expressions such as “over-the-counter
INR is normal INR is increased
drugs,” “cold medicines,” and “Pepto-Bismol”—because unless
specifically reminded, patients tend to equate the term medica-
tions with prescription drugs. If this is not done, many drugs that
are capable of influencing hemostasis in vivo and in vitro (e.g., sa-
aPTT is aPTT is aPTT is aPTT is
licylates, cold and allergy medicines, and herbal supplements) may normal prolonged normal prolonged
be missed. Mucosal and superficial bleeding is suggestive of
platelet abnormalities, and deep bleeding is suggestive of factor Determine Consider vWD, Consider Consider
deficiency. fibrinogen hemophilia, liver disease, multiple factor
It is important to be clear on the limitations of coagulation test- level. factor deficiency effects of deficiencies,
ing. At present, there are no laboratory or ex vivo methods capa- with or without drugs, and DIC, and
inhibitor, and factor VII effects of
ble of directly measuring the physiologic properties of the effects of drugs. deficiency. drugs.
endothelium. Indirect assessments of endothelial damage can be
obtained by measuring levels of several laboratory parameters
(e.g., vWF, the soluble cytokines endothelin-1 and E-selectin, and
thrombomodulin), but such measurements have no clinical utility Fibrinogen level Fibrinogen level is abnormal
in the assessment of a bleeding patient. is normal
Another issue is that of bias resulting from technical factors. PT Measure levels of fibrin
Determine factor degradation products (FDPs).
(i.e., INR) and aPTT testing involves adding activators, phospho- XIII level.
lipids, and calcium to plasma in a test tube (or the equivalent) and
determining the time to clot formation. Time to clot formation is
a relative value, in that it is compared with the time in a normal
FDP level is normal FDP level is
population. A perturbation within the coagulation cascade, an abnormal
excess of calcium, or poor sampling techniques (e.g., inadequate- Consider hypofibrinogenemia
ly filled coagulation tubes, excessive tourniquet time, and clotted and dysfibrinogenemia. Consider state
or activated samples) can bias the results. Hemolysis from the of abnormal
drawing of blood can also bias results via the effects of thrombo- fibrin(ogen)olysis.
plastins released from RBC membranes to initiate the coagulation
process. In addition, many coagulation factors are highly labile,
and failure to process and run coagulation samples immediately Factor XIII level is normal Factor XIII level is
abnormal
can bias test results.
Coagulation factor deficiency
Finally, not all coagulation tests are functionally equivalent: dif- is unlikely. Patient has factor
ferent laboratory methods may yield differing results.85 Consider causes associated XIII deficiency.
Coagulation reagents have been manufactured in such a way as to with platelets or vasculature.
ensure that the coagulation screening tests are sensitive to factor
VIII and IX deficiencies and the effects of anticoagulation with Figure 3 Algorithm depicts use of coagulation parameters in
warfarin or heparin. Thus, a normal aPTT in a patient with an assessment of coagulopathies.
abnormal INR may not exclude the possibility of common path-
way deficiencies (e.g., deficiencies of factors X, V, and II), and
Novel and Experimental Therapies for Bleeding
most current methods of determining the INR and the aPTT do
not detect low fibrinogen levels. The approach we use assumes Novel approaches to controlling bleeding have been developed
that the methods used to assess INR and aPTT can discriminate for use in two specific patient groups: (1) patients with uncon-
normal factor activity levels from abnormal levels (< 0.4 IU/ml). trolled exsanguinating hemorrhage and (2) elderly patients on
The CBC (including platelet count and differential count), the warfarin therapy who have a therapeutic INR and who present
INR, and the aPTT tests should be the primary laboratory tests with intracranial bleeding.
for differentiating coagulopathies [see Figure 3]. As noted [see Measurement of Coagulation Parameters,
Platelet count and platelet function should be considered as Normal INR, Prolonged aPTT, above], recombinant factor VIIa
independent values [see Figure 4]. Patients with congenital throm- is currently used for control of bleeding in hemophilia A patients
bocytopathies often have normal platelet counts; therefore, assess- with antibodies to factors VIII as well as in hemophilia B patients
ment of platelet function is required as well. Historically, the with antibodies to factor IX, and it has received FDA approval
bleeding time has been used to assess platelet function.This test is for this indication. The remarkable success of rVIIa in this set-
grossly inadequate, in that it may yield normal results in as many ting led many investigators to consider the possibility that giving
as 50% of patients with congenital thrombocytopathies.86,87 this agent to actively bleeding patients would enhance the
Numerous rapid tests of platelet function are currently available normal clotting mechanism and provide nonsurgical control or
that can be used to screen for platelet defects; these tests should be reduction of traumatic bleeding. Accordingly, rVIIa has been
considered in the diagnostic approach to the bleeding patient [see advocated for early use in injured patients with uncontrolled
Table 5].87-89 hemorrhage.90
One international randomized trial of rVIIa in severely injured Table 5 Tests of Platelet Function
trauma patients has been performed.91 The results of this trial sug-
gested that there was a decreased requirement for blood transfu- Product (Manufacturer) Method
sions and a trend toward decreased organ failure among blunt trau-
ma patients who received rVIIa, but no reduction in mortality was Measures time required to occlude
demonstrated. It is to be hoped that the trauma surgery communi- PFA-100 (Dade Behring) aperture after exposure to platelet
agonists at shear rates
ty will be able to organize a more robust trial that will be capable of
formally determining whether the putative benefits of rVIIa are out- hemoSTATUS (Medtronic) Measures activated clotting time; platelet-
weighed by the potential risks.92 In the absence of such a formal activating factor is the platelet agonist
determination, surgeons will continue to encounter situations in Measures changes in voltage (impedance)
AggreStat (Centocor)
which they must decide whether to use rVIIa despite its incomplete- after addition of platelet agonist
ly understood efficacy and safety profile in this setting. Accordingly,
Thromboelastograph Measures changes in the viscoelastic prop-
consensus recommendations have attempted to define appropriate erties of clotting blood induced by
(Haemascope)
usage in the light of insufficient evidence.93 a rotating piston
In elderly patients receiving therapeutic warfarin therapy, head Measures changes in the viscoelastic prop-
injuries that would normally be inconsequential can result in life- Sonoclot Analyzer (Sienco) erties of clotting blood induced by
threatening intracranial bleeding. Correction of the INR with a vibrating probe
either FFP or vitamin K may take so long that the patient becomes Clot Signature Analyzer Measures changes in platelet function at
vegetative before the hemorrhage is controlled. Prothrombin com- (Xylum) shear rates
plex concentrate appears to correct the INR more rapidly and
Used primarily for measuring the effect
effectively than FFP or vitamin K.94 One randomized trial that of platelet glycoprotein blockers (e.g., ab-
included nonanticoagulated patients who had sustained a hemor- Ultegra Analyzer (Accumetrics)
ciximab and eptifibatide); thrombin recep-
rhagic stroke suggested that administration of rVIIa reduces hem- tor activator peptide is the agonist
orrhage volume and may improve survival as well.95 With both
prothrombin complex and rVIIa, additional trials will have to be
done before routine use of these agents to correct elevated INRs Another novel agent that has been assessed as a means of
in this patient population can be recommended. achieving hemostasis in military settings is QuikClot (Z-Medica,
Wallingford, Connecticut), a granular substance containing the
mineral zeolite.To date, however, the use of this contact agent has
generally been restricted to the extremities, and the available data
Assessment of platelet status are not sufficient to determine its efficacy.
Platelet count and platelet function should
be considered as independent variables.
Mechanism and Significance of Transfusion-Related
Immunomodulation
Although a unit of packed RBCs is an exceedingly complex bio-
Platelet count is normal Platelet count is abnormal logic substance, blood is used frequently and somewhat casually,
compared with many pharmaceutical agents that have undergone
Assess platelet function. Assess platelet function. extensive regulatory review. A unit of allogeneic transfused blood
contains antigenic RBCs, WBCs, and platelets; an array of anti-
genic or immunologically active substances in plasma (including
both substances from donor plasma and substances that accumu-
Platelet Platelet Platelet Platelet
function is function function is function late during storage); and, potentially, viral, bacterial, and parasitic
normal is abnormal normal is abnormal pathogens. However, the specific transfusion-related factors that
result in dysregulation of the innate or adaptive immune respons-
Platelet-related Determine Consider Consider es, as well as the clinical consequences of this immunomodulation,
cause is whether hemodilution Bernard-
unlikely. patient has and immune Soulier remain inadequately defined.
Consider a history causes. syndrome. Interest in the immunosuppressive effect of blood transfusion
vascular of bleeding. stems from the observation by Opelz and associates in 1973 that
causes and recipients of cadaveric renal transplants experienced longer graft
plasma
factor deficits.
survival if they had undergone allogeneic blood transfusion before
transplantation.96 A subsequent randomized trial showed that even
with concomitant use of cyclosporine-based immunosuppressive
regimens, pretransplantation transfusion resulted in improved
Patient has a Patient has no renal allograft survival at 5 years after operation.97
history of bleeding history of bleeding A number of different strategies for mitigating this immunosup-
pressive effect have been considered, including the use of more
Consider vWD Consider liver disease, restrictive criteria for transfusion and the administration of autolo-
and Glanzmann uremia, MDS, and
thrombasthenia. effects of drugs.
gous blood products. Besides these two strategies, the approach
that has attracted the most interest is to decrease the number of
Figure 4 Algorithm depicts use of platelet count and platelet donor leukocytes in units of blood. In Europe, before the adoption
functional status in assessment of coagulopathies. of leukoreduction, buffy-coat reduction was employed to remove
(MDS—myelody splastic syndrome) 70% to 80% of donor leukocytes.The concept was taken one step
further by the development of leukoreduction, which typically in- randomized trials have attempted to evaluate the role of blood
volves the use of prestorage filtration techniques to remove more than transfusion in the recurrence of resected malignancies and postop-
99.9% of donor leukocytes.Although leukoreduction has been adopt- erative infection. Most of the observational studies have compared
ed by Canada and several European countries, the FDA has stopped the outcomes of transfused cohorts with those of nontransfused
short of mandating universal leukoreduction in the United States. cohorts. The randomized trials, however, have mostly evaluated
As an alternative to reducing the number of donor leukocytes, different kinds of blood transfusions against one another (e.g.
some have advocated controlling the storage time of blood prod- autologous versus allogeneic and leukoreduced versus nonleuko-
ucts so that either fresher or older blood can be provided if reduced). The literature is extensive, but many methodologic
desired. Fresh units of blood may contain fewer deformed eryth- issues have been identified that limit the validity of the studies.98
rocytes that could impair the capillary microcirculation; older units Accordingly, the evidence appears to be insufficient to establish a
of blood may contain fewer viable donor leukocytes, which may be causal connection between allogeneic blood transfusion and either
the most harmful agents immunologically. Others have advocated increased cancer recurrence or postoperative infection. Nonethe-
restricting blood donations from previously pregnant women, who, less, the heterogeneity of the study results and the finding of the
by virtue of greater alloimmunization, may have more immuno- TRICC trial that a restrictive transfusion policy may improve sur-
logically active leukocytes. vival in some patients continue to fuel debate over whether the
Since the initial report on the immunosuppressive effect of avoidance or modification of allogeneic blood transfusion may
blood transfusion,96 a plethora of observational studies and some improve patient outcomes.
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1]:53, 1999 82. Amirkhosravi M, Francis JL: Coagulation activa- Figures 1, 3, and 4 Marcia Kammerer.
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE PAIN — 1
5 POSTOPERATIVE PAIN
Henrik Kehlet, M.D., Ph.D., F.A.C.S. (Hon.)
Approach to the Patient with Postoperative Pain

Pain may usefully be classified into two varieties: acute and chron- attributed to a variety of causes [see Table 1], which to some extent
ic. As a rule, postoperative pain is considered a form of acute pain, can be ameliorated by increased teaching efforts. In general, how-
though it may become chronic if it is not effectively treated. ever, the scientific approach to postoperative pain relief has not
Postoperative pain consists of a constellation of unpleasant sen- been a great help to surgical patients in the general ward, where
sory, emotional, and mental experiences associated with auto- intensive surveillance facilities may not be available.
nomic, psychological, and behavioral responses precipitated by the
surgical injury. Despite the considerable progress that has been
made in medicine during the past few decades, the apparently Guidelines for
simple problem of how to provide total or near total relief of post- Postoperative Pain
operative pain remains largely unsolved. Pain management does Treatment
not occupy an important place in academic surgery. However, The recommendations
government agencies have attempted to foster improved postoper- provided below are aimed at
ative pain relief, and guidelines have been published.1-3 In 2001, surgeons working on the gen-
the Joint Commission on Accreditation of Healthcare Organiza- eral surgical ward; superior
tions (JCAHO) introduced standards for pain management,4 stat- regimens have been constructed by specialized groups interested
ing that patients have the right to appropriate evaluation and man- in postoperative pain research, but these regimens are not cur-
agement and that pain must be assessed. rently applicable to the general surgical population, unless an
Postoperative pain relief has two practical aims.The first is pro- acute pain service is available. Consideration is given to the effi-
vision of subjective comfort, which is desirable for humanitarian ciency of each analgesic technique, its safety versus its side effects,
reasons. The second is inhibition of trauma-induced nociceptive and the cost-efficiency problems arising from the need for inten-
impulses to blunt autonomic and somatic reflex responses to pain sive surveillance. For several analgesic techniques, evidence-based
and to enhance subsequent restoration of function by allowing the recommendations are now available.7 For many others, however,
patient to breathe, cough, and move more easily. Because these there are not sufficient data in the literature to form a valid scien-
effects reduce pulmonary, cardiovascular, thromboembolic, and tific database; accordingly, recommendations regarding their use
other complications, they may lead secondarily to improved post- are made on empirical grounds only.
operative outcome. In the past few years, efforts have been made to develop proce-
dure-specific perioperative pain management guidelines. The
impetus for these efforts has been the realization that the analgesic
Inadequate Treatment of Pain efficacy may be procedure dependent and that the choice of anal-
A common misconception is that pain, no matter how severe, gesia in a given case must also depend on the benefit-to-risk ratio,
can always be effectively relieved by opioid analgesics. It has which varies among procedures. In addition, it is clear that some
repeatedly been demonstrated, however, that in a high proportion analgesic techniques will only be considered for certain specific
of postoperative patients, pain is inadequately treated.5,6 This dis- operations (e.g., peripheral nerve blocks, cryoanalgesia, and
crepancy between what is possible and what is practiced can be intraperitoneal local anesthesia).8-10 At present, these procedure-
specific guidelines are still largely in a developmental state and are
available only for laparoscopic cholecystectomy, colon surgery,
hysterectomy, and hip replacement.10-12
Table 1—Contributing Causes of THORACIC PROCEDURES
Inadequate Pain Treatment Pain after thoracotomy is
severe, and pain therapy
Insufficient knowledge of drug pharmacology
among surgeons and nurses
should therefore include a
combination regimen, pre-
Uniform (p.r.n.) prescriptions
ferably comprising epidur-
Lack of concern for optimal pain relief
al local anesthetics and
Failure to give prescribed analgesics
opioids plus systemic non-
Fear of side effects steroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-
Fear of addiction 2 (COX-2) inhibitors (depending on risk factors). If the epidural
regimen is not available, NSAIDs and systemic opioids should be
Combine psychological preparation with

pharmacologic and other interventions to treat
postoperative pain
Consider recommended combination regimes.

Acetaminophen is recommended as a basic component
of multimodal analgesia in any of the settings below.
Thoracic Abdominal
Cardiac Noncardiac Major Minor (laparoscopic) Pelvic
Give systemic opioids with Give epidural local Give epidural local Give incisional/
NSAIDs. anesthetic–opioid combination anesthetic–opioid intraperitoneal local
with systemic NSAIDs or combination (add NSAIDs anesthetic with
Consider epidural or COX-2 inhibitors if
COX-2 inhibitors. systemic NSAIDs or
local anesthetic–opioid analgesia is insufficient).
If this combination is not COX-2 inhibitors.
combination If this combination is not
available, give systemic
opioids with NSAIDs or available, give systemic
COX-2 inhibitors. opioids with NSAIDs or
Consider cryoanalgesia. COX-2 inhibitors.
Gynecologic
Give systemic opioids with

NSAIDs or COX-2 inhibitors.
Consider epidural local
anesthetic–opioid
combination in high-risk
patients.
Approach to the Patient with Postoperative Pain
Peripheral
Vascular Superficial Major joint procedures
Give epidural local anesthetics Give incisional local anesthetic Give intrathecal local anesthetic
with systemic NSAIDs and systemic opioids with plus morphine and systemic
or NSAIDs or COX-2 inhibitors. NSAIDs or COX-2 inhibitors
Give systemic opioids with Consider peripheral nerve or
NSAIDs. blockade.
Give a peripheral nerve block
(single dose or continuous)
with systemic NSAIDs or
COX-2 inhibitors.
Consider continuous epidural
local anesthetic–opioid
combination in high-risk patients
Prostatectomy with systemic NSAIDs.
Open: Give epidural local

anesthetic–opioid
combination with systemic
Transurethral resection:
Give systemic opioids with
Final choice of treatment
Make final choice of treatment modality

on the basis of
• Efficiency of analgesic techniques
• Side effects and additive effects
• Availability of surveillance, if required
given to obtain the documented synergistic-additive effect. Cryo- morphine combination will provide effective analgesia for the
analgesia is useful because it is moderately effective, easy to per- first 8 to 16 hours, after which NSAIDs or COX-2 inhibitors may
form, free of significant side effects, and relatively inexpensive. be added. The use of peripheral nerve blocks is gaining more
Paravertebral blocks are also effective but necessitate continuous popularity and may be continued postoperatively.15,16 Acetamin-
infusion. Acetaminophen is recommended as a basic analgesic ophen is provided as a basic analgesic for multimodal analgesia.
for multimodal analgesia. After arthroscopic joint procedures, instillation of a local anes-
Pain after cardiac operation with sternotomy is less severe, and thetic and an opioid analgesic (e.g., morphine) provides effective
systemic opioids plus NSAIDs are recommended. The combined early postoperative pain relief.
regimen of epidural local anesthetics and opioids is recommended During superficial procedures, systemic opioids combined with
when more effective pain relief is necessary, and it may reduce car- NSAIDs or COX-2 inhibitors should suffice. Acetaminophen is
diopulmonary morbidity.13 provided as a basic analgesic for multimodal analgesia.
ABDOMINAL
PROCEDURES Treatment Modalities
Pain after major and up-
PSYCHOLOGICAL
per abdominal operations is
INTERVENTIONS
severe, and a combined reg-
imen of epidural local anes- Individuals differ consid-
thetics and opioids is rec- erably in how they respond
ommended because it has to noxious stimuli; much of
proved to be very effective and to have few and acceptable side ef- this variance is accounted
fects.11,12,14 Furthermore, the epidural regimen will reduce postop- for by psychological factors. Cognitive, behavioral, or social inter-
erative pulmonary complications and ileus, as compared with treat- ventions should be used in combination with pharmacologic ther-
ment with systemic opioids. Systemic NSAIDs or COX-2 inhibitors apies to prevent or control acute pain, with the goal of such inter-
are added when needed. Acetaminophen is recommended as a ventions being to guide the patient toward partial or complete self-
basic analgesic for multimodal analgesia. control of pain.17,18 Sophisticated psychological techniques, such
After gynecologic operations,12 systemic opioids plus NSAIDs or as biofeedback and hypnosis therapy, are not applicable to a busy
COX-2 inhibitors are recommended except in patients in whom surgical unit, but simple psychological techniques are a valuable
more effective pain relief is desirable. In such patients, the combined part of good medical practice.
regimen of epidural local anesthetics and opioids is preferable. Acet- Psychological preparation in patients with postoperative pain
aminophen is recommended as a basic analgesic for multimodal has been demonstrated to shorten hospital stay and reduce post-
analgesia. operative narcotic use [see Table 2].19 Psychological techniques
Pain following prostatectomy is usually not severe and may be should be combined with pharmacologic or other interventions,
treated with systemic opioids combined with NSAIDs or COX-2 but care must be taken to ensure that the pharmacologic treat-
inhibitors and acetaminophen. However, blood loss and throm- ment does not compromise the mental function necessary for the
boembolic complications are reduced when epidural local anesthet- success of the planned psychological intervention.
ics are administered.This method is therefore recommended intra-
SYSTEMIC OPIOIDS
operatively and continued in selected high-risk patients for pain
relief after open prostatectomy and transurethral resection. In low- The terminology associated with the pharmacology of the opi-
risk patients, systemic opioids with NSAIDs or COX-2 inhibitors oids is confusing, to say the least. Opiate is an appropriate term
and acetaminophen alleviate postoperative pain. for any alkaloid derived from the juice of the plant (i.e., from
opium). The proper term for the class of agents, whether exoge-
PERIPHERAL
nous, endogenous, natural, or synthetic, is opioid.
PROCEDURES
After vascular proce-
dures, postoperative pain
control is probably best
achieved with epidural Table 2—Psychological Preparation
local anesthetic–opioid mix- of Surgical Patients
tures, combined with sys-
temic NSAIDs or COX-2 inhibitors. Acetaminophen is recom- Procedural information—Give a careful and relevant description
mended as a basic analgesic for multimodal analgesia. This regi- of what will take place
men will be effective, and the increase in peripheral blood flow Sensory information—Describe the sensations that will be experienced
either during or after the operation
that is documented to occur with epidural local anesthetics may
lower the risk of graft thrombosis. Pain treatment information—Outline the plan for administering
sedative and analgesic medication, and encourage patients to
Pain relief after major joint procedures (e.g., hip and knee communicate concerns and discomforts
operations)12 may involve an epidural regimen in high-risk Instructional information—Teach patients postoperative exercises,
patients because such regimens have been shown to reduce such as leg exercises, and show them how to turn in bed or move so
thromboembolic complications and intraoperative blood loss and that pain is minimal
to facilitate rehabilitation. The severe pain noted after knee Reassurance—Reassure those who are mentally, emotionally, or
physically unable to cooperate that they are not expected to take an
replacement is probably best treated with epidural local anes- active role in coping with pain and will still receive sufficient analgesic
thetics combined with opioids. Otherwise, for routine manage- treatment
ment, a single intrathecal dose of a local anesthetic–low-dose
Table 3—Opioid Receptor Types and Physiologic Actions
Prototypical Ligand
Receptor Type Physiologic Actions
Endogenous Exogenous
Mu1 β-Endorphin Morphine Supraspinal analgesia
Mu2 β-Endorphin Morphine Respiratory depression
Delta Enkephalin — Spinal analgesia
Kappa Dynorphin Ketocyclazocine Spinal analgesia, sedation, ?visceral

analgesia
Epsilon β-Endorphin — ?Hormone
Sigma — N-Allylnormetazocine Psychotomimetic effect, dysphoria
Mechanisms of Action pharmacodynamic data are available. Use of this agent is recom-
mended; it may be given orally, intravenously, or intramuscularly
Opioids produce analgesia and other physiologic effects by
[see Table 5].
binding to specific receptors in the peripheral and central nervous
system [see Table 3]. These receptors normally bind a number of
Meperidine Detailed and sufficient pharmacokinetic and
endogenous substances called opioid peptides. These receptor-
pharmacodynamic data on meperidine are available. It is less suit-
binding interactions mediate a wide array of physiologic effects.20
able than morphine as an analgesic because its active metabolite,
Five types of opioid receptors and their subtypes have been dis-
covered: mu, delta, kappa, epsilon, and sigma receptors. Most normeperidine, can accumulate, even in patients with normal
commonly used opioids bind to mu receptors. The mu1 receptor renal clearance, and this accumulation can result in CNS excita-
is responsible for the production of opioid-induced analgesia, tion and seizures.20 Other agents should be used before meperi-
whereas the mu2 receptor appears to be related to the respiratory dine is considered. Like morphine, meperidine can be given oral-
depression, cardiovascular effects, and inhibition of GI motility ly, intravenously, or intramuscularly.
commonly seen with opioids. In studies from 2001 and 2004, Side Effects
investigators were able to obtain a reduction in the GI side effects
of morphine with a specific peripherally acting mu antagonist By depressing or stimulating the CNS, opioids cause a number
without interfering with analgesia.21,22 of physiologic effects in addition to analgesia.The depressant effects
The demonstration of the existence of peripheral opioid recep- of opioids include analgesia, sedation, and altered respiration and
tors has given rise to studies investigating the effect of administer- mood; the excitatory effects include nausea, vomiting, and miosis.
ing small opioid doses at the surgical site. Unfortunately, incision- All mu agonists produce a dose-dependent decrease in the
al opioid administration has no significant beneficial effect23; how- responsiveness of brain-stem respiratory centers to increased car-
ever, intra-articular administration does yield a modest benefit.24 bon dioxide tension (PCO2).This change is clinically manifested as
The relation between receptor binding and the intensity of the an increase in resting PCO2 and a shift in the CO2 response curve.
resultant physiologic effect is known as the intrinsic activity of an Agonist-antagonist opioids have a limited effect on the brain stem
opioid. Most of the commonly used opioid analgesics are agonists. and appear to elicit a ceiling effect on increases in PCO2.
An agonist produces a maximal biologic response by binding to its Opioids also have effects on the GI tract. Nausea and vomiting
receptor. Other opioids, such as naloxone, are termed antagonists are caused by stimulation of the chemoreceptor trigger zone of the
because they compete with agonists for opioid receptor binding medulla. Opioids enhance sphincteric tone and reduce peristaltic
sites. Still other opioids are partial agonists because they produce contraction. Delayed gastric emptying is caused by decreased
a submaximal response after binding to the receptor. (An excellent motility, increased antral tone, and increased tone in the first part
example of a submaximal response produced by partial agonists is of the duodenum. Delay in passage of intestinal contents because
buprenorphine’s action at the mu receptor.) of decreased peristalsis and increased sphincteric tone leads to
Drugs such as nalbuphine, butorphanol, and pentazocine are greater absorption of water, increased viscosity, and desiccation of
known as agonist-antagonists or mixed agonist-antagonists.20 bowel contents, which cause constipation and contribute to post-
These opioids simultaneously act at different receptor sites: their operative ileus. Opioids also increase biliary tract pressure. Finally,
action is agonistic at one receptor and antagonistic at another [see opioids may inhibit urinary bladder function, thereby increasing
Table 4]. The agonist-antagonists have certain pharmacologic the risk of urinary retention.
properties that are distinct from those of the more common mu Several long-acting, slow-release oral opioids are currently avail-
agonists: (1) they exhibit a ceiling effect and cause only submaxi- able, but their role (in particular, their safety) in the setting of
mal analgesia as compared with mu agonists, and (2) administra- moderate to severe postoperative pain remains to be established.
tion of an agonist-antagonist with a complete agonist may cause a In addition, modern principles of treatment increasingly empha-
reduction in the effect of the complete agonist.20 size the use of opioid-sparing analgesic approaches to enhance
recovery (see below).
Agents
EPIDURAL AND SUBARACHNOID OPIOIDS
Morphine Morphine is the opioid with which the most clin-
ical experience has been gained. Sufficient pharmacokinetic and Opioids were first used in the epidural and subarachnoid space
Table 4—Intrinsic Activity of Opioids
Receptor Type
Opioid
Mu Kappa Delta Sigma
Agonists
Morphine Agonist — — —
Meperidine (Demerol) Agonist — — —
Hydromorphone (Dilaudid) Agonist — — —
Oxymorphone (Numorphan) Agonist — — —
Levorphanol (Levo-Dromoran) Agonist — — —
Fentanyl (Duragesic) Agonist — — —
Sufentanil (Sufenta) Agonist — — —
Alfentanil (Alfenta) Agonist — — —
Methadone (Dolophine) Agonist — — —
Agonist-Antagonists
Buprenorphine (Buprenex) Partial agonist — — —
Butorphanol (Stadol) Antagonist Agonist Agonist —
Nalbuphine (Nubain) Antagonist Partial agonist Agonist —
Pentazocine (Talwin) Antagonist Agonist Agonist —
Dezocine (Dalgan) Partial agonist — — Agonist
Antagonists
Naloxone (Narcan) Antagonist Antagonist Antagonist Antagonist
in 1979. Since that time, they have become the mainstay of post- solubility of an opioid determines its access to the dorsal horn via
operative management for severe pain. Epidural opioids may be (1) diffusion through the arachnoid granulations and (2) diffusion
administered in a single bolus or via continuous infusions. They into spinal radicular artery blood flow.
are usually combined with local anesthetics in a continuous Subarachnoid opioids should be used when the required dura-
epidural infusion to enhance analgesia.14 tion of analgesia after surgery is relatively short. When protracted
analgesia is required, epidural administration is preferred; repeat-
Mechanisms of Action ed injections may be given through epidural catheters, or contin-
Opioids injected into the epidural or subarachnoid space cause uous infusions may be used. Smaller doses of subarachnoid opi-
segmental (i.e., selective, spinally mediated) analgesia by binding oids are generally required to produce analgesia. Ordinarily, no
to opioid receptors in the dorsal horn of the spinal cord.25 The more than 0.1 to 0.25 mg of morphine should be used. These
lipid solubility of an opioid, described by its partition coefficient, doses, which are about 10% to 20% of the size of comparably
predicts its behavior when introduced into the epidural or sub- effective epidural doses, provide reliable pain relief with few side
arachnoid space. Opioids with low lipid solubility (i.e., hydrophilic effects.26 Fentanyl has also been extensively used in the subarach-
opioids) have a slow onset of action and a long duration of action. noid space in a dose range of 6.25 to 50 µg. Pain relief after
Opioids with high lipid solubility (i.e., lipophilic opioids) have a administration of subarachnoid fentanyl is as potent but not as
quick onset of action but a short duration of action.Thus, the lipid prolonged as analgesia after administration of morphine.
Table 5—Suggested Regimens for

Systemic Morphine Administration
Intermittent Administration (Suggested Initial Dose)*
p.o. I.M. I.V. Duration (hr)
Morphine 30–50 mg 10 mg 5–10 mg 3–4
Continuous I.V. Infusion†
Morphine ≈ 3 mg/hr (loading dose: 5 –10 mg)

*Number of doses to be given is calculated with the following formula:
24 hr
actual duration of single effective dose (hr)
Single doses should be given at calculated fixed intervals approximately 30 min before expected
recurrence of pain. Single dose should be readjusted daily. Elderly patients may be more susceptible
to opioids.
†
Dose should be adjusted according to effect and side effects.
Regimens for Acute Pain Relief

regional nerve blockade. In addition, there is a great deal of exper-
It is generally agreed that at least 2 mg of epidural morphine is imental evidence that documents the benefits of blocking noxious
needed to achieve a significant analgesic response, but the criteria impulses.28 Local anesthetic neural blockade is unique among
used to assess this response have varied greatly in reported stud- available analgesic techniques in that it may offer sufficient affer-
ies, and no firm conclusion can be derived from them.25,27 ent neural blockade, resulting in relief of pain; avoidance of seda-
Epidural opioids are less efficient in the earliest stages of the acute tion, respiratory depression, and nausea; and, finally, efferent sym-
pain state than on subsequent days; moreover, they appear to be pathetic blockade, resulting in increased blood flow to the region
more successful at alleviating pain after procedures in the lower of neural blockade.28 Despite the considerable scientific data doc-
half of the body than at alleviating upper abdominal and thoracic umenting these beneficial effects, the place of epidural local anes-
pain. In general, 2 to 4 mg of morphine administered epidurally is thesia as a method of pain relief remains somewhat controversial
sufficient after minor procedures, whereas about 4 mg is needed in comparison with that of other analgesic techniques. Its side
after vascular and gynecologic procedures and after major upper effects (e.g., hypotension, urinary retention, and motor blockade)
abdominal and thoracic procedures.20,25,27 On postoperative day 1, and the need for trained staff for surveillance argue against its use;
however, such a regimen, even when repeated as many as three however, these side effects can be reduced by using combination
times, relieves pain completely in fewer than 50% of patients; on regimens (see below).27
subsequent days, the success rate is substantially higher. The effi-
ciency of this approach is lowest after major procedures. Mechanism of Action
There is evidence to suggest that continuous epidural adminis- Local anesthetic neural blockade is a nondepolarizing block
tration of low-dosage morphine (0.1 to 0.3 mg/hr) or fentanyl (10 that reduces the permeability of cell membranes to sodium ions.29
to 20 µg/hr) may lower the risk of late respiratory depression and Whether different local anesthetics have different effects on differ-
may be more efficient than intermittent administration of higher ent nerve fibers is debatable.
dosages of morphine.27 The continuous low-dosage approach is
therefore recommended. Choice of Drug
Side Effects For optimal management of postoperative pain, the anesthetic

agent should provide excellent analgesia of rapid onset and long
The chief side effects associated with epidural and subarach- duration without inducing motor blockade. The various local
noid opioids are respiratory depression, nausea and vomiting, pru- anesthetic agents all meet one or more of these criteria; however,
ritus, and urinary retention.25-27 The poor lipid solubility of mor- the ones that come closest to meeting all of the criteria are bupi-
phine is responsible for its protracted duration of action but also vacaine, ropivacaine, and levobupivacaine. This should not pre-
allows morphine to undergo cephalad migration in the cere- clude the use of other agents, because their efficacy has also been
brospinal fluid. This migration can cause delayed respiratory demonstrated. Ropivacaine and levobupivacaine may have a bet-
depression, with a peak incidence 3 to 10 hours after an injection. ter safety profile, but the improvement may be relevant only when
The high lipid solubility of lipophilic opioids such as fentanyl high intraoperative doses are given.29
allows them to be absorbed into lipids close to the site of admin-
istration. Consequently, the lipophilic opioids do not migrate ros- Continuous Epidural Analgesia
trally in the CSF and cannot cause delayed respiratory depression.
No regimen has been found that provides complete analgesia in
Of course, the high lipid solubility of lipophilic opioids allows
all patients all of the time, and it is unlikely that one ever will be
them to be absorbed into blood vessels, which may cause early res-
piratory depression, as is commonly seen with systemic adminis-
tration of opioids. Table 6—Regimen for Pain Relief
Naloxone reverses the depressive respiratory effects of spinal with Continuous Epidural Bupivacaine during
opioids. In an apneic patient, 0.4 mg I.V. will usually restore ven-
tilation. If a patient has a depressed respiratory rate but is still
Initial 24 Postoperative Hours
breathing, small aliquots of naloxone (0.2 to 0.4 mg) can be given
until the respiratory rate returns to normal. Interspace
Type of Concentration Volume
for Catheter
Nausea and vomiting are caused by transport of opioids to the Operation Insertion (%) (ml/hr)
vomiting center and the chemoreceptor trigger zone in the medul-
la via CSF flow or the systemic circulation. Nausea can usually be Thoracic
T4–6 0.250–0.125 5–10
treated with antiemetics or, if severe, with naloxone (in 0.2 mg procedures
increments, repeated if necessary).
Upper laparotomy T7–8 0.250–0.125 4–12
Pruritus is probably the most common side effect of the spinal
opioids. Histamine is released by certain opioids, but this mecha- Gynecologic
T10–12 0.250–0.125 4–10
nism probably plays a negligible role in the genesis of itching. laparotomy
Treatment of pruritus is similar to that of nausea.
Hip procedures L2 0.125–0.0625 4–8
The mechanism of spinal opioid–induced urinary retention in-
volves inhibition of volume-induced bladder contractions and block- Vascular T10–12 0.250–0.125 4–10
ade of the vesical reflex. Naloxone administration is the treatment of procedures
choice, though bladder catheterization is sometimes required.
Note: indications for postoperative epidural bupivacaine may be strengthened if this
method is also indicated for intraoperative analgesia. Dosage requirements may vary
EPIDURAL LOCAL ANESTHETICS AND OTHER REGIONAL and should be assessed 3 hr after the start of treatment, every 6 hr thereafter on the
BLOCKS first day, and then every 12 hr (more often if pain occurs). The duration of treatment
is 1–4 days, depending on the intensity of the pain. The concentration of bupiva-
Local anesthetics have become increasingly popular because of caine employed should be the lowest possible and should be decreased with time
postoperatively. Some patients, especially those who have undergone major upper
the growing familiarity with both epidural catheterization and abdominal operation, require 0.5% bupivacaine initially.
epidural local anesthetics are used in weak solutions.32 Motor

blockade may delay mobilization; however, its incidence can be
Table 7—Procedures for Maintenance of
reduced by using the weakest concentration of local anesthetic
Epidural Anesthesia for Longer Than 24 Hours that is compatible with adequate sensory blockade. Cerebral and
epidural analgesia should not be employed in patients already
1. Administer appropriate drug in appropriate dosage at selected
infusion rate as determined by physician. receiving anticoagulant therapy, but it may be started with cathe-
2. Nurse evaluates vital signs and intake and output as required for a ter insertion before vascular or other procedures in which con-
postoperative patient. trolled heparin therapy is used. Epidural analgesia has been used
3. Nurse checks infusion pump hourly to ensure that it is functioning in patients receiving thromboembolic prophylaxis with low-dose
properly, that infusion rate is proper, and that alarm is on. heparin and low-molecular-weight heparin without significant
4. Nurse also assesses risk,27 provided that current guidelines are followed.33,34 It should
• Bladder—for distention, if patient is not catheterized be emphasized that the heparin doses commonly employed in the
• Lower extremities—for status of motor function United States are higher than those recommended in Europe; the
• CNS—for signs of toxicity or respiratory depression higher doses may pose a risk when heparin prophylaxis is com-
• Relief of pain (drug dosage may require modification) bined with epidural analgesia.33,34 The complications associated
• Skin integrity on back (breakdown may occur if motor function with the epidural catheter are minimal when proper nursing pro-
is not present) tocols are followed [see Table 7].27 The decision to employ epidur-
• Tubing and dressing (disconnection of tubing or dislodgment al local anesthetics in such patients should be made only after the
of catheter may occur) risks33,34 are carefully compared with the documented advantages
5. Every 48 hr, the catheter dressing should be removed, the of such anesthetics.27,31 It is important that the level of insertion
catheter entrance site cleaned, and topical antibiotic applied
(much as in care of a central venous catheter). into the epidural space correspond with the level of incision.
Other Nerve Blocks
The popularity of single-dose intercostal block and intrapleural
found. As a rule, the block should be limited to the area in which regional analgesia has decreased in comparison with that of con-
pain is felt. Care should be taken to avoid motor blockade and to tinuous epidural treatment. Intermittent or continuous administra-
spare autonomic function to the urinary bladder, as well as to for- tion of local anesthetics through a catheter inserted into the paraver-
mulate a regimen that requires only minimal attention from staff tebral space seems to be a promising approach to providing anal-
members and carries no significant toxicity. Given these require- gesia after thoracic and abdominal procedures,35 but further data
ments, continuous infusion [see Table 6] is more effective and reli- are needed. Intravenous and intraperitoneal administration of local
able than intermittent injection.27 Whether low hourly volume and anesthetics cannot be recommended for postoperative analgesia,
high concentration approaches are preferable to high hourly vol- because they are not efficacious,36 except in laparoscopic cholecys-
ume and low concentration approaches remains to be deter-
tectomy.12,37 Intraincisional administration of bupivacaine, which has
mined.27 The weaker solutions may produce less motor blockade
negligible side effects and demands little or no surveillance, is rec-
while continuing to block smaller C and A-delta pain fibers and
ommended for patients undergoing relatively minor procedures.38
are recommended in lumbar epidural analgesia as a means of
Several studies have now reported that continuous administra-
reducing the risk of orthostatic hypotension and lower-extremity
tion of local anesthetics into the wound improves postoperative
motor blockade.27
analgesia in a variety of procedures38-44; however, there is still a
Specific indications for continuous epidural analgesia that are
need for more procedure-specific data before general recommen-
supported by data from controlled morbidity studies include (1) pain
dations can be made. Continuous peripheral nerve blocks are grow-
relief and reduction of deep vein thrombosis, pulmonary embolism,
ing in popularity, and the analgesic treatment may be continued
and hypoxemia after total hip replacement and prostatectomy; (2)
after discharge.15,16,45 Before general recommendations for contin-
pain relief, facilitation of coughing, and reduction of chest infec-
uous peripheral blockade can be formulated, however, further
tions after thoracic, abdominal, and orthopedic procedures; (3)
safety data are required.
pain relief, control of hypertension, and enhancement of graft flow
after major vascular operations; and (4) pain relief and reduction More detailed information on special blocks can be found in the
of paralytic ileus after abdominal procedures.30,31 anesthesiology literature. In general, despite its disadvantages,
neural blockade with local anesthetics is recommended for relief of
Side Effects
The main side effects of epidural local anesthesia are hypoten- Table 8—Recommended Dosages of
sion caused by sympathetic blockade, vagal overactivity, and NSAIDs or COX-2 Inhibitors for
decreased cardiac function (during a high thoracic block). Under
Relief of Postoperative Pain
no circumstances should epidural local anesthetics be used before
a preexisting hypovolemic condition is treated. Hypotension may
NSAID Dosage
be treated with ephedrine, 10 to 15 mg I.V., and fluids, with the
patient tilted in a head-down position. Atropine, 0.5 to 1.0 mg Acetylsalicylic acid 500–1,000 mg q. 4–6 hr
I.V., may be effective during vagal overactivity. Acetaminophen 500–1,000 mg q. 4–6 hr
Urinary retention occurs in 20% to 100% of patients. Indomethacin 50–100 mg q. 6–8 hr
Fortunately, urinary catheterization for only 24 to 48 hours in the Ibuprofen 200–400 mg q. 4–6 hr
course of a high-dose regimen probably has no important side Ketorolac 30 mg q. 4–6 hr
effects, and many patients for whom epidural analgesia is indicat- Celecoxib 200–400 mg q. 12 hr
ed need an indwelling catheter for other reasons in any case. The Rofecoxib 12–25 mg q. 12 hr
incidence of urinary retention is probably below 10% when
moderate to severe postoperative pain because of the advanta- this setting,58,59 and the investigators concluded that these drugs
geous physiologic effects it exerts and the reduction in postopera- were therefore contraindicated in CABG patients. The larger
tive morbidity it brings about. question is whether these drugs should also be contraindicated for
perioperative use, or at least used with caution, in high-risk car-
CONVENTIONAL NSAIDS AND COX-2 INHIBITORS
diovascular patients who are undergoing procedures other than
NSAIDs are minor analgesics that, because of their anti-inflam- CABG. At present, the data are insufficient to allow any conclu-
matory effect, may be suitable for management of postoperative sions, but in my view, until more information is available, it may
pain associated with a significant degree of inflammation (e.g., be prudent to avoid perioperative use of COX-2 inhibitors in all
bone or soft tissue damage).46 They may, however, have central high-risk cardiovascular patients (i.e., those with uncontrolled
analgesic effects as well and thus may have analgesic efficacy after hypertension, previous myocardial infarction, heart failure, or pre-
all kinds of operations. Conventional NSAIDs inhibit both COX- vious cerebral vascular disorders). In other patients, however, peri-
1 and COX-2. Selective COX-2 inhibitors, which do not inhibit operative administration of selective COX-2 inhibitors may be jus-
COX-1, have the potential to achieve analgesic efficacy compara- tified if the advantageous effects appear to outweigh the potential
ble to that of conventional NSAIDs but with fewer side effects [see (low) risk of complications.
Table 8].47-49 Finally, the already quite low risk of NSAID-induced asthma may
Only a few of the NSAIDs may be given parenterally.The data be further reduced by the use of selective COX-2 inhibitors.48,49
now available on the use of NSAIDs for postoperative pain are Peripheral (i.e., surgical site) administration of NSAIDs may
insufficient to allow definitive recommendation of any agent or have a slight additional analgesic effect in comparison with sys-
agents over the others, and selection therefore may depend on temic administration,60 but further data on safety are required.
convenience of delivery, duration, and cost.46 It is clear, however, Acetaminophen also possesses anti-inflammatory capability,
that these agents may play a valuable role as adjuvants to other both peripherally and centrally. Its analgesic effect is somewhat
analgesics; accordingly, they have been recommended as basic (about 20% to 30%) weaker than those of conventional NSAIDs
analgesics for all operations in low-risk patients. All of the NSAIDs and COX-2 inhibitors; however, it lacks the side effects typical of
have potentially serious side effects: GI and surgical site hemor- these agents.61-63 Combining acetaminophen with NSAIDs may
rhage, renal failure, impaired bone healing and asthma. The endo- improve analgesia, especially in smaller and moderate-sized oper-
scopically verified superficial ulcer formation seen within 7 to 10
days after the initiation of NSAID therapy is not seen with selec-
tive COX-2 inhibitor treatment in volunteers. The clinical rele-
vance of these findings for perioperative treatment remains to be
established, however, given that acute severe GI side effects
(bleeding, perforation) are extremely rare in elective cases.
Because prostaglandins are important for regulation of water
and mineral homeostasis by the kidneys in the dehydrated patient,
perioperative treatment with NSAIDs, which inhibit prostaglandin
synthesis, may lead to postoperative renal failure. So far, specific
COX-2 inhibitors have not been demonstrated to be less nephro-
toxic than conventional NSAIDs.48-51 Although little systematic
evaluation has been done, extensive clinical experience with NSAIDs
suggests that the renal risk is not substantial.51 Nonetheless, con-
ventional NSAIDs and COX-2 inhibitors should be used with
caution in patients who have preexisting renal dysfunction.
Although conventional NSAIDs prolong bleeding time and
inhibit platelet aggregation, there generally does not seem to be a
clinically significant risk of increased bleeding. However, in some
procedures for which strict hemostasis is critical (e.g., tonsillectomy,
cosmetic surgery, and eye surgery), these drugs have been shown to
increase the risk of bleeding complications and should therefore be
replaced with COX-2 inhibitors, which do not inhibit platelet
aggregation.52,53 The observation that prostaglandins are involved in
bone and wound healing has given rise to concern about potential
side effects in surgical patients. Although there is experimental evi-
dence that both conventional NSAIDs and COX-2 inhibitors can
impair bone healing,54-57 the clinical data available at present are
insufficient to document wound or bone healing failure with these
drugs.This is a particularly important issue for future study, in that
many orthopedic surgeons remain reluctant to use NSAIDs.
Currently, there is widespread concern about the increased risk
of cardiovascular complications associated with long-term treat-
Figure 1 Illustrated is the procedure for performing cryoanalge-
ment with selective COX-2 inhibitors. Generally, such side effects sia in a thoracotomy. The intercostal nerve in the thoracotomy
have appeared after 1 to 2 years of treatment. In the past few years, space is isolated, together with the two intercostal nerves above the
however, two studies of patients undergoing coronary artery space and the two below it, and the cryoprobe is applied to the
bypass grafting (CABG) found that the risk of cardiovascular nerves for 45 seconds. The probe is then defrosted and reapplied to
complications was increased significantly (two- to threefold) in the nerves for 45 seconds.The analgesia obtained lasts about 30 days.
ations61-62; accordingly, this agent is recommended as a basic com-

ponent of multimodal analgesia in all operations.
Table 9—Prescription Guidelines for Intravenous
Despite the gaps in our current understanding of the workings and Patient-Controlled Analgesia
differential effects of NSAIDs and COX-2 inhibitors, what is known
is sufficiently encouraging to suggest that they should be recommend- Drug (Concentration) Demand Dose Lockout Interval (min)
ed for baseline analgesic treatment after most operative procedures,
Morphine
with the exceptions already mentioned (see above). This recom- 0.5–3.0 mg 5–12
(1 mg/ml)
mendation is based not only on their analgesic efficacy but also on their
opioid-sparing effect, which may enhance recovery (see below). Meperidine
5–30 mg 5–12
(10 mg/ml)
Glucocorticoids are powerful anti-inflammatory agents and
have proven analgesic value in less extensive procedures,64 espe- Fentanyl
10–20 µg 5–10
(10 µg/ml)
cially dental, laparoscopic, and arthroscopic operations. In addi-
tion, they have profound antiemetic effects. Concerns about pos- Hydromorphone
0.1–0.5 mg 5–10
sible side effects in the setting of perioperative administration have (0.2 mg/ml)
not been borne out by the results of randomized studies.64 Oxymorphone
0.2–0.4 mg 8–10
(0.25 mg/ml)
OTHER ANALGESICS
Methadone
Tramadol is a weak analgesic that has several relatively minor 0.5–2.5 mg 8–20
(1 mg/ml)
side effects (e.g., dizziness, nausea, and vomiting).65 It can be com-
Nalbuphine
bined with acetaminophen to yield analgesic activity comparable 1–5 mg 5–10
(1 mg/ml)
to that of NSAIDs.66
Several systematic reviews have suggested that some analgesic
and perioperative opioid-sparing effects can be achieved by adding the widespread patient satisfaction with patient-controlled analge-
an N-methyl-D-aspartate receptor antagonist (e.g., ketamine),67-69 sia (PCA).75,76 It must be emphasized, however, that the effect of
gabapentin, or pregabalin70 [see Combination Regimens, below]. PCA on movement-associated pain is limited in comparison with
that of epidural local anesthesia.14
CRYOANALGESIA
Cryoanalgesia is the application of low temperatures (–20º to Mechanisms of Action

–29º C) to peripheral nerves with the goal of producing axonal Traditional I.M. dosing of opioids does not result in consistent
degeneration and thus analgesia [see Figure 1]. Axonal regeneration blood levels,75,76 because opioids are absorbed at a variable rate
takes place at a rate of 1 to 3 mm/day, which means that analgesia from the vascular bed of muscle. Moreover, administration of tra-
after intercostal blocks lasts about 30 days. Cryoanalgesia has no ditional I.M. regimens results in opioid concentrations that exceed
cardiac, respiratory, or cerebral side effects, and local side effects the concentrations required to produce analgesia only about 30%
(e.g., neuroma formation) are extremely rare. In this context, it of the time during any 4-hour dosing interval. PCA avoids these
should be emphasized that postthoracotomy patients are at sub- pitfalls by allowing repeated dosing on demand. PCA yields more
stantial risk (~30%) for chronic neuropathic pain without the use of constant and consistent plasma opioid levels and therefore pro-
cryoanalgesia71; however, this technique can be used only on senso- vides better analgesia.75,76
ry nerves or on nerves supplying muscles of no clinical importance.
At present, no information is available on the use of cryoanal- Modes of Administration and Dosing Parameters
gesia in operative procedures other than herniotomy and thoracot- There are several modes by which opioids can be administered
omy.72 Cryoanalgesia is not efficacious after herniotomy.73 The data under patient control. Intermittent delivery of a fixed dose is known
on postthoracotomy cryoanalgesia, however, suggest improved as demand dosing. Background infusions have been used to sup-
pain alleviation and a concomitant reduction in the need for nar- plement patient-administered doses, but this practice increases the
cotics, which, in conjunction with the simplicity and low cost of risk of respiratory depression and should therefore be avoided.75,76
the modality and the absence of side effects, present a strong argu- There are several basic prescription parameters for PCA: load-
ment for more extensive use of cryoanalgesia. ing dose, demand dose, lockout interval, and 4-hour limits [see
Table 9].75,76 When PCA is used for postoperative care, it is usual-
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
ly initiated in the recovery room.The patient is made comfortable
Transcutaneous electrical nerve stimulation (TENS) is the by administering as much opioid as is needed (i.e., a loading
application of a mild electrical current through the skin surface dose). When the patient is sufficiently recovered from the anes-
to a specific area, such as a surgical wound, to achieve pain relief; thetic, he or she may begin to use the infuser.
the exact mechanism whereby it achieves this effect is yet to be
explained. Many TENS devices are available for clinical use, but Side Effects
the specific values and the proper uses of the various stimulation Minor side effects associated with PCA include nausea, vomiting,
frequencies, waveforms, and current intensities have not been sweating, and pruritus. Clinically significant respiratory depression with
determined. Unfortunately, the effect of TENS on acute pain is PCA is rare.There is no evidence to suggest that PCA is associated with
too small to warrant a recommendation for routine use.74 a higher incidence of side effects than are other routes of systemic
opioid administration.75,76 Side effects are the result of the pharma-
PATIENT-CONTROLLED ANALGESIA
cologic properties of opioids, not the method of administration.75,76
Patient-controlled administration of opioids has experienced a
COMBINATION REGIMENS
dramatic increase in use. This increase may be attributed to (1)
awareness of the inadequacy of traditional I.M. opioid regimens, Because no single pain treatment modality is optimal, combi-
(2) the development of effective and safe biotechnology, and (3) nation regimens (e.g., balanced analgesia or multimodal treatment)
offer major advantages over single-modality regimens, whether by The potential of combination regimens is especially intriguing
maintaining or improving analgesia, by reducing side effects, or by with respect to the concept of perioperative opioid-sparing anal-
doing both.77,78 Combinations of epidural local anesthetics and gesia.The use of one or several nonopioid analgesics in such regi-
morphine,14,27 of NSAIDs and opioids,46,77,78 of NSAIDs and mens may enhance recovery, in that the concomitant reduction in
acetaminophen,61,62 of acetaminophen and opioids,63 of aceta- the opioid dosage will lead to decreased nausea, vomiting, and
minophen and tramadol,66 and of a selective COX-2 inhibitor and sedation.80-84 Both the adverse events associated with postopera-
gabapentin79 have been reported to have additive effects. At pres- tive opioid analgesia and the relatively high costs of such analgesia
ent, information on other combinations (involving ketamine, argue for an opioid-sparing approach.85,86 Another argument that
clonidine, glucocorticoids, and other agents) is too sparse to allow has been advanced is that the introduction of the JCAHO pain ini-
firm recommendations; however, multimodal analgesia is tiative may precipitate increased use of opioids (and thereby an
undoubtedly promising, and multidrug combinations should cer- increased risk of side effects), though it is not certain that this will
tainly be explored further. be the case.87,88
Perception of Pain
Figure 2 Shown are the major neural pathways involved in

nociception. Nociceptive input is transmitted from the
periphery to the dorsal horn via A-delta and C fibers (for
somatic pain) or via afferent sympathetic pathways (for vis-
ceral pain). It is then modulated by control systems in the
dorsal horn and sent via the spinothalamic tracts and spin-
oreticular systems to the hypothalamus, to the brain stem
and reticular formation, and eventually to the cerebral cor-
tex. Ascending transmission of nociceptive input is also mod-
ulated by descending inhibitory pathways originating in the
brain and terminating in the dorsal horn. Nociception may
be enhanced by reflex responses that affect the environment
of the nociceptors, such as smooth muscle spasm.
Trauma
Capillary
To the Limbic System Descending Inhibitory Pathway

Neurotransmitters at
Dorsal Horn Level:
Norepinephrine Release of:
Serotonin Substance P
Enkephalins Histamine
Serotonin
Primary Afferent Bradykinin
Neurotransmitter Prostaglandins
Candidates
Substance P
Spinothalamic Tract L-Glutamate
GABA
VIP Release of:
CCK-8 Norepinephrine
Sensory Nerve
Somatostatin
Muscle
Motor of Other Efferent Nerve
Segmental Reflexes:
Increased Skeletal Muscle Tension
Decreased Chest Compliance
More Nociceptive Input
Increased Sympathetic Tone
Decreased Gastric Mobility
IIeus, Nausea, Vomiting
Discussion
Physiologic Mechanisms of Acute Pain injury tissue, thereby generating smooth muscle spasm, which am-
The basic mechanisms of acute pain are (1) afferent transmis- plifies the sensation.
sion of nociceptive stimuli through the peripheral nervous system POSTINJURY CHANGES IN PERIPHERAL AND
after tissue damage, (2) modulation of these injury signals by con- CENTRAL NERVOUS SYSTEMS
trol systems in the dorsal horn, and (3) modulation of the ascend-
ing transmission of pain stimuli by a descending control system After an injury, the afferent nociceptive pathways undergo phys-
originating in the brain [see Figure 2].89-92 iologic, anatomic, and chemical changes.91,92 These changes
include increased sensitivity on the part of peripheral nociceptors,
PERIPHERAL PAIN RECEPTORS AND NEURAL as well as the growth of sprouts from damaged nerve fibers that
TRANSMISSION TO SPINAL CORD become sensitive to mechanical and alpha-adrenergic stimuli and
eventually begin to fire spontaneously. Moreover, excitability may
Peripheral pain receptors (nociceptors) can be identified by
be increased in the spinal cord, which leads to expansion of recep-
function but cannot be distinguished anatomically. The respon-
tive fields in dorsal horn cells. Such changes may lower pain
siveness of peripheral pain receptors may be enhanced by endoge-
thresholds, may increase afferent barrage in the late postinjury
nous analgesic substances (e.g., prostaglandins, serotonin,
state, and, if normal regression does not occur during convales-
bradykinin, nerve growth factor, and histamine), as well as by
cence, may contribute to a chronic pain state.91
increased efferent sympathetic activity.89 Antidromic release of
Neural stimuli have generally been considered to be the main
substance P may amplify the inflammatory response and thereby
factor responsible for initiation of spinal neuroplasticity; however,
increase pain transmission.The peripheral mechanisms of visceral
it now appears that such neuroplasticity may also be mediated by
pain still are not well understood90 —for example, no one has yet
cytokines released as a consequence of COX-2 induction.92
explained why cutting or burning may provoke pain in the skin but
Improved understanding of the mechanisms of pain may serve as
not provoke pain in visceral organs. Peripheral opioid receptors
a rational basis for future drug development and may help direct
have been demonstrated to appear in inflammation on the periph- therapy away from symptom control and toward mechanism-spe-
eral nerve terminals, and clinical studies have demonstrated that cific treatment.94
there are analgesic effects from peripheral opioid administration In experimental studies, acute pain behavior or hyperexcitabili-
during arthroscopic knee surgery.93 ty of dorsal horn neurons may be eliminated or reduced if the
Somatic nociceptive input is transmitted to the CNS through afferent barrage is prevented from reaching the CNS. Preinjury
A-delta and C fibers, which are small in diameter and either neural blockade with local anesthetics or opioids can suppress
unmyelinated or thinly myelinated. Visceral pain is transmitted excitability of the CNS; this is called preemptive analgesia.
through afferent sympathetic pathways; the evidence that afferent Because similar antinociceptive procedures were less effective in
parasympathetic pathways play a role in visceral nociception is experimental studies when applied after injury, timing of analgesia
inconclusive.90 seems to be important in the treatment of postoperative pain;
DORSAL HORN CONTROL SYSTEMS AND MODULATION however, a critical analysis of controlled clinical studies that com-
OF INCOMING SIGNALS
pared the efficacy of analgesic regimens administered preopera-
tively with the efficacy of the same regimens administered postop-
All incoming nociceptive traffic synapses in the gray matter of eratively concluded that preemptive analgesia does not always pro-
the dorsal horn (Rexed’s laminae I to IV). Several substances may vide a clinically significant increase in pain relief.95,96 Nonetheless,
be involved in primary afferent transmission of nociceptive stimuli it is important that pain treatment be initiated early to ensure that
in the dorsal horn: substance P, enkephalins, somatostatin, neu- patients do not wake up with high-intensity pain. As long as the
rotensin, γ-aminobutyric acid (GABA), glutamic acid, angiotensin afferent input from the surgical wound continues, continuous
II, vasoactive intestinal polypeptide (VIP), and cholecystokinin treatment with multimodal or balanced analgesia may be the most
octapeptide (CCK-8).91 From the dorsal horn, nociceptive infor- effective method of treating postoperative pain.95,97
mation is transmitted through the spinothalamic tracts to the
hypothalamus, through spinoreticular systems to the brain stem
and reticular formation, and finally to the cerebral cortex. Effects of Pain Relief
DESCENDING PAIN CONTROL SYSTEM METABOLIC RESPONSE TO OPERATION

A descending control system for sensory input originates in the It still is not generally appreciated that acute pain in the post-
brain stem and reticular formation and in certain higher brain operative period or after hospitalization for accidental injury not
areas. The main neurotransmitters in this system are norepineph- only serves no useful function but also may actually exert harmful
rine, serotonin, and enkephalins. Epidural-intrathecal administra- physiologic and psychological effects.Therefore, except in the ini-
tion of alpha-adrenergic agonists (e.g., clonidine) may therefore tial stage in acutely injured hypovolemic patients for whom
provide pain relief.91 increased sympathetic activity may provide cardiovascular sup-
port, the pain-induced reflex responses that may adversely affect
SPINAL REFLEXES
respiratory function, increase cardiac demands, decrease intestinal
Nociception may be enhanced by spinal reflexes that affect the motility, and initiate skeletal muscle spasm (thereby impairing
environment of the nociceptive nerve endings. Thus, tissue dam- mobilization) should be counteracted by all available means.
age may provoke an afferent reflex that causes muscle spasm in the The traditional view of the physiologic role of the stress response
vicinity of the injury, thereby increasing nociception. Similarly, to surgical injury is that it is a homeostatic defense mechanism that
sympathetic reflexes may cause decreased microcirculation in helps the body heal tissue and adapt to injury. However, the neces-
sity for the stress response in modern anesthesiology and surgery greater extent than a local anesthetic regimen would.22 Another
has been questioned.28 Thus, concern about the detrimental effects explanation may be inadequate study design in some cases: most
of operative procedures (e.g., myocardial infarction, pulmonary studies to date have focused on the effects of a single factor (i.e.,
complications, and thromboembolism) that cannot be attributed epidural analgesia) on overall postoperative morbidity, which is
solely to imperfections in surgical technique has led to the hypoth- probably too simplistic an approach, given that overall postopera-
esis that the unsupported continuous injury response may instead tive outcome is known to be determined by multiple factors.103,104
be a maladaptive response that erodes body mass and physiologic Besides postoperative pain relief, reinforced psychological prepa-
reserve.28,98 Because neural stimuli play an important role in releas- ration of the patient, reduction of stress by performing neural
ing the stress response to surgical injury, pain relief may modify this blockade or opting for minimal invasive procedures, and enforce-
response, but this modulation is dependent on the mechanism of ment of early oral postoperative feeding and mobilization may all
action of the pain treatment modality employed.28 play a significant role in determining outcome.103,104 Prevention of
Alleviation of pain through antagonism of peripheral pain medi- intraoperative hypothermia, avoidance of fluid overloading, and
ators (i.e., through use of NSAIDs) has no important modifying avoidance of hypoxemia may be important as well.103,104
effect on the response to operation.22,30 The effects of blockade of Therefore, although adequate pain relief is obviously a prereq-
afferent and efferent transmission of pain stimuli by means of uisite for good outcome, the best results are likely to be achieved
regional anesthesia have been studied in detail.22,31 Spinal or by combining analgesia with all the aforementioned factors in a
epidural analgesia with local anesthetics prevents the greater part multimodal rehabilitation effort.103,104 Observations from patients
of the classic endocrine metabolic response to operative proce- undergoing a variety of surgical procedures suggest that such a
dures in the lower region of the body (e.g., gynecologic and uro- multimodal approach may lead to significant reductions in hospi-
logic procedures and orthopedic procedures in the lower limbs) tal stay, morbidity, and convalescence.103,104 Admittedly, these pre-
and improves protein economy; however, this effect is consider- liminary observations require confirmation by randomized or
ably weaker in major abdominal and thoracic procedures, proba- multicenter trials. The role of the acute pain service105 and the
bly because of insufficient afferent neural blockade. The modify- effect of establishing a postoperative rehabilitation unit should be
ing effect of epidural analgesia on the stress response is most pro- assessed as well.
nounced if the neural blockade takes effect before the surgical
insult.The optimal duration of neural blockade for attenuating the TOLERANCE, PHYSICAL DEPENDENCE, AND ADDICTION
hypermetabolic response has not been established, but it should Continued exposure of an opioid receptor to high concentra-
include at least the initial 24 to 48 hours.22,31 tions of opioid will cause tolerance. Tolerance is the progressive
Alleviation of postoperative pain through administration of decline in an opioid’s potency with continuous use, so that higher
epidural-intrathecal opioids has a smaller modifying effect on the and higher concentrations of the drug are required to cause the
surgical stress response, in comparison with the degree of pain same analgesic effect. Physical dependence refers to the produc-
relief it provides22,31; furthermore, it does not provide efferent sym- tion of an abstinence syndrome when an opioid is withdrawn. It is
pathetic blockade. Systemic administration of opioids, either ac- defined by the World Health Organization as follows106:
cording to a fixed administration regimen or according to a demand-
based regimen, has no important modifying effect on the stress A state, psychic or sometimes also physical, resulting from interactions
between a living organism and a drug, characterized by behavioural
response.22 The effects of pain relief by acetaminophen, tramadol,
and other responses that always include a compulsion to take the drug
cryoanalgesia, or TENS on the stress response have not been estab- on a continuous or periodic basis in order to experience its psychic
lished but probably are of no clinical significance. Further studies effects, and sometimes to avoid discomfort from its absence.
aimed at defining the effects of multimodal analgesia on the sur-
gical stress response are required. This definition is very close to the popular conception of addic-
tion. It is important, however, to distinguish addiction (implying
POSTOPERATIVE MORBIDITY compulsive behavior and psychological dependence) from toler-
The effects of nociceptive blockade and pain relief on postop- ance (a pharmacologic property) and from physical dependence
erative morbidity remain to be defined, except with respect to (a characteristic physiologic effect of a group of drugs). Physical
intraoperative spinal or epidural local anesthetics in lower-body dependence does not imply addiction. Moreover, tolerance can
procedures, about which the following four conclusions can be occur without physical dependence; the converse does not appear
made.22,99 First, intraoperative blood loss is reduced by about to be true.
30%. Second, thromboembolic and pulmonary complications are The possibility that the medical administration of opioids could
reduced by about 30% to 40%. Third, when epidural local anes- result in a patient’s becoming addicted has generated much debate
thetics are continuously administered (with or without small doses about the use of opioids. In a prospective study of 12,000 hospi-
of opioids) to patients undergoing abdominal or thoracic proce- talized patients receiving at least one strong opioid for a protract-
dures, pulmonary infectious complications appear to be reduced ed period, there were only four reasonably well documented cases
by about 40%.30 Fourth, the duration of postoperative ileus is of subsequent addiction, and in none of these was there a history
reduced14,31; this effect may be of major significance, in that reduc- of previous substance abuse.107 Thus, the iatrogenic production of
tion of ileus allows earlier oral nutrition,31 which has been demon- opioid addiction may be very rare.
strated to improve outcome.
CONCLUSION
The impact of continuous epidural analgesia on postoperative
outcome after major operations remains the subject of some debate. The choice of therapeutic intervention for acute postoperative
Three large randomized trials from 2001 and 2002 found no pos- pain is determined largely by the nature of the patient’s problem,
itive effects except for improved pulmonary outcome.100-102 One the resources available, the efficacy of the various treatment tech-
explanation for these negative findings may be the use of a pre- niques, the risks attendant on the procedures under consideration,
dominantly opioid-based epidural analgesic regimen, which would and the cost to the patient.108 Whereas trauma has been the sub-
hinder the normal physiologic responses supporting recovery to a ject of intensive research, the mechanisms of the pain associated
with trauma and surgical injury and the optimal methods of reliev- morbidity, will stimulate more surgeons to turn their attention to
ing such pain have received comparatively little attention from sur- this area. Effective control of postoperative pain, combined with a
geons. It is to be hoped that our growing understanding of basic high degree of surgical expertise and the judicious use of other
pain mechanisms and appropriate therapy, combined with the perioperative therapeutic interventions within the context of mul-
promising data supporting the idea that adequate inhibition of timodal postoperative rehabilitation, is certain to improve surgical
surgically induced nociceptive stimuli may reduce postoperative outcome.
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J Surg 186:472, 2003 Acknowledgments
70. Dahl JB, Mathiesen O, Møiniche S: Prospective pre-
medication: an option with gabapentin and related 89. Kidd BL, Urban LA: Mechanisms of inflammatory Figure 1 Carol Donner.
drugs? Acta Anaesthesiol Scand 48:1130, 2004 pain. Br J Anaesth 87:3, 2001 Figure 2 Dana Burns Pizer.
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 6 POSTOPERATIVE MANAGEMENT — 1
6 POSTOPERATIVE MANAGEMENT
OF THE HOSPITALIZED PATIENT
Deborah L. Marquardt, M.D., Roger P.Tatum, M.D., F.A.C.S., and Dana C. Lynge, M.D., F.A.C.S
At the beginning of the modern era of surgery, operative proce- examination carried out, the procedure to be performed is decided
dures commonly took place in an operating theater, performed by on. This decision then initiates a discussion of the complexity and
plainclothes surgeons in aprons for audiences of students and potential complications associated with the procedure, as well as of
other onlookers. Afterward, patients were typically cared for at the concerns and special needs related to any comorbid conditions
home or in a hospital ward, with scarcely any monitoring and lit- that may be present. If, as is often the case, the surgeon requires
tle to help them toward recovery besides their own strength and some assistance with planning the operation around the patient’s
physiologic reserve. In the current era, surgery is a high-tech, other health problems, input from appropriate medical and surgi-
rapid-paced field, with new knowledge and technological cal colleagues can be extremely helpful. Key factors to take into
advances seemingly appearing around every corner. Many of these consideration include the potential complications related to the
new discoveries have allowed surgeons to work more efficiently procedure and the urgency of their treatment; the level of monitor-
and safely, and as a result, a number of operations have now ing the patient will require with respect to vital signs, neurologic
become same-day procedures. In addition, some very complex examination, and telemetry; and the degree of care that will be nec-
operations that were once thought to be impossible or to be asso- essary with respect to treatments, use of drains, and wound care.
ciated with unacceptably high morbidity and mortality have now There are relatively few published references describing specific
become feasible, thanks to advances in surgical technique, anes- criteria for the various disposition categories; however, most hospi-
thesia, postoperative management, and critical care. The focus of tals and surgery centers will have developed their own policies spec-
our discussion is on the postoperative considerations that have ifying a standard of care to be provided for each category.
become essential for successful recovery from surgery.
Each patient is unique, and each patient’s case deserves thought- SAME-DAY SURGERY
ful attention; no two patients can be managed in exactly the same Same-day surgery is appropriate for patients who (1) have few or
way. Nevertheless, there are certain basic categories of postopera- no comorbid medical conditions and (2) are undergoing a proce-
tive care that apply to essentially all patients who undergo surgical dure that involves short-duration anesthesia or local anesthesia plus
procedures. Many of these categories are discussed in greater detail sedation and that carries a low likelihood of urgent complications.
elsewhere in ACS Surgery. Our objective in this chapter is to pro- Operations commonly performed on a same-day basis include
vide a complete yet concise overview of each pertinent topic. inguinal or umbilical hernia repair, simple laparoscopic cholecys-
tectomy, breast biopsy, and small subcutaneous procedures.
The growth in the performance of minor and same-day proce-
Disposition
dures has led to the development of various types of short-stay
The term disposition refers to the location and level of care and units or wards. The level of care provided by a short-stay ward is
monitoring to which the patient is directed after the completion of generally equivalent to that provided by a regular nursing ward;
the operative procedure. Although disposition is not often dis- however, the anticipated duration of care is substantially shorter,
cussed as a topic in its own right, it is an essential consideration typically ranging from several hours to a maximum of 48 hours.
that takes into account many important factors. It may be classi- Short-stay wards also undergo some modifications to facilitate the
fied into four general categories, as follows: use of streamlined teaching protocols designed to prepare patients
1. Home or same-day surgery via the recovery room. for home care. Many hospitals now have short-stay units, as do
2. The intensive care unit, with or without a stay in the recovery some independent surgery centers.
room. SURGICAL FLOOR
3. The surgical floor via the recovery room.
4. The telemetry ward via the recovery room. The vast majority of patients receive the postoperative care they
require on the surgical floor (or regular nursing ward). Assessment
The disposition category that is appropriate for a given patient of vital signs, control of pain, care of wounds, management of
is determined by considering the following four factors: tubes and drains, and monitoring of intake and output are
addressed every 2 to 8 hours (depending on the variable). Assign-
1. The patient’s preoperative clinical status (including both the
ment of the patient to the regular nursing ward presupposes that
condition being treated and any comorbid conditions), as indi-
he or she is hemodynamically stable and does not need continu-
cated by the history, the physical examination, and the input
ous monitoring.
of other medical practitioners.
The telemetry ward is a variant of the regular nursing ward.The
2. The operative procedure to be performed.
care provided in the telemetry ward is generally equivalent to that
3. The course and duration of the operative procedure.
provided on other floor wards, except that patients undergo con-
4. The patient’s clinical status at the completion of the proce-
tinuous cardiac monitoring. Patients commonly assigned to the
dure, as managed with the help of anesthesia colleagues.
telemetry ward after operation include (1) those with a known
The initial phase of disposition planning begins preoperatively. medical history of arrhythmias that may necessitate intervention,
After a full history has been obtained and a complete physical (2) those with intraoperative arrhythmias or other electrocardio-
graphic (ECG) changes who are not believed to require ICU issue specific orders to ensure that this concern is appropriately
monitoring but who do need this form of cardiac follow-up, and addressed. As a rule, surgical nurses are well acquainted with tube
(3) those making the transition from the ICU to a regular ward maintenance; however, if thick secretions are expected, orders for
who are hemodynamically stable but who require ongoing follow- routine flushing may be indicated. When the tube is no longer
up of a cardiac issue. indicated, its removal may be ordered.
INTENSIVE CARE UNIT URINARY CATHETERS
When early postoperative complications may necessitate urgent Urinary catheters can serve a large variety of purposes. In the
intervention and close observation is therefore essential, patients setting of bladder or genitourinary surgery, they are often
should be admitted to the ICU for postoperative care. Postoper- employed to decompress the system so that it will heal more read-
ative ICU admission may also be appropriate for patients who are ily. After general surgical procedures—and many other surgical
clinically unstable after the procedure; these patients often require procedures as well—they are used to provide accurate measure-
ongoing resuscitation, intravenous administration of vasoactive ments of volume output and thus, indirectly, to give some indica-
agents, ventilatory support, or continuous telemetry monitoring tion of the patient’s overall volume and resuscitation status.
for dysrrhythmias. In addition, admission to the ICU should be Furthermore, after many procedures, patients initially find it
considered for patients in whom the complexity of drain manage- extremely difficult or impossible to mobilize for urination, and a
ment, wound care, or even pain control may necessitate frequent urinary catheter may be quite helpful during this time.
postoperative monitoring that is not available on a regular nursing Their utility and importance notwithstanding, urinary
ward. At present, there is no single set of accepted guidelines catheters are associated with the development of nosocomial uri-
directing ICU admission. There are, however, published sources nary tract infections (UTIs). As many as 40% of all hospital infec-
that can provide some guidance. For example, a 2003 article sup- tions are UTIs, and 80% to 90% of these UTIs are associated
plied recommendations for the various services to be provided by with urinary catheters [see Complications, below]. Accordingly,
differing levels of ICUs.1 Published recommendations of this sort when catheterization is no longer deemed necessary, prompt
may be adopted or modified by individual hospitals and surgery removal is indicated. As a rule, orders specifically pertaining to
centers as necessary. urinary catheter care are few, typically including gravity drainage,
flushing to maintain patency (if warranted), and removal when
appropriate. At times, irrigation is employed after urologic proce-
Care Orders dures or for the management of certain infectious agents.
Nurses and other ancillary personnel provide the bulk of the
OXYGEN THERAPY
care received by patients after a surgical procedure; accordingly, it
is essential that they receive clear and ample instructions to guide Supplemental administration of oxygen is often necessary after
their work. Such instructions generally take the form of specific a surgical procedure. Common indicators of a need for postoper-
postoperative orders directed to each ancillary service. Services ative oxygen supplementation include shallow breathing and pain,
for which such orders may be appropriate include nursing, respi- atelectasis, operative manipulation in the chest cavity, and postop-
ratory therapy, physical therapy (PT), occupational therapy (OT), erative impairment of breathing mechanics. Because supplemen-
and diet and nutrition. In what follows, we briefly outline some of tal oxygen is considered a medication, a physician’s order is
the common tasks that require orders to be directed toward these required before it can be administered. In many cases, oxygen
services. supplementation is ordered on an as-needed basis with the aim of
enabling the patient to meet specific peripheral oxygen saturation
NASOGASTRIC TUBES
criteria. In other cases, it is ordered routinely in the setting of
Nasogastric (NG) tubes are commonly placed after gastroin- known preoperative patient oxygen use.
testinal operations, most frequently for drainage of gastric secre- An important factor to keep in mind is that oxygen supplemen-
tions when an ileus is anticipated or offloading of the upper GI tation protocols may vary from one nursing unit to another.
tract when a fresh anastomosis is located close by. Although NG Different units may place different limitations on the amount of
tubes have often been placed routinely after abdominal surgery, the supplemental oxygen permitted, depending on their specific mon-
current literature cites a number of reasons why routine use is itoring and safety guidelines. Another important factor is that
inadvisable and selective use is preferable. For example, significant- patients with known obstructive pulmonary disease and carbon
ly earlier return of bowel function, a trend toward less pulmonary dioxide retention are at increased risk for respiratory depression
complications, and enhanced patient comfort and decreased nau- with hyperoxygenation; accordingly, particular care should be
sea are reported when NG tubes are not routinely placed or when exercised in ordering supplemental oxygen for these patients.
they are removed within 24 hours after operation.2
DRAINS
When postoperative placement of an NG tube is considered
appropriate, an order from a physician is required, along with Drains and tubes are placed in a wide variety of locations for a
direction regarding the method of drainage. Sometimes, NG number of different purposes—in particular, drainage of purulent
tubes are placed to low continuous suction; more often, however, materials, serum, or blood from body cavities. Several types are
they are placed to low intermittent suction to eliminate the chance commonly used, including soft gravity drains (e.g., Penrose),
of continuous suction against a visceral wall and to promote gen- closed suction drains (e.g., Hemovac, Jackson-Pratt, and Blake),
eralized drainage. If large volumes of secretions are not expected, and sump drains, which draw air into one lumen and extract fluid
continuous gravity may be used instead of suction. A key concern via a companion lumen. Traditionally, surgeons have often made
with NG tubes is maintenance of the patency of both the main the decision to place a drain on the basis of their surgical training
port and the sump port. Should either port become blocked, the and practice habits rather than of any firm evidence that drainage
tube will be rendered ineffective. This concern should be dis- is warranted. Multiple randomized clinical trials have now
cussed with the nursing staff. At times, it may be necessary to demonstrated that routine use of drains after elective operations—
including appendectomies and colorectal, hepatic, thyroid, and closed primarily as a consequence of contamination or inability to
parathyroid procedures—does not prevent anastomotic and other approximate the skin edges. Wet-to-dry dressings provide a moist
complications (though it does reduce seroma formation). environment that promotes granulation and wound closure by
Consequently, it is recommended that drains, like NG tubes, be secondary intention. Moreover, their removal and replacement
employed selectively.3-5 Once a drain is in place, specific orders causes debridement of excess exudate or unhealthy superficial tis-
must be issued for its maintenance.These include use of gravity or sue. Postoperative orders should specify the frequency of dressing
suction (and the means by which suction is to be provided if changes, as well as the solution used to provide dampness. For
ordered), management and measurement of output, stripping, most clean open incisions, twice-daily dressing changes using nor-
and care around the drain exit site. mal saline solution represent the most common approach. If there
Biliary tract drains include T tubes, cholecystostomy tubes, per- is excess wound exudate to be debrided, dressing changes may be
cutaneous drains of the biliary tree, and nasobiliary drains. Daily performed more frequently. If there is particular concern about
site maintenance, flushing, and output recording are performed by wound contamination or superficial colonization of organisms,
the nursing staff. Most biliary tract drains are removed by the substitution of dilute Dakin solution for normal saline may be
practitioner or other trained midlevel staff members. considered.
T tubes are generally placed after operative exploration or repair A new era of wound management arrived in the late 1990s with
of the common bile duct (CBD).The long phalanges are left with- the introduction of negative-pressure wound therapy (NPWT). In
in the CBD, and the long portion of the tube is brought out to the NPWT, a vacuum-assisted wound closure device places the
skin for drainage. The tube is left in place until the CBD is prop- wound under subatmospheric pressure conditions, thereby
erly healing and there is evidence of adequate distal drainage (sig- encouraging blood flow, decreasing local wound edema and excess
naled by a decrease in external drainage of bile). Before the T tube fluid (and consequently lowering bacterial counts and encourag-
is removed, a cholangiogram is recommended to document distal ing wound granulation), and increasing wound contraction.10,11
patency and rule out retained gallstones or leakage.6 Since the first published animal studies, NPWT has been success-
Cholecystostomy tubes are placed percutaneously—typically fully employed for a multitude of wound types, including complex
under ultrasonographic guidance and with local anesthesia—to traumatic and surgical wounds, skin graft sites, and decubitus
decompress the gallbladder. Generally, they are used either (1) wounds. Before vacuum-assisted closure is used, however, it is
when cholecystectomy cannot be performed, because concomi- necessary to consider whether and to what extent the wound is
tant medical problems make anesthesia or the stress of operation contaminated, the proximity of the wound to viscera or vascular
intolerable, or (2) when the presence of severe inflammation leads structures, and the potential ability of the patient to tolerate dress-
the surgeon to conclude that dissection poses too high an opera- ing changes.Wounds that are grossly contaminated or contain sig-
tive risk. Particularly in the latter setting, delayed elective cholecys- nificant amounts of nonviable tissue probably are not well suited
tectomy may be appropriate; if so, the cholecystostomy tube may to an occlusive dressing system of this type, given that frequent
be removed at the time of the operation. evaluation and possibly debridement may be needed to prevent
Nasobiliary tubes are placed endoscopically in the course of bil- ongoing tissue infection and death. Furthermore, the suction
iary endoscopy. They are used to decompress the CBD in some effect of the standard vacuum sponge may cause serious erosion of
settings.They usually are placed to gravity and otherwise are man- internal viscera or exposed major blood vessels. Some silicone-
aged in much the same way as NG tubes.7 impregnated nonadherent sponges are available that may be suit-
able in this setting, but caution should be exercised in using them.
WOUND CARE
Finally, because of the adherence of the sponge and the occlusive
The topic of wound care is a broad one. Here, we focus on ini- adhesive dressing, some patients may be unable to tolerate dress-
tial postoperative dressing care, traditional wet-to-dry dressings, ing changes without sedation or anesthesia.
and use of a vacuum-assisted closure device (e.g.,VAC Abdominal
Dressing System; Kinetic Concepts, Inc., San Antonio, Texas).
These and other components of wound care are discussed in more Nutrition
detail elsewhere [see 1:7 Acute Wound Care and 3:3 Open Wound The patient’s nutritional status has a significant effect on post-
Requiring Reconstruction]. operative morbidity and even mortality. After most operative pro-
Initial wound management after an operative procedure gener- cedures that do not involve the alimentary tract or the abdomen
ally entails placement of a sterile dressing to cover the incision.The and do not affect swallowing and airway protection, the usual
traditional recommendation has been to keep this dressing in practice is to initiate the return to full patient-controlled oral nutri-
place and dry for the first 48 hours after operation; because epithe- tion as soon as the patient is fully awake. In these surgical settings,
lialization is known to take place within approximately this period, therefore, it is rarely necessary to discuss postoperative nutrition
the assumption is that this measure will reduce the risk of wound approaches to any great extent.
infection. Although most surgeons still follow this practice, espe- After procedures that do involve the alimentary tract or the
cially in general surgical cases, supporting data from randomized abdomen, however, the situation is different. The traditional
clinical studies are lacking. In addition, several small studies that practice has been to institute a nihil per os (NPO) policy, with
evaluated early showering with closed surgical incisions found no or without nasogastric drainage, after all abdominal or alimen-
increases in the rate of infection or dehiscence.8,9 It should be kept tary tract procedures until the return of bowel function, as evi-
in mind, however, that these small studies looked primarily at soft denced by flatus or bowel movement, is confirmed. The routine
tissue and other minor skin incisions that did not involve fascia. application of this practice has been challenged, however, espe-
Thus, even though the traditional approach to initial dressing cially over the past 15 years. Data from prospective studies of
management is not strongly supported, the data currently avail- high statistical power are lacking, but many smaller studies eval-
able are insufficient to indicate that it should be changed. uating early return to enteral nutrition after alimentary tract
Wet-to-dry dressings are used in a variety of settings. In a surgi- procedures have yielded evidence tending to favor more routine
cal context, they are most often applied to a wound that cannot be use of enteral intake within 48 hours after such procedures.
Issues related to postoperative nutritional support are discussed complication rates and shorter hospital stays. In contrast,TPN is
further and in greater detail elsewhere [see 8:23 Nutritional known to be associated with altered immune function, an
Support]. increased rate of infectious complications, and, in some studies,
a higher incidence of anastomotic complications after GI
NPO STATUS
surgery. Moreover, there are as yet no data to indicate that acute
In the setting of elective colorectal surgery, it is well-accepted utilization of TPN during short periods of starvation benefits
practice to initiate a return to patient-controlled enteral-oral patients who are adequately nourished preoperatively.TPN may,
feeding within 24 to 48 hours after operation; this practice yields however, be lifesaving in patients who are malnourished and who
no increase in the incidence of postoperative complications (e.g., do not have functioning GI tracts (e.g., those with short gut syn-
anastomotic leakage, wound and intra-abdominal infection, and drome, severe gut dysmotility or malabsorption, mesenteric vas-
pneumonia) or the length of hospital stay and, according to some cular insufficiency, bowel obstruction, high-output enteric fistu-
reports, may even decrease them.12 In the setting of upper GI las, or bowel ischemia).15
surgery (specifically, gastric resection, total gastrectomy, and
CALORIC GOALS
esophagectomy), the situation is less clear-cut. Traditional con-
cerns—in particular, the need to avoid distention stress on gas- Once a route of nutritional support has been decided on, over-
tric or gastrojejunal anastomoses after gastric resection, the more all goals for caloric and protein intake may be established on the
tenuous nature of a esophagojejunostomy after total gastrecto- basis of the patient’s ideal body weight (IBW) and expected post-
my, and the delayed gastric conduit emptying, aspiration risk, operative metabolic state. One approach is to rely on a general esti-
and anastomotic stress seen after esophagectomy or resection— mate; a commonly used formula is 25 kcal/kg IBW. Another ap-
have led to the current practice of instituting nasogastric proach is to calculate a basal energy requirement by using the Harris-
drainage and placing the patient on NPO status postoperatively Benedict equation. This calculation is separate from the calcula-
until evidence of the return of bowel function is apparent, as well tion of protein needs. A daily protein intake goal may be calculat-
as, in some cases, investigating the anastomosis for possible leak- ed on the basis of the patient’s estimated level of physical stress. A
age by means of contrast fluoroscopy. There are no clinical trial well-nourished unstressed person requires a protein intake of
data to support this approach. In fact, many surgeons routinely approximately 1.0 g/kg IBW/day. A seriously ill patient under on-
remove the NG tube within 24 hours after gastric resection and going severe physical stress, however, may require 2.0 g/kg IBW/day;
early feeding without incurring increased complications. in some settings (e.g., extensive burns), a protein intake as high as
However, there are also no clinical trial data indicating that the 3.0 g/kg IBW/day may be recommended. Once the patient’s needs
current approach is potentially ineffective or harmful. specific needs have been calculated, the amount and type of nutri-
Consequently, traditional management methods after upper GI ent solution to be provided enterally or via TPN is determined. If
procedures still are often endorsed in the literature.13,14 the patient is on a full oral diet, a calorie count or recording of the
percentage of items eaten at each meal or snack may be made by
ENTERAL NUTRITION
the nursing staff and used to estimate the patient’s intake, with
Enteral nutrition may be delivered via several routes. Most nutritional supplementation provided as needed.16
patients who have undergone an operation are able to take in an Patients who require assistance with nutritional intake should
adequate amount of calories orally.When they are unable to do so, be monitored to determine whether the interventions being car-
whether because of altered mental status, impaired pulmonary func- ried out are having the desired effect. The most common method
tion, or some other condition, the use of enteral feeding tubes may of monitoring patients’ nutritional status with nutritional supple-
be indicated. In the acute setting, nasogastric and nasojejunal feed- mentation is to measure the serum albumin and prealbumin
ing tubes are the types most commonly employed to deliver enter- (transthyretin) concentrations. Albumin has a half life of approxi-
al solutions into the GI tract. Either type is appropriate for this pur- mately 14 to 20 days and thus serves as a marker of longer-term
pose; the two types are equivalent overall as regards their ability to nutritional status. A value lower than 2.2 g/dl is generally consid-
provide adequate nutrition, and there are no significant differences ered to represent severe malnutrition, but even somewhat higher
in outcome or complications. In cases where prolonged inability to values (< 3.0 g/dl) have been associated with poorer outcomes
take in adequate calories orally is expected, the use of an indwelling after elective surgery. Although the serum albumin concentration
feeding tube, such as a gastrostomy or jejunostomy tube, may be is a commonly used marker, it is not always a reliable one. Because
indicated. These tubes must be placed either at the time of opera- of albumin’s relatively long half-life, the serum concentration does
tion or subsequently via surgical or percutaneous means, and there not reflect the patient’s more recent nutritional status. In addition,
is some potential for complications.The specific indications for the the measured concentration can change quickly in response to the
use of such tubes are patient derived; they are not routinely associ- infusion of exogenous albumin or to the development of dehydra-
ated with the performance of specific procedures. tion, sepsis, and liver disease despite adequate nutrition. Pre-
albumin is a separate serum protein that has a half-life of approx-
TOTAL PARENTERAL NUTRITION
imately 24 to 48 hours and thus can serve as a marker of current
Total parenteral nutrition (TPN) is a surrogate form of nutri- and more recent nutritional status. Like the albumin concentra-
tion in which dextrose, amino acids, and lipids are delivered via tion, the prealbumin concentration can be affected by liver and
a central venous catheter. It is a reliable method, in that it deliv- renal disease. Overall, however, it is more immediately reliable in
ers nutrients and calories regardless of whether the patient’s gut following the effects of nutritional intervention.
is functioning or not. Nevertheless, multiple studies over the past
20 years have shown that when the patient has a functioning
intestinal tract, enteral feeding is clearly preferable to TPN. Fluid Management
Although the specific mechanisms are not fully understood, Intravenous fluids may be classified into two main categories:
enteral nutrition is known to foster gut mucosal integrity, to sup- resuscitation and maintenance. Supplemental fluids constitute a
port overall immune function, and to be associated with lower third category.
RESUSCITATION FLUIDS citation, with colloid an acceptable substitute when its secondary
Resuscitation fluids maintain tissue perfusion in the setting of effects are desired in specific situations.17,18
hypovolemia by restoring lost volume to the intravascular space. MAINTENANCE FLUIDS
They may be further classified into two subcategories: crystalloids
and colloids. Maintenance fluids provide required daily amounts of free
water and electrolytes (e.g., sodium, potassium, and chloride) in
Crystalloids order to balanced expected daily losses and maintain homeostasis.
Crystalloid solutions are water-based solutions to which elec- A basic rule of thumb used by many practitioners to calculate the
trolytes (and, sometimes, organic molecules such as dextrose) infusion rate for maintenance I.V. fluids is the so-called 4, 2, 1
have been added. The crystalloid solutions used for resuscitation rule:
are generally isotonic to blood plasma and include such common • 4 ml/kg/hr for the first 10 kg of body weight;
examples as 0.9% sodium chloride, lactated Ringer solution, and • 2 ml/kg/hr for the next 10 kg of body weight; and
Plasma-Lyte (Baxter Healthcare, Round Lake, Illinois). The • 1 ml/kg/hr for every 1 kg of body weight above 20 kg.
choice to use one solution over another is usually inconsequential,
but there are a few notable exceptions. For example, in the setting Generally accepted maintenance requirements include 30 to 35
of renal dysfunction, there is a risk of hyperkalemia when potassi- ml/kg/day for free water, 1.5 mEq/kg/day for chloride, 1
um-containing solutions such as lactated Ringer solution and mEq/kg/day for sodium, and 1 mEq/kg/day for potassium. In the
Plasma-Lyte are used. As another example, the administration of setting of starvation or poor oral intake, dextrose 5% is often
large volumes of 0.9% sodium chloride, which has a pH of 5.0 added to maintenance fluids to inhibit muscle breakdown. In reg-
and a chloride content of 154 mmol/L, can lead to hyperchlore- ular practice, however, these specific values are not commonly
mic metabolic acidosis. Regardless of which crystalloid solution is used: more often, a rough estimate is made of expected daily fluid
used, large volumes may have to be infused to achieve a significant requirements, and solutions are ordered in accordance with this
increase in the circulating intravascular volume. Only one third to estimate. Although this practice is unlikely to cause noticeable
one quarter (250 to 330 ml/L) of the fluid administered stays in harm in the majority of postoperative patients, there are situations
the intravascular space; the rest migrates by osmosis into the inter- where inaccurate calculations can lead to dehydration and volume
stitial tissues, producing edema and potential impairment of tissue overload. Three studies from the early 2000s evaluated patients
perfusion (the latter is a theoretical consequence whose existence undergoing elective colorectal surgery with the aim of determin-
has not yet been directly demonstrated).17 ing whether providing higher volumes of fluid perioperatively had
an impact on outcome.19-21 In all three, the data supported the use
Colloids of smaller fluid volumes perioperatively, which was shown to
Colloid solutions are composed of microscopic particles dis- result in earlier return of gut function after operation, shorter hos-
persed in a second substance in such a way that they are sus- pital stays, and overall decreases in cardiopulmonary and tissue-
pended and do not separate out by normal filtration. Colloids healing complications.
are derived from three main forms of semisynthetic molecules:
SUPPLEMENTAL FLUIDS
gelatins, dextrans, and hytroxyethyl starches. All of the common-
ly used synthetic colloids are dissolved in crystalloid solution. Supplemental fluids are given to replace any ongoing fluid loss
Nonsynthetic colloids also exist, including human albumin solu- beyond what is expected to occur via insensible loss and excretion
tions, fresh frozen plasma, plasma-protein fraction, and in urine and stool.They are most commonly required by patients
immunoglobulin solutions. Compared with crystalloid solu- with prolonged NG tube output, enterocutaneous fistulas, diar-
tions, colloid solutions increase the circulating intravascular vol- rhea, high-output ileostomies, or large open wounds associated
ume to a much greater degree per unit of volume infused. In this with excessive insensible fluid loss. In each case, the amount of
respect, the various colloids may be thought of as a single group; fluid lost daily should be calculated, and replacement fluid should
however, in practice, they are most often given selectively on the be given in a quantity determined by this measurement (either as
basis of secondary characteristics other than their volume- a whole or in part) and by the patient’s overall intravascular vol-
increasing action, such as effect on hemostasis, risk of allergic ume status. The particular solution to be used depends on the
reaction, and cost. characteristics of the fluid loss. The components and volume of
the fluids produced in the GI tract are different at different sites
Crystalloids versus Colloids [see Table 1].
The debate over whether crystalloids or colloids are superior for
resuscitation has been going on for at least 30 years. Although
multiple randomized, controlled trials have compared the two Pain Control
types of solutions in a variety of settings, including sepsis, trauma, The topic of postoperative pain control covers a broad spec-
burns, and surgery, the evidence accumulated to date has not trum of possible interventions that serve a wide range of purpos-
established that one is clearly better than the other in terms of es.The most obvious purpose is simply to relieve the suffering and
overall outcome. Supporters of crystalloid resuscitation cite the stress associated with postoperative pain. Another is to improve
risk of altered hemostasis, the increased likelihood of drug inter- the patient’s overall postoperative status. Bringing the patient clos-
actions and allergic reactions, the potential for volume overload, er to the baseline sensory state by reducing pain allows him or her
and the relatively high cost as factors arguing against the use of to engage in activities that promote healing and prevent complica-
colloids. Supporters of colloid resuscitation cite the large volume tions, including mobilization to help prevent deep vein thrombo-
of crystalloid needed to produce significant volume effects, the sis (DVT) and deep breathing and coughing to help prevent pneu-
subsequent tissue edema, and for the potential for impaired tissue monia. Common methods of pain relief include intravenous infu-
perfusion and oxygenation as factors arguing against the use of sion of narcotics, epidural analgesia using local anesthetics with or
crystalloids. Current recommendations favor crystalloid for resus- without narcotics, oral administration of narcotics, and the use of
Table 1—Electrolyte Content and Rate of Production of

Fluids Secreted in the Gastrointestinal Tract
Electrolyte Concentration (mEq/L) Rate of

Source of
Production
Secretion
Na+ K+ Cl– HCO3– H+ (ml/day)
Salivary glands 50 20 40 30 100–1,000

Stomach
Basal 100 10 140 30 1,000
Stimulated 30 10 140 100 4,000
Bile 140 5 100 60 500–1,000
Pancreas 140 5 75 100 1,000
Duodenum 140 5 80 100–2,000
Ileum 140 5 70 50 100–2,000
Colon 60 70 15 30
nonnarcotic oral medications such as nonsteroidal anti-inflamma- ORAL ADMINISTRATION OF NARCOTICS

tory drugs (NSAIDs) and acetaminophen (see below).These and Oral administration of narcotics is one of the oldest methods of
other issues related to postoperative pain control are discussed in providing postoperative pain relief. Numerous different narcotic
greater detail elsewhere [see 1:5 Postoperative Pain]. agents are now available for use in this setting. When deciding
I.V. NARCOTIC ANALGESIA
which narcotic to prescribe, however, physicians typically do not
select freely from the entire available range; rather, they tend to
Intravenous narcotics may be administered either by the med- choose from a small subset of agents that they know well and are
ical staff or, if patient-controlled analgesia (PCA) is feasible, by the comfortable with. A key point to keep in mind is that in some for-
patient. In most cases, with the exception of brief hospital stays (< mulations, narcotics are combined with other compounds (e.g.,
48 hours) and ICU settings where the patient may not be alert acetaminophen or aspirin), and these added medications can have
enough to manage a patient-controlled system, PCA is now gen- side effects of their own if taken in excessively high doses. Such
erally considered preferable to as-needed nurse-administered I.V. formulations may require more careful titration than narcotics
narcotic analgesia. Numerous studies and reviews have shown that alone would. Another key point is that many narcotics are available
PCA is safe and is no more likely to cause side effects (e.g., overse- in both short-acting and long-acting versions. In patients who are
dation, overdose, itching, and nausea) than nurse-administered experiencing substantial postoperative pain, a combination of
I.V. narcotic analgesia is. In addition, the use of PCA improves long-acting agents and short-acting agents may yield more sus-
patients’ subjective perceptions of the efficacy of pain relief and the tained and predictable pain relief than either type alone would.
timeliness of drug administration.22 Finally, for patients who have a history of chronic pain condi-
tions and who regularly used pain medications preoperatively, the
EPIDURAL ANALGESIA
assistance of an acute pain service management team may be
Epidural analgesia usually makes use of a local anesthetic (e.g., invaluable in treating pain postoperatively.
bupivicaine), with or without the addition of a narcotic (e.g., fen-
tanyl). The anesthetic solution is instilled into the epidural space, NSAIDS AND ACETAMINOPHEN
bathing the nerve roots in a given region and thereby providing NSAIDs are available both by prescription and over the counter.
pain relief. Until the past decade or so, epidural analgesia was con- They not only provide effective analgesia for pain from minor pro-
sidered a more dangerous method of pain relief and was not rou- cedures but also may be a powerful adjunct to narcotics in more
tinely employed outside the ICU. With time and further observa- acute hospital settings. Their major disadvantages, which in some
tion has come the recognition that epidural analgesia is safe and contexts are substantial enough to limit their use, include their
effective for postoperative pain control in a routine floor setting if propensity to cause gastric irritation and ulceration; their antiplatelet
managed by the proper supporting team of physicians. effects, which increase the tendency toward bleeding; and their
There has been some debate regarding whether epidural anal- potential nephrotoxic effects in some formulations.When employed
gesia leads to earlier return of bowel function after GI surgery or in settings where these disadvantages are not considered to pose a
reduces the incidence of pulmonary complications; at present, this high risk, NSAIDs can be a useful addition to narcotics, both by
debate remains unresolved. There is clear evidence, however, that providing further pain relief and by reducing the required narcotic
patients subjectively experience less pain with epidural analgesia, doses (and thus the incidence of narcotic-related side effects).
both at rest and in the course of activities such as mobilization and Like the NSAIDs, acetaminophen provides minor pain relief
coughing. Moreover, in patients who have sustained traumatic rib and is an antipyretic, but unlike the NSAIDs, it has no anti-
fractures, early use of epidural analgesia in place of I.V. narcotic inflammatory effect. Acetaminophen also is often added to narcot-
analgesia has been shown to reduce the incidence of associated ic regimens or formulations to reduce the need for narcotics. Its
pneumonia and shorten the time for which mechanical ventilation greatest potential side effect is hepatic toxicity with excessive use.
is required.23 Epidural analgesia does have certain drawbacks, Accordingly, the dosage should be less than 2 g/day in patients
including an increased incidence of orthostatic episodes and a with normal hepatic function and even lower in those with
need for more frequent adjustments of the medication dosage. impaired hepatic function. It is particularly important to keep
Nevertheless, it can be highly effective and can be a reasonable these dose limits in mind when narcotic-acetaminophen combina-
option when judged appropriate by the anesthesiologist and tions are prescribed on an as-needed basis; in this situation, safe
agreed to by the patient.24,25 dosage limits may well be exceeded if sufficient care is not taken.
Glycemic Control
involving laparotomy—especially bowel resections—where intra-
Over the last decade, blood glucose control in the postoperative abdominal abscess is a possible complication).
period has become a topic of great interest. Many studies, begin-
ning with that of Van den Berghe and associates in 2001,26 have PNEUMONIA
found that strict glucose control reduces morbidity and mortality Respiratory infections in the postoperative period are generally
in critically ill surgical ICU patients. Although most of the data considered nosocomial pneumonias and, as such, are potentially
currently available are derived from ICU patients rather than from serious complications [see 8:16 Nosocomial Infection].The estimat-
the surgical population as a whole, the principle of tight glycemic ed incidence of postoperative pneumonia varies significantly, with
control has been generalized to apply to most postoperative many estimates tending to run high. A 2001 study of more than
patients. 160,000 patients undergoing major noncardiac surgery provided
The target glucose range has been the subject of debate, with what may be a reasonable overall figure, finding the incidence of
most institutions using a range of 80 to 140 mg/dl. The ability to postoperative pneumonia to be approximately 1.5%.29 In the
achieve this target range and the means of achieving it vary 2,466 patients with pneumonia, the 30-day mortality was 21%.
according to the level of nursing care that is provided. Options Thoracic procedures, upper abdominal procedures, abdominal
include continuous I.V. insulin infusion and combinations of subaortic aneurysm repair, peripheral vascular procedures, and neu-
cutaneous injections that utilize various long- and short-acting rosurgical procedures were all identified as placing patients at sig-
insulin formulations. Episodes of hypoglycemia are an ever-pre- nificantly increased risk for pneumonia. Patient-specific risk fac-
sent risk with tight glucose control; accordingly, the use of stan- tors included age greater than 60 years, recent alcohol use, depen-
dard dosage regimens and careful monitoring are recommended dent functional status, long-term steroid use, and a 10% weight
to reduce the risk of such episodes. loss in the 6 months preceding the operation.29
The debate over the specifics of glycemic control notwithstand- The diagnosis of postoperative pneumonia is based on the
ing, it is generally well accepted that this issue should be addressed usual combination of index of suspicion, findings from the histo-
in all patients who have undergone major operative procedures, ry and physical examination (e.g., fever, shortness of breath,
regardless of whether they carry a preoperative diagnosis of dia- hypoxia, productive cough, and rales on lung auscultation), imag-
betes mellitus.26,27 ing, and laboratory evaluation [see 8:17 Postoperative and Ventilator-
Associated Pneumonia]. Appropriate workup, directed by the clini-
cal findings, typically starts with chest x-rays (preferably in both
Postoperative Complications posteroanterior and lateral views, if possible) and sputum cul-
There are numerous complications that may arise in the post- tures, sometimes accompanied by CT scanning of the chest and,
operative period. Many of these are specific to particular operative possibly, bronchoscopy with bronchoalveolar lavage (which may
procedures and hence are best discussed in connection with those be useful in directing antibiotic therapy when sputum cultures are
procedures. Many others, however, may develop after virtually any nondiagnostic). Empirical broad-spectrum antibiotic therapy is
operation and thus warrant a general discussion in this chapter typically initiated before the causative organism is identified; this
(see below). Prompt discovery and treatment of these latter com- practice has been shown to reduce mortality. Piperacillin-tazobac-
plications relies heavily on a sufficiently high index of suspicion. tam, which is effective against Pseudomonas aeruginosa, is com-
monly used for this purpose; however, when Gram’s staining of
POSTOPERATIVE FEVER
the sputum identifies gram-positive cocci, vancomycin or linezol-
Postoperative temperature elevations are quite common, occur- id may be used initially instead.30 Once the causative organism is
ring in nearly one third of patients after surgery. Only a relatively identified, specific antibiotic therapy directed at that organism is
small number of these are actually caused by infection. Fevers that indicated, as in treatment of other infectious processes. Drainage
are caused by infections (e.g., pneumonias, wound infections, or of parapneumonic effusions may also be necessary, and this mea-
urinary tract infections) tend to reach higher temperatures (> sure may be helpful in diagnosing or preventing the development
38.5°C), usually are associated with moderate elevation of the of empyema.
white blood cell (WBC) count 3 or more days after operation, and
typically extend over consecutive days. Noninfectious causes of SURGICAL SITE INFECTION
postoperative fevers include components of the inflammatory Surgical site infection (SSI) is one of the most common post-
response to surgical intervention, reabsorption of hematomas, and operative complications and may occur after virtually any type of
(possibly) atelectasis.28 procedure [see 1:2 Prevention of Postoperative Infection]. Rates of
Beyond checking the WBC count, a shotgun approach to the infection vary widely (from less than 1% to approximately 20%),
workup of postoperative fever probably is not warranted. A depending on the procedure performed, the classification of the
focused approach based on well-directed questioning and a care- operative wound (clean, clean-contaminated, contaminated, or
ful physical examination is more likely to obtain the highest diag- dirty), and a host of patient-related and situation-specific fac-
nostic yield. Coughing, sputum production, and respiratory effort tors. The majority of SSIs, regardless of site, are caused by skin-
should be noted, and the lungs should be auscultated for rales. All based flora, most commonly gram-positive cocci (e.g., staphylo-
incisions should be inspected for erythema and drainage, and cur- cocci). Gram-negative infections are also commonly seen after
rent and recent I.V. sites should be checked for evidence of celluli- GI procedures, and anaerobes may be present after pharyngoe-
tis. If a central line has been placed, particularly if it has been in sophageal procedures.31 With SSI, as with other postoperative
place for several days, the possibility of a line infection should be infectious complications, prompt recognition of the signs and
considered. Patients who have undergone prolonged nasogastric symptoms is the key to successful management. Hence, regular
intubation may have sinusitis, which is most readily diagnosed examination of the wound, particularly in the setting of postop-
through computed tomography of the sinuses. Further workup for erative fever, is critical. Erythema and induration (indicative of
fever may include, as indicated, chest x-ray, sputum cultures, uri- cellulitis) are obvious signs of SSI, as is active drainage of pus
nalysis, blood cultures, or CT of the abdomen (after procedures from the wound. A more subtle sign is pain that is greater than
CARDIAC COMPLICATIONS
expected, especially when the pain seems to be increasing sever-
al days after operation. Cardiac dysrhythmias may occur after a wide variety of surgical
In most cases, it is necessary to open and drain the wound procedures; as one might imagine, they are most common after
(which is easily done at the bedside or in the clinic in most cases) cardiac operations. Predisposing factors and possible causes are
and allow it to heal via secondary intention. Generally, wet-to-dry numerous and various, including underlying cardiac disease, peri-
dressing changes with saline are employed; however, larger operative systemic stress, electrolyte and acid-base imbalances,
wounds may benefit from NPWT [see Care Orders,Wound Care, hypoxemia, and hypercarbia.Thus, controlling such conditions to
above]. Success with NPWT has been widely reported, and this the extent possible both preoperatively and postoperatively is an
technique has been used to treat such difficult wounds as exposed important part of preventing and managing postoperative cardiac
vascular grafts and sternotomy infections.32,33 The use of antibi- dysrhythmias. Treatment generally involves first achieving hemo-
otics depends on the presence and degree of cellulitis. The initial dynamic stability and then converting the rhythm back to sinus if
choice of an agent should be guided by the likelihood that partic- possible.
ular organisms will be present, which is estimated on the basis of Supraventricular tachycardias (SVTs) are the dysrhythmias
the site of the operation and the type of procedure being per- most commonly seen in the postoperative period, occurring after
formed. Whenever possible, any purulent material in the SSI approximately 4% of noncardiac major operations. Atrial fibrilla-
should be cultured; this step may permit more targeted antimicro- tion and atrial flutter account for the majority of SVTs.38
bial therapy. Ventricular rate control may be achieved pharmacologically by
infusing diltiazem. Digoxin has long been used for this purpose,
DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM
but it is less effective in acute settings than diltiazem is. Amioda-
In the absence of appropriate prophylaxis, the incidence of rone, which is used to treat ventricular dysrhythmias [see 8:2 Acute
DVT may be as high as 30% in abdominal and thoracic surgery Cardiac Dysrhythmia], may also be used to restore sinus rhythm post-
patients, and that of fatal pulmonary embolism (PE) may be as operatively in some cases, especially after cardiac procedures.39 When
high as 0.9%. Thus, prophylaxis against thromboembolism is pharmacologic rate control is not possible, particularly in hypoten-
clearly of high importance in the postoperative care of many sive patients, cardioversion is indicated.
patients [see 6:6 Venous Thromboembolism]. Major risk factors for Approximately one third of patients who undergo noncardiac
DVT and PE in this setting include the operation itself, physical surgery in the United States have some degree of coronary artery
immobility, advanced age, the presence of a malignancy, obesity, disease and thus are at increased risk for perioperative MI. The
and a history of smoking.34 incidence of coronary artery disease is even higher in certain sub-
DVT should be suspected postoperatively whenever a patient com- populations, such as patients who undergo major vascular proce-
plains of lower-extremity pain or one leg is noticeably more swollen dures.40,41 In the perioperative setting, however, the pathophysiol-
than the other. The gold standard for diagnosis remains a venous ogy of coronary ischemia is different from that in nonsurgical set-
duplex examination, which has a sensitivity of 97% for detecting DVT tings, where plaque rupture is the most common cause of MI.
of the femoral and popliteal veins.35 In most cases, treatment involves Approximately 50% of all MIs occurring in surgical patients are
starting a heparin infusion (typically without a loading bolus in the caused by increased myocardial oxygen demand in the face of
postoperative setting), targeting a partial thromboplastin time inadequate supply resulting from factors such as fluid shifts, phys-
(PTT) that is double to triple the normal PTT (i.e., approximate- iologic stress, hypotension, and the effects of anesthesia. The
ly 60 to 80 seconds), and then switching to warfarin therapy when majority of cardiac ischemic events occur in the first 4 days of the
the patient is stable and able to tolerate oral medications. postoperative period.41
PE should be suspected whenever a postoperative patient expe- Perioperative beta blockade for patients at risk for MI is now
riences a decrease in oxygen saturation or shortness of breath; this routine. Multiple trials and meta-analyses have demonstrated that
decrease may be accompanied by chest pain, tachycardia, and this practice yields significant risk reductions in terms of both car-
diaphoresis, all of which may also be seen in the setting of myocar- diac morbidity and mortality42,43 and that these risk reductions are
dial infarction (MI).When PE is suspected, it may be appropriate achieved regardless of the type of surgery being performed. Although
to start heparin therapy even before the diagnosis has been con- there has been some variation in the protocols used by these trials
firmed, depending on the degree of suspicion and the relative risk and the results reported, there is general agreement that beta
anticoagulation may pose to the patient. Currently, the principal blockade should be initiated preoperatively, delivered at the time
means of diagnosing acute PE is spiral CT. This modality has rel- of surgery, and continued postoperatively for up to 1 week.42
atively wide availability, can be performed fairly rapidly, and has a Diagnosis of postoperative MI is complicated by the fact that as
sensitivity of 53% to 100% and a specificity of 81% to 100%. In many as 95% of patients who experience this complication may not
addition, it is readily usable in most critically ill patients, including present with classic symptoms (e.g., chest pain). Identification of
those undergoing mechanical ventilation (though the amount of MI may be further hindered by the ECG changes brought on by
I.V. contrast material it requires may limit its use in patients with the stress of the perioperative period (including dysrhythmias).
renal insufficiency). Greater diagnostic yield may be obtained by Ultimately, the most useful signal of an ischemic cardiac event in
combining spiral CT with a lower-extremity venous duplex exam- the postoperative period is a rise in the levels of cardiac enzymes,
ination.36 For most patients with postoperative PE, anticoagula- particularly troponin-I. Accordingly, cardiac enzyme activity should
tion is administered in the form of heparin. Low-molecular-weight be assessed whenever there is a high index of suspicion for MI or a
heparins (LMWHs) are also generally safe and effective; however, patient is considered to be at significant perioperative risk for MI.40
because their effect cannot be turned off in the same way as that Treatment of postoperative MI focuses on correcting any fac-
of I.V. unfractionated heparin, they may be less useful in the peri- tors contributing to or exacerbating the situation that led to the
od after operation.37 In patients with massive PE, surgical embo- event (e.g., hypovolemia or hypotension). Typically, although
lectomy or suction-catheter embolectomy may be considered, as antiplatelet agents (e.g., aspirin) are sometimes given, thrombolyt-
conditions warrant. Thrombolytic therapy is generally contraindi- ic therapy is avoided because of concerns about postoperative
cated in the postoperative setting. bleeding. Acute percutaneous coronary intervention is also associ-
ated with an increased risk of bleeding, but it has nonetheless been Over the past two decades, critical pathways, which are orga-
used successfully in the perioperative setting and is recommended nized plans that outline the sequence of patient care and dis-
by some physicians.44 Beta blockade is often advocated as a means charge, have been increasingly used in managing postoperative
of treating postoperative MI, though it is probably more effective care after a variety of procedures from all disciplines. They have
when used both preoperatively and perioperatively as a means of been shown to reduce hospital stays and maintain safety in
preventing MI.40 patients undergoing common procedures (e.g., colectomy),
patients undergoing complex procedures (e.g., esophagectomy),47
and patients with high comorbidity.48 Individual pathways are typ-
Discharge ically specific to a hospital or health care system; thus, the dis-
Planning for discharge from the hospital is clearly an essential charge criteria are those agreed on by the providers involved in the
part of perioperative care. In the best of circumstances, discharge care of eligible patients at that particular institution. Critical path-
planning starts before admission for elective surgery and is dis- ways can be helpful not only by standardizing care and improving
cussed with the patient and family as part of preoperative patient the relative appropriateness of postoperative discharge but also, in
education. Starting the process early enables the provider to esti- many cases, by decreasing the overall length of postoperative hos-
mate the patient’s probable needs at the end of acute hospitaliza- pitalization.46 In a 2003 study of 27 postoperative critical path-
tion and thus to make preliminary arrangements as needed. For ways used at the Johns Hopkins Hospital, the authors found that
example, if it appears likely that the patient will have to stay in a seven (27%) of the pathways were associated with significant (5%
skilled nursing or extended care facility or will require prolonged to 45%) decreases in length of stay.49
physical therapy and rehabilitation, these matters can be Regardless of whether critical pathways are implemented, if dis-
addressed to the mutual satisfaction of both patient and physician charge planning is not addressed preoperatively, addressing it as
in advance of hospital discharge. In this way, delays in discharge early as possible in the postoperative period is extremely valuable
and unnecessary days of acute hospitalization can be avoided, at not only for ensuring an appropriate length of stay but also for
least in some instances. maintaining the satisfaction and comfort of both patient and fam-
Criteria for discharge or transfer from acute hospital care vary ily. Specific issues should be addressed at this point as needed,
widely, depending on the procedure, the provider, and the patient; including the home resources and support available to the patient,
rarely are they codified. For example, in a 2005 survey of 16 sur- wound care, ostomy care, management of feeding tubes and
geons performing open colorectal resections within one hospital, drains, I.V. antibiotic therapy, and physical rehabilitation.Thus, as
only two factors—absence of complications and reported postop- soon as it appears that a patient is on track either for discharge
erative bowel movement—were considered criteria for early dis- home or for transfer to a rehabilitation or skilled nursing facility, a
charge by most (but not all) of the surgeons.45 There was wide dis- discussion with the appropriate social work or discharge planning
agreement on all other criteria, including postoperative mobility personnel should be scheduled. Physical therapy and occupation-
and the ability to tolerate a general diet. Given such variation in al therapy (PT/OT) evaluations early in the postoperative course
discharge criteria for even one category of procedure, it is clear can also be of great assistance in determining a patient’s needs
that a discussion of specific criteria for each type of surgery is well upon discharge, and such evaluations are essential for any patient
beyond the scope of this chapter. It is worth pointing out, howev- who may need a stay in an inpatient rehabilitation facility.Typically,
er, that the various discharge criteria now in use, despite their dif- it requires at least 1 day to set up services such as home health care
ferences, have a common basis—namely, the idea that at dis- and outpatient physical therapy, and it may take this long or longer
charge, the patient should ideally be able to manage basic self-care to obtain a bed at an appropriate rehabilitation or skilled nursing
activities (e.g., feeding, wound care, and mobility) without facility. Consequently, the earlier these plans are made, the better.
advanced assistance and that the likelihood of readmission should For many surgical patients, formal discharge planning and PT/OT
be minimized to the extent possible. Identification, investigation, evaluations are not actually necessary. Brief discussions with the
and control of factors such as nausea, pain, fever, deconditioning, patient, the family, or the nursing staff caring for the patient will
and fatigue are important in determining whether a patient is at assist in determining which surgical patients are most likely to
risk for a return to the hospital in the postoperative period.46 benefit from this approach.
References
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Engl J Med 345:1345, 2001 issues: postoperative arrhythmias. Surg Clin North pathways effective for reducing postoperative
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1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 7 ACUTE WOUND CARE — 1
7 ACUTE WOUND CARE

Stephen R. Sullivan, M.D., Loren H. Engrav, M.D., F.A.C.S., and Matthew B. Klein, M.D.
Approach to Acute Wound Management
Acute wounds are the result of Wound Preparation

local trauma and may be asso-
ciated with severe life-threaten- ANESTHESIA
ing injuries. The approach to a Adequate general or local
patient with an acute wound anesthesia, preceded by care-
begins with assessment of the ful motor and sensory exami-
ABCs (Airway, Breathing, and nation, must be instituted
Circulation). Management of before examination and treat-
any life-threatening injuries present is addressed first; only after ment of the wound can begin. General anesthesia in the OR is
more urgent problems have been ruled out or corrected is manage- employed if the patient is unable to tolerate local anesthesia; ade-
ment of the wound itself addressed. A complete history is obtained quate pain control cannot be achieved with a local block; the
and a thorough physical examination performed, with special wound requires significant debridement, exploration, or repair;
attention paid to both local and systemic wound environment fac- bleeding is difficult to control; or the local anesthetic dose required
tors that may affect healing. Information about the cause of injury for adequate pain control exceeds the maximum dose that can be
is sought. In the case of a hand injury, the patient’s hand domi- safely delivered. Local anesthesia is usually sufficient for debride-
nance and occupation are determined. All patients with acute ment and closure of most small traumatic wounds. Often, the local
wounds should be assessed for malnutrition, diabetes, peripheral anesthetic may be injected directly into wounded tissue. However,
vascular disease, neuropathy, obesity, immune deficiency, autoim- direct wound injection may be less reliable in inflamed or infected
mune disorders, connective tissue diseases, coagulopathy, hepatic tissue or may distort important anatomic landmarks used to align
dysfunction, malignancy, smoking practices, medication use that wound edges. In these situations, regional nerve blocks directed at
could interfere with healing, and allergies. The local wound envi- specific sensory nerves outside the injured field may be employed
ronment should be evaluated to determine the extent and com- instead.
plexity of injury, the tissues involved, the presence or absence of The main injectable anesthetics can be broadly divided into
contamination by microorganisms or foreign bodies, and the amides and esters [see Table 1]. (An easy way of remembering
degree of any damage related to previous irradiation or injury to which category an agent belongs to is to recall that the amides all
surrounding tissues. have two Is in their generic name, whereas the esters have only
Gloves and a shielded mask are worn to protect the practition- one.) Lidocaine, an amide, is the most commonly used local anes-
er from exposure to body fluids. Gloves must be powder free, as thetic. Its advantages include its rapid onset of action (< 2 min-
well as latex free (to prevent allergic reactions to latex).1 The utes), its extended duration of action (60 to 120 minutes), its rel-
wound is carefully examined, with particular attention paid to ative safety in comparison with more potent anesthetics (e.g.,
size, location, bleeding, arterial or venous insufficiency, tissue bupivacaine), and its availability in multiple forms (e.g., liquid,
temperature, tissue viability, and foreign bodies.The possibility of jelly, and ointment) and concentrations (e.g., 0.5%, 1.0%, and
damage to vessels, nerves, ducts, cartilage, muscles, or bones in 2.0%). In addition, lidocaine rarely causes allergic reactions,
proximity to the injury is assessed. X-rays and a careful motor whereas ester anesthetics (e.g., tetracaine) are metabolized to
and sensory examination may be required to rule out such coex- para-aminobenzoic acid, to which some persons are allergic.
isting injuries.While these tests are being performed, moist gauze Cocaine, an ester, is an excellent local anesthetic for wounds in
should be applied to wounds. For thorough assessment of
injuries, it may be necessary to probe ducts (e.g., the parotid duct
or the lacrimal duct). Table 1—Common Injectable Anesthetics3
At this point, decisions must be made about acute wound care.
The goal of acute wound management is a closed, healing wound Amides Esters
that will result in the best functional and aesthetic outcome. In
what follows, we address the key considerations in management of Lidocaine (Xylocaine) Procaine (Novocain)
Bupivacaine (Marcaine) Chloroprocaine (Nesacaine)
the acute wound, including anesthesia, choice of repair site (i.e.,
Mepivacaine (Carbocaine) Tetracaine (Pontocaine)
operating room or emergency department), debridement, irriga-
Prilocaine (Citanest) Benzocaine (multiple brands)
tion, hemostasis, closure materials, timing and methods of closure, Etidocaine (Duranest) Propoxycaine (Ravocaine)
appropriate closure methods for specific wound types, dressings, Phenocaine Cocaine
adjunctive treatment (e.g., tetanus and rabies prophylaxis, antibi- Dibucaine (Nupercainal)
otics, and nutritional supplementation), postoperative wound Ropivacaine (Naropin)
care, and potential disturbances of wound healing. Finally, we Levobupivacaine (Chirocaine)
briefly review the physiology of wound healing.
Patient presents with acute wound Initial measures are complete, and wound care is initiated
Prepare wound:
Obtain complete history, and perform thorough physical
examination. Life-threatening conditions take priority • Anesthesia: use local anesthesia in most cases. Use general
over wound care. anesthesia if local anesthesia cannot be tolerated, if pain cannot be
controlled with local anesthesia, if wound requires significant repair,
Examine local wound environment, look for local and
if bleeding is hard to control, or if local anesthetic dose needed
systemic factors that may impair healing, and identify
would be unsafe.
wounded structures.
• Debridement: debride necrotic tissue, and remove foreign bodies.
Consider antibiotic prophylaxis for clean or clean-
If there is significant questionably viable tissue, defer debridement
contaminated wounds if factors likely to impair wound
until status is clarified, and initiate dressing changes.
healing [see Table 7] are present. Initiate antibiotic
prophylaxis for contaminated and dirty wounds and • Irrigation: use only nontoxic irrigants, avoiding antibiotics and strong
for wounds with extensive devitalized tissue. antiseptics. Low pressure is preferable to high pressure (but bulb
syringe is inadequate).
• Hemostasis: use pressure, cauterization, or ligation (but do not
ligate lacerated arteries proximal to amputated part). Place drain if
there is risk of hematoma or fluid collection.
Abrasion Laceration Crush injury
Remove foreign bodies to prevent Close immediately if patient presents with Severity of injury is not always
traumatic tattooing. clean wound within 8 hr of injury (or 24 hr for apparent.
Allow healing by secondary closure. simple facial injury). Otherwise, delay closure Monitor for compartment syndrome,
Tape or glue may be used. or allow wound to heal without closure. and treat on urgent basis.
Close deep laceration in layers.
Puncture wound Complex wound Extravasation injury
Leave wound open, and Inform patient of potential for poor aesthetic Conservative management (i.e., elevation,
allow healing by outcome, and discuss alternatives. ice, and monitoring) suffices in most cases.
secondary closure. Close immediately if wound is clean and tissue Injury involving high volume, high osmolarity,
viable. Delay closure if wound is contaminated or chemotherapeutic agent may necessitate
or there is significant nonviable or questionably additional measures (e.g., hydrocortisone,
viable tissue. incision and drainage, hyaluronidase, saline,
Perform primary closure if possible. Severe injury or aspiration).
may necessitate delayed primary closure,
secondary closure, skin grafting, or tissue transfer.
Consider tetanus treatment, antibiotic

prophylaxis, or both.
Apply dressings as appropriate
for individual wound type.
Abrasion Laceration, complex wound closed primarily, injection injury,

high-velocity wound, bite wound, or sting
Use occlusive dressings (impregnated
gauze may be used for small superficial
Consider three-layer dressings for open draining wound, with inner
wounds). Avoid dry dressings.
nonadherent layer, middle absorbent layer, and outer binding layer.
Consider ointment if there is minimal drainage.
Wound is ready for closure
Select closure materials: sutures, tapes, staples, or adhesives.

Determine timing and methods of closure:
• Immediate primary closure: clean wound without contraindications
to closure
• Delayed primary closure: contaminated wound, wound with
questionably viable tissue, or patient who cannot tolerate immediate
closure Approach to
• Secondary closure (allowing wound to heal by itself): wound with
contamination or contraindication to closure, patient who cannot
Acute Wound Management
tolerate closure, or wound for which closure is not needed for
aesthetic result
• Skin grafting: large superficial wound
• Tissue transfer: large wound with exposed vital structure
Formulate specific closure approach suitable for individual wound type.
Injection injury Bite wound
Wound appearance is often deceptively benign. Take into account risks of rabies, bacterial and other viral
Examine wound area carefully and obtain infections, and envenomation.
appropriate radiographs. Treat with exploration, irrigation, and debridement.
Treat aggressively with incision, wide exposure, Close immediately if wound is clean and tissue viable. Delay
debridement, and removal of foreign bodies. closure if wound is contaminated or there is significant nonviable
Allow healing by secondary closure. or questionably viable tissue.
Perform primary closure if possible. Severe injury may necessitate
secondary closure, skin grafting, or tissue transfer.
Consider rabies treatment, rabies prophylaxis, or both.
High-velocity wound Sting
Wound appearance is often deceptively Take into account risk of envenomation.

benign; foreign bodies are frequently present. Symptoms may be local or systemic.
Examine wound area carefully and obtain Treatment is usually directed toward local
appropriate radiographs. symptoms. For systemic reactions,
Debride wound extensively and identify epinephrine, diphenhydramine, and
all injured tissue. supportive airway and BP care may be
Avoid immediate primary closure. Perform required.
delayed primary closure or allow healing by
secondary closure.
Complex wound left open or closed after delay Extravasation injury or crush injury
Generally, use wet-to-dry dressings; use wet-to-wet Avoid compression dressings.

dressings if wound bed contains tendons, arteries,
nerves, or bone. Avoid compression dressings.
Consider NPWT for large open wound.
mucous membrane (e.g., those in the nose or the throat). It is sive bacterial contamination. To reduce the risk of infection in an
unique among local anesthetics in that it causes vasoconstriction, acute wound, necrotic tissue and foreign bodies must be re-
which helps reduce hemorrhage.Typically, cocaine is applied top- moved.11 The wound and the surrounding local tissue must be
ically by soaking gauze or pledgets in a solution. exposed so that necrotic tissue can be identified and debrided.
Vasoconstriction can also be produced by adding epinephrine to Hair may be trimmed with scissors or an electric clipper or re-
a local anesthetic, usually in a dilution of 1:100,000 or 1:200,000 tracted with an ointment or gel to facilitate exposure, debride-
(5 to 10 μg/ml). Through vasoconstriction, epinephrine prolongs ment, and wound closure. Close shaving with a razor should be
the anesthetic agent’s duration of action, allows a larger dose to be avoided, however, because it potentiates wound infections.12 Clip-
safely administered, and aids in hemostasis.2 Traditionally, local ping of eyebrows should also be avoided, both because the eye-
anesthetics with epinephrine have not been used in finger and toe brows may not grow back and because the hair is necessary for
wounds, because of the theoretical risk of ischemia and tissue loss; proper alignment.
however, these adverse effects have not yet been reported clinically Some wounds contain a significant amount of questionably
or documented by any prospective studies.3 viable tissue. If there is enough questionably viable tissue to pre-
Local anesthetics can cause systemic toxicity when injected clude acute debridement, dressing changes may be initiated.When
intravascularly or given in excessive doses. Manifestations of sys- all tissue has been declared to be either viable or necrotic and
temic toxicity begin with central nervous system effects (e.g., verti- when the necrotic tissue has been debrided surgically or by means
go, tinnitus, sedation, and seizures) and may progress to cardiovas- of dressing changes, the wound can be closed.
cular effects (e.g., hypotension, cardiac conduction abnormalities, Most foreign bodies are easily removed from wounds either by
and cardiovascular collapse).Treatment for systemic toxicity is sup- hand or via surgical debridement. Abrasion injuries or gunpowder
portive, with oxygen, airway support, and cardiovascular bypass (if explosions can cause small foreign body fragments to be embed-
necessary) provided until the anesthetic has been metabolized by ded in and beneath the skin. These small foreign bodies are often
the liver.The maximum safe dose of lidocaine is 3 to 5 mg/kg with- difficult to extract but should be removed as soon after the injury
out epinephrine and 7 mg/kg with epinephrine. Doses as high as 55 as possible. Irrigation usually suffices for removal of loose foreign
mg/kg have been used without toxicity for tumescent anesthesia in bodies, but surgical debridement with a small drill, a sharp instru-
patients undergoing liposuction4; however, in this scenario, some of ment, or a brush may be required for removal of more firmly
the anesthetic is aspirated by the liposuction, which means that the embedded foreign material. If the interval between injury and
effective dose is lower. The lidocaine doses used for local wound treatment exceeds 1 to 2 days, the wounds will begin to epithelial-
injection should be substantially smaller than those used in liposuc- ize and the embedded material will be trapped in the skin, result-
tion.The maximum safe dose of cocaine is 2 to 3 mg/kg.To prevent ing in traumatic tattooing.
local anesthesia from causing systemic toxicity, the recommended
IRRIGATION
safe doses of the anesthetics should not be exceeded, and aspiration
should be performed before injection into the wound to ensure that After debridement of necrotic tissue and foreign bodies, the
the agent will not be injected intravascularly. next step is irrigation of the wound.This may be accomplished by
The pain associated with injection of the local anesthetic can be means of several different methods, including bulb syringe irriga-
minimized by using a small-caliber needle (27 to 30 gauge), warm- tion, gravity flow irrigation, and pulsatile lavage. These methods
ing the anesthetic, injecting the agent slowly, using a subcutaneous can be further divided into high-pressure (35 to 70 psi) and low-
rather than an intradermal injection technique,5 providing coun- pressure (1 to 15 psi) delivery systems. High-pressure pulsatile
terirritation, buffering the anesthetic with sodium bicarbonate to lavage reduces bacterial concentrations in the wound more effi-
reduce acidity (in a 1:10 ratio of sodium bicarbonate to local anes- ciently than low-pressure and bulb syringe irrigation do,13 but it
thetic),6 and applying a topical local anesthetic before injection. also causes considerable disruption to soft tissue structure14 and
Topical local anesthetics (e.g., TAC [tetracaine, adrenaline (epi- results in deeper penetration and greater retention of bacteria in
nephrine), and cocaine] and EMLA [a eutectic mixture of lido- soft tissue than low-pressure lavage does.15 In general, low-pres-
caine and prilocaine]) are as effective as injectable anesthetics when sure systems should be employed for acute wound irrigation,
applied to an open wound.7 EMLA requires approximately 60 though merely running saline over a wound is of little value. To
minutes to induce sufficient anesthesia for open wounds; TAC obtain continuous irrigation with pressures as low as 5 to 8 psi,
requires approximately 30 minutes.8 EMLA is more effective than one group recommended using a saline bag in a pressure cuff
TAC for open wounds of the extremity. Benzocaine 20% (in gel, inflated to 400 mm Hg and connected to I.V. tubing with a 19-
liquid, or spray form) can also be used for topical anesthesia and is gauge angiocatheter.16
frequently employed before endoscopic procedures. It is poorly Only nontoxic solutions (e.g., 0.9% sterile saline, lactated
absorbed through intact skin but well absorbed through mucous Ringer solution, sterile water, and tap water) should be used for
membranes and open wounds. A 0.5- to 1-second spray is usually wound irrigation.17 Irrigation with an antibiotic solution appears
recommended, though even with a standardized spray duration, to offer no advantages over irrigation with a nonsterile soap solu-
the delivered dose can vary considerably.9 A 2-second spray results tion, and the antibiotic solution may increase the risk of wound-
in a statistically, though not clinically, significant increase in methe- healing problems.18 Strong antiseptics (e.g., povidone-iodine,
moglobin levels.10 Methemoglobinemia is a rare but life-threaten- chlorhexidine, alcohol, sodium hypochlorite, and hydrogen perox-
ing complication of benzocaine spray use. If symptoms of methe- ide) should not be placed directly into the wound, because they
moglobinemia develop (e.g., cyanosis or elevated methemoglobin are toxic to the tissues and impede healing. The surrounding skin
levels on cooximetry), prompt treatment with intravenous methyl- should be prepared with an antibacterial solution, and a sterile
ene blue, 1 to 2 mg/kg, is indicated.9 field created to limit contamination.
DEBRIDEMENT HEMOSTASIS
Normal healing can proceed only if tissues are viable, if the In most wounds, hemorrhage can be readily controlled with
wound contains no foreign bodies, and if tissues are free of exces- pressure, cauterization, or ligation of vessels. Lacerated arteries
proximal to amputated parts such as fingers or ears, however, increase the risk of infection. Monofilament sutures hold knots less
should not be ligated, because an intact vessel is necessary for well than multifilament sutures, requiring five knots for security;
microsurgical replantation. Packing, wrapping, and elevating can multifilament sutures are easier to handle and require only three
help control hemorrhage temporarily. If necessary (though the knots.With all sutures, the knots must be square to be secure and
need should be rare), a tourniquet may be applied to an injured must be only tight enough to coapt the wound edges.To minimize
extremity. Hemostasis prevents hematoma formation, which in- foreign body bulk, buried suture knot ends should be cut right on
creases the risk of infection and wound inflammation. If there ap- the knot. In terms of absorbability, either absorbable or nonab-
pears to be a potential risk of hematoma or fluid collection, drains sorbable sutures may be appropriate, depending on the situation.
should be placed. Although drains may help prevent accumulation Absorbable sutures are generally used for buried sutures to approx-
of blood or serum in the wound, they are not a replacement for imate deep tissues (e.g., dermis, muscle, or fascia). Absorption of
meticulous hemostasis. Drains facilitate approximation of tissues, synthetic suture material occurs by hydrolysis and causes less tis-
particularly under flaps; however, they also tend to potentiate bac- sue reaction than absorption of natural suture material, which
terial infections and should therefore be removed from the wound occurs by proteolysis. Nonabsorbable sutures (e.g., those made of
as soon as possible.19 silk, nylon, polyester, or polybutester) are most commonly used for
As a rule, drains can be safely removed when drainage reaches wounds in the skin, from where they will eventually be removed, or
levels of 25 to 50 ml/day. If a hematoma or seroma forms, the sub- for wounds in deeper structures that require prolonged support
sequent course of action depends on the size of the fluid collec- (e.g., abdominal wall fascia, tendons, nerves, and blood vessels).
tion. Small hematomas and seromas usually are reabsorbed and Staple closure is less expensive and significantly faster than
thus can be treated conservatively. Larger hematomas and sero- suture closure, and it offers a slightly, though not significantly, bet-
mas provide a significant barrier to healing, and treatment may ter cosmetic outcome when used to close scalp wounds.22,23 Con-
require reopening the wound and placing drains. Intermittent taminated wounds closed with staples have a lower incidence of
sterile aspirations, followed by application of a compressive dress- infection than those closed with sutures.24 In addition, staple clo-
ing, may be indicated for seromas. If this approach fails to elimi- sure eliminates the risk that a health care provider will experience
nate the seroma, a drain may be reintroduced. a needle stick, which is a particularly important consideration in
caring for a trauma patient with an unknown medical history.
The tapes used for wound closure either are rubber-based or
Wound Closure employ an acrylate adhesive. Rubber-based tapes (e.g., athletic
tape) are a potential irritant to skin, degrade with exposure to
MATERIALS
heat, light, and air, and are occlusive, thereby preventing transepi-
Once the appropriate dermal water loss. Tapes that include acrylate adhesives (e.g.,
preparatory measures have Micropore and Steri-Strip), however, are hypoallergenic, have a
been taken (see above), the long shelf life, and are porous, thereby allowing water to evapo-
wound is ready to be closed. rate.25 Linear wounds in areas with little tension are easily approx-
The first step is to choose the imated with tape alone, whereas wounds in areas where the skin is
material to be used for wound closure. The materials currently more taut (e.g., the extremities) generally require that tape skin
available for this purpose include sutures, staples, tapes, and glues. closure be supplemented by dermal sutures.The use of tape alone
Selection of the appropriate material is based on the type and loca- is desirable when feasible, in that it spares the patient the discom-
tion of the wound, the potential for infection, the patient’s ability to fort associated with suture removal, prevents suture puncture
tolerate closure, and the degree of mechanical stress imposed by scars, and avoids the emotional upset that may attend suture clo-
closure. The selected material must provide wound edge approxi- sure of small facial wounds on children.25 Tape closure has some
mation until the tensile strength of the wound has increased to the significant advantages: it immobilizes wound edges, permits early
point where it can withstand the stress present. suture removal, is easy to perform and comfortable for the patient,
The majority of wounds are closed with sutures. A suture is a leaves no marks on the skin, and yields a lower infection rate in
foreign body by definition, and as such, it may generate an inflam- contaminated wounds than suture closure does.26 It also has a few
matory response, interfere with wound healing, and increase the disadvantages: patients may inadvertently remove the tapes, and
risk of infection. Accordingly, the number and diameter of sutures wound edge approximation is less precise with tapes alone than
used to close a wound should be kept to the minimum necessary with sutures. In addition, tape will not adhere to mobile areas
for coaptation of the edges. under tension (e.g., the plantar aspects of the feet) or to moist
Sutures are categorized on the basis of material used, tensile areas (e.g., mucous membranes and groin creases), and wound
strength, configuration, absorbability, and time to degradation [see edema can lead to blistering at the tape margins and to inversion
Table 2]. Suture material may be either natural or synthetic; natur- of taped wound edges.
al fibers (e.g., catgut and silk) cause more intense inflammatory The use of tissue adhesives (e.g., octylcyanoacrylate) is a fast,
reactions than synthetic materials (e.g., polypropylene) do.20 The strong, and flexible method of approximating wound edges. Com-
tensile strength of suture material is defined as the amount of pared with sutures, staples, and tapes, adhesives provide a faster
weight required to break a suture divided by the suture’s cross-sec- closure and are essentially equivalent in terms of cosmetic out-
tional area. It is typically expressed in an integer-hyphen-zero form, come, infection rate, and dehiscence rate.27 Adhesives can be used
whereby larger integers correspond to smaller suture diameters on most parts of the body and have been employed to close
(e.g., 3-0 sutures have a greater diameter and more tensile strength wounds ranging from 0.5 to 50 cm in length. Their advantages
than 5-0 sutures do).21 Closure of acute wounds rarely requires include reduced cost, ease of application, and the absence of any
sutures larger than 4-0. In terms of configuration, suture material need for needles or suture removal; their major disadvantage is
may be composed either of a single filament or of multiple fila- lack of strength.28 They must not be applied to tissues within
ments. Multifilament suture material may be twisted or braided, wounds but, rather, should be applied to intact skin at wound
and the interstices created by braiding may harbor organisms and edges, where they serve to hold injured surfaces together. In addi-
Table 2—Types and Characteristics of Suture Material Used for Wound Closure
Tensile
Method of Time to
Suture Type Material Comment Configuration Strength at
Absorption Degradation
2 Wk
Plain catgut (bovine intestinal serosa) Natural; high tissue reactivity Monofilament Proteolysis 0% 10–14 days
Chromic catgut (bovine intestinal Natural; stronger, less reactive, and

serosa treated with chromic acid) longer-lasting than plain catgut Monofilament Proteolysis 0% 21 days
Fast-absorbing catgut Natural Monofilament Proteolysis 0% 7–10 days
Polyglytone 6211 (Caprosyn) Synthetic Monofilament Hydrolysis 10% 56 days
Glycomer 631 (Biosyn) Synthetic Monofilament Hydrolysis 75% 90–110 days

Absorbable
Polyglycolic acid (Dexon) Synthetic Monofilament/ Hydrolysis 20% 90–120 days
multifilament
Polyglactic acid (Vicryl) Synthetic Multifilament Hydrolysis 20% 60–90 days
Polyglyconate (Maxon) Synthetic Monofilament Hydrolysis 81% 180–210 days
Polyglycolide (Polysorb) Synthetic Multifilament Hydrolysis 80% 56–70 days
Polydioxanone (PDS) Synthetic Monofilament Hydrolysis 74% 180 days
Polyglecaprone 25 (Monocryl) Synthetic Monofilament Hydrolysis 25% 90–120 days
Polyglactin 910 (Vicryl RAPIDE) Synthetic Multifilament Hydrolysis 0% 7–14 days
Synthetic; low tissue reactivity; Monofilament

Polybutester (Novafil) — High —
elastic; good knot security
Synthetic; low tissue reactivity;

Nylon (Monosof, Dermalon, Ethilon) memory effect necessitates Monofilament — High
more knots —
Nylon (Nurolon) Synthetic; low tissue reactivity Multifilament — High —
Synthetic; silicon coated; low tissue

Nylon (Surgilon) Multifilament — High —
reactivity
Polypropylene (Prolene, Surgilene, Synthetic; low tissue reactivity; Monofilament — High —

Surgipro) slippery
Polyethylene (Dermalene) Synthetic Monofilament — High —
Lowest tissue reactivity of all

Nonabsorbable sutures; poor handling; creates Monofilament/
Stainless steel — Highest —
artifact on CT scan; moves with multifilament
MRI
Cotton Natural Multifilament — — —

Natural; high tissue reactivity; good Multifilament
Silk (Sofsilk) — Poor —
knot security
Synthetic; uncoated; high

Polyester (Dacron, Mersilene, friction; low tissue reactivity; poor Multifilament — High —
Surgidac) knot security
Synthetic; silicon coated; low

Polyester (Ticron) tissue reactivity; good knot Multifilament — High —
security
Synthetic; polybutylate coated;

Polyester (Ethibond) low tissue reactivity; good knot Multifilament — High —
security
Synthetic; Teflon coated; low Multifilament —

Polyester (Ethiflex, Tevdek) tissue reactivity; good knot High —
security
tion, they should not be used for wounds in mucous membranes, nylon sutures under loupe or microscope magnification. For ische-
contaminated wounds, deep wounds, or wounds under tension. mic or amputated tissues (e.g., an ear, a digit, or a limb), vessel re-
Adhesives are particularly useful for superficial wounds or wounds pair is performed with 8-0 to 10-0 monofilament nylon sutures
in which the deep dermis has been closed with sutures. under magnification.
In subcutaneous fat, suture placement should be avoided
TIMING AND METHODS
whenever possible; if sutures in this location are absolutely neces-
Appropriate materials having been selected, the next issue to sary, they should be placed at the fat-fascia junction or the fat-der-
address is the timing of wound closure. The choices are (1) to mis junction, not in fat alone. Fat cannot hold sutures by itself,
close the wound at the time of initial presentation, (2) to delay clo- and because it has a poor blood supply, suturing may lead to fat
sure until after a period of healing or wound care, and (3) to allow necrosis. The deeper fascial layers that contribute to the structur-
the wound to heal on its own.The best choice in a given situation al integrity of areas such as the abdomen, the chest, and the galea
depends whether the patient is stable and able to undergo wound should be closed as a separate layer to prevent hernias, structural
repair, whether hemorrhage is under control, whether necrotic deformities, and hematomas.
material has been adequately debrided and foreign bodies At the skin level, the deep dermis is responsible for the strength
removed, whether and to what degree bacterial contamination is of the acute wound closure. Deep dermal repair is performed with
present, and what the expected aesthetic outcome of immediate 4-0 absorbable suture material (e.g., polyglactin 910) and a cutting
closure might be in comparison with that of delayed closure or needle. The sutures are buried and placed 5 to 8 mm apart, with
secondary healing. care taken to evert the skin edges. Buried dermal sutures are often
The timing of wound closure determines the method that will used in conjunction with tapes (e.g., Steri-Strips), fine epidermal
be employed. The closure methods available include (1) primary sutures, or adhesives to facilitate precise alignment. Skin edges
closure by direct approximation; (2) delayed primary closure, in should be coapted and everted with 4-0 to 6-0 nylon or polypropy-
which the wound is closed after a healing period; (3) secondary lene sutures placed in the superficial dermis and the epidermis.The
closure, in which the wound is allowed to heal on its own; (4) skin graft- distance between the sutures and the distance between the wound
ing; and (5) the use of local or distant flaps. The ideal wound clo- edge and the suture insertion point should be equal to the thick-
sure method would support the wound until it has nearly reached ness of the skin (epidermis and dermis combined).
full strength (i.e., about 6 weeks), would not induce inflammation, Several different skin suturing methods may be used, depend-
would not induce ischemia, would not penetrate the epidermis and ing on the nature of the wound. Simple interrupted sutures are
predispose to additional scars, and would not interfere with the useful for irregular wounds.Vertical mattress sutures are good for
healing process. Unfortunately, no existing method accomplishes either thick (e.g., scalp) or thin (e.g., eyelid) skin. Horizontal mat-
all of these goals in all cases; some sort of compromise is virtually tress sutures can lead to ischemia and thus must be applied loose-
always necessary. In the acute wound setting, the simplest method ly; they may look untidy early after repair, but they generally
that will achieve a good closure is preferred. achieve good wound-edge eversion and long-term healing. Half-
Primary closure provides optimal wound healing when two per- buried horizontal and vertical mattress sutures are used for flap
pendicular, well-vascularized wound edges are approximated with- edges to minimize ischemia. A continuous intradermal or subcu-
out tension. Closure should proceed from deep to superficial.The ticular suture is easy to remove and relatively inconspicuous visu-
initial step is to identify landmarks and line up tissues, using skin ally. A simple continuous suture should be used only for linear
hooks or fine forceps to keep from causing wound edge trauma. wounds; it is quick to place but tends to invert the wound edges.
Although wound closure is usually a straightforward process, situ- Flap tips should be sutured with a three-point method to prevent
ations occasionally arise in which special caution is necessary. For strangulation [see Figure 1]. For children, suture removal can be
instance, when a wound crosses tissues with different characteris- both emotionally and physically traumatic; accordingly, when
tics (e.g., at the vermilion border of the lip, the eyebrow, or the hair- suturing is employed for skin closure in a pediatric patient, the use
line of the scalp), particular care must be taken to align the dam- of fast-absorbing suture material (e.g., plain catgut) or a pullout
aged structures accurately. In the repair of soft tissue, it is critical to continuous subcuticular suturing method should be considered.
handle tissue gently with atraumatic surgical technique, to place Primary direct approximation of wounds is not always indicat-
sutures precisely, and to minimize tension and contamination. ed. In cases where obvious bacterial contamination is present,
The next step is tissue-specific repair, which may require the there is a substantial amount of questionably necrotic tissue, or
consultation of an experienced surgeon. Bone fractures are re- the patient is unstable and unfit to undergo primary repair at the
duced and repaired with plates, rods, or external fixation devices. time of presentation, delayed primary closure is performed.
Muscle lacerations should be repaired because muscle is capable Delayed primary closure involves direct approximation of wound
of a significant degree of regeneration. A completely lacerated edges after a period (usually 4 to 5 days) of wound hygiene. This
muscle that is properly repaired recovers approximately 50% of its closure method markedly diminishes the incidence of wound
ability to produce tension and 80% of its ability to shorten, where- infection in patients with contaminated wounds.
as a partially lacerated muscle that is properly repaired recovers Secondary closure, in which the wound is left open and allowed
approximately 60% of its ability to produce tension and 100% of to heal on its own, is also sometimes chosen. Secondary closure
its ability to shorten.29 Tendon lacerations should be meticulously depends on contraction of the surrounding tissue and epithelializa-
approximated to allow gliding and restore tensile strength. Either tion from the wound margins.When this approach is followed, cau-
4-0 multifilament polyester or monofilament polypropylene is a tion and close observation are essential because the process of tis-
reasonable choice for muscle and tendon repair.30 Early active sue contraction can sometimes lead to contracture, a pathologic
mobilization promotes the restoration of tensile strength in mus- scar deformity. Secondary closure can, however, yield acceptable
cles and tendons. Penetrating nerve trauma is treated with ten- results with specific wound types and at specific anatomic sites.
sion-free coaptation at the time of wound closure by primary With puncture wounds, for example, secondary closure is pre-
repair or repair with a nerve graft or nerve tube. Epineurial coap- ferred because it diminishes the likelihood of infection. For both
tation is typically achieved by placing 8-0 to 10-0 monofilament abrasions and puncture wounds, the functional and aesthetic
Figure 1 Shown is the method for inserting three-point sutures, along with three different applications
of this method.
results of secondary closure are generally as good as or better than proving quite difficult to remove. Complete debridement of these
those obtained by primary or delayed primary closure. For wounds embedded foreign bodies within 24 to 48 hours of injury is crucial
on anatomically concave surfaces (e.g., the medial canthal region, in preventing so-called traumatic tattooing. In the early postinjury
the nasolabial region, or the perineum), secondary wound healing period, surgical debridement with a small drill, a sharp instru-
generally yields excellent results.31 Secondary closure should also ment, or a scrub brush may suffice for removal of the foreign
be considered for severely contaminated wounds, infected wounds, material causing the traumatic tattoo; later, dermabrasion will be
wounds with significant amounts of devitalized tissue, wounds with necessary.34,35 Once the wound is adequately debrided, semiocclu-
foreign bodies, lacerations older than 24 hours, wounds in patients sive dressings should be applied to optimize epithelialization.
who are in shock, and high-velocity wounds.32
Occasionally, an acute wound is so large that neither primary Puncture Wounds
nor secondary closure will suffice. Such wounds must be covered Puncture wounds should be
with skin grafts or transferred tissue (i.e., flaps) [see 3:3 Open examined for foreign bodies,
Wound Requiring Reconstruction and 3:7 Surface Reconstruction which must be removed when
Procedures]. Local or distant flaps must be considered for wounds found. They are typically left
that involve exposed bone denuded of periosteum, cartilage open, treated with wound
denuded of perichondrium, tendon denuded of paratenon, or care, and allowed to heal by
nerve denuded of perineurium. secondary intention. With
puncture wounds, secondary closure reduces the risk of infection
CLOSURE OF SPECIFIC TYPES OF WOUNDS
and generally yields excellent aesthetic results.
Wounds may be divided into 10 main types: abrasions, puncture
wounds, lacerations, complex wounds, crush injuries, extravasation Lacerations
injuries, injection injuries, high-velocity wounds, bite wounds, and The type of wound most
stings. In addition, the American College of Surgeons (ACS) has commonly encountered by
divided wounds into four major categories: clean, clean-contami- surgeons is a superficial or
nated, contaminated, and dirty [see Table 3].The likelihood of infec- deep acute traumatic or surgi-
tion after any surgical procedure is correlated with the ACS wound cal wound that is suitable for
category: class I and II wounds have infection rates lower than 11%, primary closure by direct
whereas wounds in class IV have infection rates as high as 40%.33 approximation of the wound
edges. In this setting, the goal is to provide the best possible chance
Abrasions for uncomplicated healing. If the wound is to be closed, primary
Abrasions are superficial closure at the time of evaluation is preferred if it is feasible. As a
wounds caused by scraping. rule, closure should be completed within 6 to 8 hours of the injury,
They involve only the epider- though simple noncontaminated wounds of the face can be safely
mis and a portion of the der- closed as long as 24 hours after the injury. Primary closure is gen-
mis and frequently heal secon- erally desirable in that it eliminates the need for extensive wound
darily within 1 to 2 weeks. If an care, allows the wound to heal more quickly, and minimizes
abrasion is to be closed pri- patient discomfort. However, lacerations containing foreign bod-
marily, tape or glue may be used for epidermal approximation to ies or necrotic tissue that cannot be removed by irrigation or
prevent suture mark scars (which could be worse than the actual debridement and lacerations with excessive bacterial contamina-
wound scar). In some patients who have experienced abrasion tion should not be closed primarily, nor should wounds in which
injuries (e.g., motorcycle accidents in which victims slide along hemostasis is incomplete. Hematomas,36 necrotic tissue,37 and for-
asphalt) or blast injuries (e.g., firework explosions), small foreign eign bodies38 all promote bacterial growth and place a mechanical
body fragments become embedded in and beneath the skin, often barrier between healing tissues.
Complex Wounds Table 3—Classification and Infection

The term complex wounds Rates of Operative Wounds
includes stellate wounds and
those caused by degloving,
avulsion, and mutilation. The Infection Rate
Classification Wound Characteristics
(%)
goals of treatment include
achieving closure within 6 to 8 Atraumatic, uninfected; no entry of
hours of the injury, providing Clean (class I) 1.5–5.1
GU, GI, or respiratory tract
treatment in a manner consistent with the patient’s general health,
Minor breaks in sterile technique;
keeping bacterial counts at a low level, protecting tissues from des- Clean-contaminated
7.7–10.8 entry of GU, GI, or respiratory
(class II)
iccation, applying only nonnoxious agents, and supplying adequate tract without significant spillage
permanent coverage. In addition, it is important to discuss with the Traumatic wounds; gross spillage
patient the particular treatment difficulties posed by these wounds. Contaminated
15.2–16.3 from GI tract; entry into infected
(class III)
Often, a patient with a complex wound must be treated in the OR tissue, bone, urine, or bile
under general anesthesia because the injury is extensive or because Drainage of abscess; debridement
there is a need for exploration of tissues, removal of foreign bodies, Dirty (class IV) 28.0–40.0
of soft tissue infection
and debridement of nonviable tissue.
Stellate wounds can be approximated with careful placement of
interrupted and three-point sutures. Severely injured tissue may sure) is less than or equal to 30 mm Hg, compartment syndrome
have to be removed as an ellipse, with the resulting defect closed. is considered to be present. If clinical symptoms develop or the
Degloving refers to circumferential elevation of skin and fat delta pressure is below 30 mm Hg, appropriate therapeutic mea-
from muscle; the skin flap created by this process rarely survives. sures should be taken, including restoration of normal blood pres-
In the acute setting, questionably viable flaps of tissue may be sure in the hypotensive patient, removal of all constrictive dress-
evaluated by administering fluorescein, up to 15 mg/kg I.V., and ings, and maintenance of the limb at heart level.1 If the delta pres-
observing the flap for fluorescence under an ultraviolet lamp after sure remains below 30 mm Hg, clinical symptoms and signs per-
10 to 15 minutes have elapsed.39 Viable flap tissue fluoresces sist despite conservative measures, or both, fasciotomies should be
green.Tissue that is determined to be devascularized, on the basis performed within 6 hours.41 Hyperbaric oxygen therapy may also
of either physical examination or fluorescein testing, should be be beneficial in cases of crush injury with compartment syndrome
debrided. If the viability of a tissue segment is in doubt, the seg- in an extremity.43 Compartment syndrome with muscle damage
ment may be sewn back into its anatomic location and allowed to can also lead to rhabdomyolysis and renal failure. If an elevated
define itself as viable or nonviable over time. serum creatine kinase concentration is reported, intravascular vol-
Large open wounds resulting from avulsion can be either left to ume is stabilized, and urine flow is confirmed, a forced mannitol-
heal by secondary intention or treated with delayed skin grafting.32 alkaline diuresis should be initiated as prophylaxis against hyper-
Mutilating wounds caused by machinery (e.g., farm equip- kalemia and acute renal failure.44
ment) are often contaminated by a mixture of gram-positive and
Extravasation Injuries
gram-negative organisms, though not always excessively so.40 When
such a wound is grossly contaminated, antibiotic therapy (prefer- In some patients with arter-
ably with an agent or combination of agents that offers broad-special or venous catheters in place,
trum coverage) is indicated. Contaminated wounds closed with a vessel may become occluded
either tape or staples have a lower incidence of infection than those or a catheter dislodged from
closed with sutures.24,26 the intravascular space, leading
to extravasation injury, where-
Crush Injuries by solutions or medicines are
A notable feature of crush delivered into the interstitial space. The majority of acute extrava-
injury is that the severity of the sation injuries are quickly diagnosed and heal without complica-
wound is not always readily tions, and in most cases, conservative management (i.e., elevation
apparent. In many cases, no of the limb, application of ice packs, and careful monitoring) is ade-
external laceration can be quate.45 However, extravasation injuries involving high fluid vol-
seen, even though deep tissue umes, high-osmolar contrast agents, or chemotherapeutic drugs can
damage may be extensive. have more serious effects, resulting in skin ulceration and extensive
Ultrasonography or magnetic resonance imaging may help identi- soft tissue necrosis.Treatment of these injuries is not standardized;
fy a hematoma that is amenable to evacuation.32 Deep tissue it may include conservative management, hydrocortisone cream,
injury can lead to compartment syndrome and subsequent incision and drainage, hyaluronidase injection, saline injection, and
extremity loss. Early diagnosis is the key to successful treatment. aspiration by means of liposuction.45-47
Generally, the diagnosis can be made on the basis of physical signs
Injection Injuries
and symptoms, including increasing pain that is out of proportion
to the stimulus, altered sensation, pain on passive stretching of the Wounds caused by injection
affected muscle compartment, muscle weakness, and palpable of foreign materials (e.g.,
tenseness of the compartment.41 paint, oil, grease, or dirty
If compartment syndrome is suspected, the intracompartmen- water) can be severe. Injection
tal pressure should be measured.42 If the intracompartmental injuries usually result from the
pressure exceeds 30 mm Hg or if the so-called delta pressure (i.e., use of high-pressure spray
the diastolic blood pressure minus the intracompartmental pres- guns (600 to 12,000 psi) and
often occur on the nondominant hand.48,49 On initial examination, obic and anaerobic organisms commonly found in cat-bite wounds
the injury may appear deceptively benign, with only a punctate are similar to those found in dog-bite wounds, and antibiotic pro-
entry wound visible; however, foreign material is often widely dis- phylaxis with amoxicillin-clavulanate is appropriate.57 Acute regional
tributed in the deeper soft tissues. Radiographs are obtained to lymphadenitis after a cat scratch is known as cat-scratch disease
identify any fractures present and, in some cases, to determine the and is caused by Bartonella henselae58; it is treated by administer-
extent to which the injected material is distributed. Injection ing azithromycin.59
wounds must be treated aggressively with incision, wide exposure, Dog-bite wounds are at lower (16%) risk for infection than
debridement, and removal of foreign bodies to prevent extensive human-bite or cat-bite wounds and tend to be less severely con-
tissue loss and functional impairment. The functional outcome is taminated with bacteria. The aerobic species commonly isolated
determined by the time elapsed between injury and treatment and from such wounds include Pasteurella (P. canis), Streptococcus,
by the type of material injected. Oil-based paint is more damaging Staphylococcus, Moraxella, and Neisseria; common anaerobic iso-
to tissues than water-based paint, oil, grease, water, or air.50,51 lates include Fusobacterium, Bacteroides, Porphyromonas, and
Prevotella.57 Prophylactic treatment with a combination of a β-lac-
High-Velocity Wounds tam antibiotic with a β-lactamase inhibitor (e.g., amoxicillin-
High-velocity wounds from clavulanate) is appropriate.57,60
explosions or gunshots cause
extensive tissue damage as a Venomous animals Snake bites. Four types of poisonous
consequence of the release of snakes are native to the United States: the coral snakes (Micrurus
kinetic energy. Small entry and Micruroides species), from the family Elapidae, and three species
wounds are common, but the of pit vipers, from the family Viperidae (rattlesnakes [Crotalus
seemingly benign appearance species], copperheads [Agkistrodon tortortrix], and cottonmouths
of such a wound often belies the actual severity of injury: the exit or water moccasins [Agkistrodon piscivorus]).61-63 Pit vipers can be
wound and interspace may contain large areas of ischemic and identified by the pit between the eye and the nostril on each side
damaged tissue that affect critical structures (e.g., bone and blood of the head, the vertical elliptical pupils, the triangle-shaped head,
vessels). Clothing and dirt may also be transmitted into the deep the single row of subcaudal plates distal to the anal plate, and the
spaces. Radiographs may identify radiopaque foreign bodies (e.g., two hollow fangs protruding from the maxillae that produce the
metal objects or pieces of leaded glass).52 Treatment of wounds cre- characteristic fang marks.64 Coral snakes have rounder heads and
ated by high-velocity missiles involves extensive debridement and eyes and lack fangs; they are identified by their characteristic color
identification of injured tissue.Wounds should be left open to heal by pattern, consisting of red, yellow, and black vertical bands.
secondary or delayed primary closure.32 Patients bitten by any of the pit vipers must be examined for
massive swelling and pain, which, in conjunction with fang marks,
Bite Wounds suggest envenomation. Local pain and swelling typically develops
Treatment of bite wounds within 30 minutes of the bite, though in some cases, these manifes-
involves thorough exploration, tations may take up to 4 hours to appear. Erythema, petechiae, bul-
irrigation, and debridement. X- lae, and vesicles are sometimes seen. Severe envenomation may
rays must be obtained and induce systemic reactions, including disseminated intravascular
wounds explored to evaluate coagulation (DIC), bleeding, hypotension, shock, acute respiratory
the patient for fractures or open distress syndrome (ARDS), and renal failure. Patients bitten by
joint injuries. If a joint capsule coral snakes, on the other hand, show no obvious local signs when
has been violated, the joint must be thoroughly cleaned. Because of envenomation has occurred. Consequently, the physician must
the infection risk, wounds may be allowed to heal by secondary or look for systemic signs, such as paresthesias, increased salivation,
delayed primary closure; primary closure is also possible if thor- fasciculations of the tongue, dysphagia, difficulty in speaking, visu-
ough debridement is performed.32 Rabies prophylaxis treatment al disturbances, respiratory distress, convulsions, and shock.These
should be considered for patients who have been bitten by wild ani- symptoms may not develop until several hours after the bite.
mals [see Adjunctive Wound Treatment, Rabies Prophylaxis, below]. If signs or symptoms suggestive of envenomation are found,
appropriate laboratory tests (hematocrit, fibrinogen level, coagula-
Humans and nonvenomous animals Most human bite tion studies, platelet count, urinalysis, and serum chemistries)
wounds are clenched fist wounds sustained by young men.53 should be ordered. Laboratory tests should be repeated every 8 to
Human bite wounds are considered infected from the moment of 24 hours for the first 1 to 3 days to determine whether envenoma-
infliction and must be treated with antibiotics.54,55 The antibiotic tion is progressing. Severe envenomation can cause decreased fib-
regimen should be selected on the basis of the bacterial species rinogen levels, coagulopathy, bleeding, and myoglobinuria.
believed to be present. Common isolates from bite wounds Treatment of venomous snake bites includes immobilization
includes Streptococcus anginosus, Staphylococcus aureus, Eikenella and elevation. If envenomation is suspected or confirmed, anti-
corrodens, Fusobacterium nucleatum, Prevotella melaninogenica, and venin should be administered intravenously and as early as possi-
Candida species.53 To cover these species, a broad-spectrum ble. Antivenins commonly used in the United States include Anti-
antibiotic or combination of antibiotics (e.g., amoxicillin-clavu- venin (Crotalidae) Polyvalent (ACP) (Wyeth Pharmaceuticals,
lanate or moxifloxacin) should be administered.53 Collegeville, Pennsylvania) and Crotalidae Polyvalent Immune
Nonhuman primates can cause viral infection, most commonly Fab (Ovine) (CroFab; Protherics Inc., Nashville, Tennessee).65
with cercopithecine herpesvirus type 1. If left untreated, such in- Fab antivenom (FabAV) is less allergenic and more potent than
fection can lead to meningoencephalitis, which carries a 70% mor- ACP and thus has largely supplanted it in the United States.65,66
tality. Accordingly, acyclovir prophylaxis is recommended.56 Patients are treated with a loading dose of four to six vials of
Wounds caused by cat bites or scratches are at high (80%) risk FabAV, followed by three two-vial maintenance doses at 6, 12, and
for infection, usually attributable to Pasteurella multocida. The aer- 18 hours to prevent recurrence of symptoms. If symptoms
progress despite antivenin treatment, an additional four to six vials throughout the northwestern United States, they live in low places
of FabAV are given twice more; if symptoms continue to progress, and build funnel-shaped webs in dark spaces. Hobo spiders have
consideration should be given to using ACP. ACP remains the been reported to inflict painful bites that lead to wound ulcera-
most effective antivenin for patients with coral snake bites and tion, dermonecrosis, and a persistent headache, though the accu-
those who do not respond to FabAV. Before ACP is administered, racy of such reports has been debated.69,72,73 A slow-healing ulcer
the patient must be tested for sensitivity. The major complication that leaves a central crater has been described.Treatment consists
of antivenin therapy is serum sickness. This complication occurs of local wound care.
in approximately 50% to 75% of patients treated with ACP but in
only 16% of those treated with FabAV.65,67 Stings
Compartment syndrome is a rare but severe complication of a Scorpions Stings from
snake bite. Fasciotomy is sometimes required to relieve extremity most of scorpion species found
compartment syndrome, but it is not necessary for prophylactic in the United States cause only
purposes. Tourniquets, incision and suction, cryotherapy, and limited local reactions that can
electric shock treatment are of little value for snake bites and may be managed conservatively;
increase complication rates.There is no clear evidence to support however, stings from Centru-
antibiotic prophylaxis in this setting.64 roides sculpturatus, which is
found in California and many
Spider bites. The bites of most spiders found in the United southern states, may be more severe. Centruroides has a sting that
States cause little to no wound or local reaction; however, there are causes envenomation with a neurotoxin. Erythema, edema, and
three types that are capable of injecting venom with skin-penetrat- ecchymosis at the site of the sting are evidence that envenomation
ing bites. Brown recluse spiders (Loxosceles reclusa) can be identi- did not take place. Instead, envenomation is indicated by an
fied by a violin-shaped dorsal mark. They are nocturnal, live in immediate and intense burning pain at the wound site.74 The ini-
dark and dry places, and are found in the central and southern tial local pain may then be followed by systemic symptoms such
United States. The venom is a phospholipase enzyme that acts as as muscle spasm, excess salivation, fever, tachycardia, slurred
a dermal toxin and almost always causes a local reaction.68 Local speech, blurry vision, convulsions, or death.68 Treatment consists
signs and symptoms may be limited to minor irritation, though of icing and elevation of the wounded area, followed by adminis-
they may also progress to extreme tenderness, erythema, and tration of barbiturates for control of neuromuscular activity and
edema.The onset of local signs and symptoms may be delayed for institution of supportive therapy with antihistamines, cortico-
as long as 8 hours after a bite, and tissue necrosis may then devel- steroids, and analgesics.74
op over the following days to weeks. Systemic reactions may
include mild hemolysis, mild coagulopathy, and DIC, though Centipedes Centipedes are slender, multisegmented, and
severe intravascular hemolytic syndrome and death have also been multilegged arthropods that range in size from 1 to 30 cm and in
reported.68,69 Oral administration of dapsone (50 to 100 mg/day) color from bright yellow to brownish black. The first pair of legs
to minimize tissue necrosis has been advocated by some70; howev- are modified into sharp stinging structures that are connected to
er, this treatment is of uncertain efficacy, and no prospective data venom glands. Centipedes prefer dark, damp environments and
currently support its use. Moreover, dapsone can cause a serious may be found throughout the southern United States. Local
unwanted side effect, hemolytic anemia.69 If systemic symptoms symptoms associated with centipede stings include pain, erythe-
develop, systemic corticosteroid therapy and supportive measures ma, edema, lymphangitis, lymphadenitis, weakness, and paresthe-
are indicated. Brown recluse antivenin is not available in the sia. Skin necrosis may occur at the envenomation site. Systemic
United States. symptoms may include anxiety, fever, dizziness, palpitations, and
Black widow spiders (Latrodectus mactans) can be identified by nausea.75 Treatment consists of symptomatic pain control, infiltra-
a red-hourglass ventral mark.63 They live in dark, dry, and protect- tion of local anesthetics, administration of antihistamines, and
ed areas and are distributed widely throughout the continental local wound care.75
United States.The venom is a neurotoxin that produces immedi-
ate and severe local pain. Local signs and symptoms include two Hymenoptera The order Hymenoptera includes wasps,
fang marks, erythema, swelling, and piloerection.68 Systemic reac- bees, and ants. Wasps, which are found across the United States,
tions with neurologic signs may develop within 10 minutes and live in small colonies and may attack in groups when provoked.
may include muscle pain and cramps starting in the vicinity of the Honeybees (Apis mellifera) and bumblebees (Bombus species), also
bite, abdominal pain, vomiting, tremors, increased salivation, found across the United States, are generally docile and rarely
paresthesias, hyperreflexia, and, with severe envenomation, shock. sting unless provoked. Africanized honeybees (Apis mellifera scutel-
Systemic symptoms may last for days to weeks. High-risk persons lata, also referred to as killer bees), found primarily in the south-
(e.g., those who are younger than 16 years, the elderly, pregnant western states, are far more aggressive than other bees. Fire ants
women, hypertensive patients, or persons who continue to show (Solenopsis invicta and Solenopsis richteri) are wingless, ground-
symptoms despite treatment) may experience paralysis, hemoly- dwelling arthropods that are found in many southern states and
sis, renal failure, or coma. Treatment includes 10% calcium glu- that attack in an aggressive swarm.
conate I.V. for relief of muscle spasm, methocarbamol or diaze- Although Hymenoptera stingers are small, they can evoke se-
pam for muscle relaxation, and a single dose of antivenin. Anti- vere local and systemic reactions.The local response to a Hymen-
venin causes serum sickness in as many as 9% of patients; conse- optera sting is a painful, erythematous, and edematous papule that
quently, its use is controversial except in cases where the patient is develops within seconds and typically subsides in 4 to 6 hours.
at high risk.71 Some stingers are barbed and must be removed with a scraping,
Hobo spiders (Tegenaria agrestis) can be identified by their long rather than pinching, motion to prevent the injection of more
hairy legs and a cephalothorax that is marked by two stripes and venom. Systemic reactions occur in about 5% of the population
butterfly markings dorsally and two stripes ventrally. Found and may lead to anaphylaxis with syncope, bronchospasm, hypo-
tension, and arrhythmias. Wounds and local reactions are treated With sutured wounds, dressings are required only until
with ice, elevation, and analgesics. Systemic reactions are treated drainage from the wound ceases.With nondraining wounds, dress-
with subcutaneous epinephrine, diphenhydramine, and support- ings may be removed after 48 hours, by which time epithelial cells
ive airway and blood pressure care.68 Persons with a history of sys- will have sealed the superficial layers of the wound. An alternative
temic reactions to insect stings should carry epinephrine kits. method of treating minimally draining incisional wounds is to
apply an antibacterial ointment [see Adjunctive Wound Treatment,
DRESSINGS FOR SPECIFIC
Topical Antimicrobials, below]. Such ointments are occlusive and
TYPES OF WOUNDS
maintain a sterile, moist environment for the 48 hours required for
Generally, the functions of a epithelialization. In anatomic areas that are difficult to dress (e.g.,
wound dressing include pro- the scalp), it may be reasonable to forgo a dressing and simply
tection, antisepsis, pressure, apply ointments or allow a scab to form on the wound surface.
immobilization, debridement, Operative incisional wounds are also sometimes covered with an
provision of a physiologic envi- occlusive dressing to optimize epithelialization [see Abrasions,
ronment, absorption, packing, above]. Some of these dressings are transparent, allowing observa-
support, information, comfort, and aesthetic appearance. More tion of the wound.The disadvantage of occlusive dressings is their
specifically, the functions of a dressing should be tailored to the limited absorptive capacity, which allows drainage from the wound
wound type, and the purpose of the dressing must be carefully to collect underneath.
considered before application.
Complex Wounds
Abrasions For complex wounds containing questionably necrotic tissue,
Abrasions heal by epithelialization, which is accelerated by the foreign bodies, or other debris that cannot be removed sharply,
warm, moist environment created by an occlusive dressing.76,77 wet-to-dry dressings are effective, simple, and inexpensive. A sin-
Such an environment not only promotes epithelialization but also gle layer of coarse wet gauze is applied to a wound, allowed to dry
enhances healing, both because of the moisture itself and because over a period of 6 hours, and removed. Necrotic tissue, granula-
of the low oxygen tension that promotes the inflammatory phase.78 tion tissue, debris, and wound exudate become incorporated with-
A variety of dressings are suitable for treatment of abrasions, in- in the gauze and are removed with the dressing.The disadvantages
cluding biologic dressings, hydrogels, hydrocolloids, and semiper- of wet-to-dry dressings are pain and damage to or removal of some
meable films.These dressings need not be changed as long as they viable tissue. If the wound bed contains tendons, arteries, nerves,
remain adherent. Small, superficial wounds also heal readily when or bone, wet-to-wet dressings should be used to prevent desicca-
dressed with impregnated gauze dressings (e.g., Xeroform and tion of these critical structures.
Scarlet Red [Kendall, Mansfield, Massachusetts]), which allow Wet-to-wet dressings, which are not allowed to dry, cause less
exudates to pass through while maintaining a moist wound bed.78 tissue damage than wet-to-dry dressings but do not produce as
These less adherent dressings must be changed more regularly.79 much debridement. Most wet-to-wet dressings are kept moist with
Dry dressings (e.g., gauze) should be avoided with abrasions saline. Wounds with significant bacterial contamination may be
because they facilitate scab formation. Scabs slow epithelialization, treated with dressings that contain antibacterial agents (e.g.,
in that advancing cells must enzymatically debride the scab- mafenide, silver sufadiazine, silver nitrate, or iodine).
wound interface in order to migrate.80 Wounds covered with a scab Biologic and semipermeable films also maintain a moist wound
also tend to cause more discomfort than wounds covered with bed, but they are difficult to use on deep or irregular wounds and
occlusive dressings. wounds with a great deal of drainage. Consequently, wet-to-wet
dressings with agents such as silver sulfadiazine are often used for
Lacerations these types of wounds. Enzymatic agents can debride wounds
For sutured deep wounds, the specific purposes of a dressing effectively and are a reasonable alternative to wet-to-dry or wet-to-
are to prevent bacterial contamination, to protect the wound, to wet dressings for wounds that contain necrotic tissue.82
manage drainage, and to facilitate epithelialization. Dressings used
on such wounds usually consist of three basic layers. The inner
(contact) layer is chosen to minimize adherence of the dressing to Table 4—Recommendations for
the wound and to facilitate drainage through itself to the overlying Tetanus Immunization89,90
layers. Common choices for this layer include fine-mesh gauze,
petrolatum gauze, Xeroform or Xeroflo (Kendall, Mansfield,
Tetanus Immunization History Tt* TIG
Massachusetts) gauze, and Adaptic (Johnson & Johnson, New
Brunswick, New Jersey).These substances should be applied only Unknown Yes Yes
as a single layer; in multiple layers, they become occlusive. The
middle layer is chosen for absorbency and ability to conform to > 10 yr since last booster Yes Yes
shape of the wound area. It is usually composed of fluffs, Kerlix ≥ 5 and ≤ 10 yr since last booster Yes No
(Kendall, Mansfield, Massachusetts), or wide-mesh gauze, all of
< 5 yr since last booster No No
which facilitate capillary action and drainage.81 The middle layer
must not be allowed to become soaked, because if it is, exudate Note: Tetanus toxoid (Tt) and tetanus immune globulin (TIG) should be administered with
will collect on the wound surface, and maceration and bacterial separate syringes at different anatomic sites. Tetanus and diphtheria toxoids are contraindi-
cated for the wounded patient if there is a history of a neurologic or severe hypersensitivity
contamination may occur. The outer (binding) layer serves to reaction after a previous dose. Local side effects alone do not preclude continued use. If a
systemic reaction is suspected of representing allergic hypersensitivity, immunization should
secure the dressing. Common choices for this layer include Kling be postponed until appropriate skin testing is performed. If a contraindication to a Tt-con-
(Johnson & Johnson, New Brunswick, New Jersey), ACE ban- taining preparation exists, TIG alone should be used.
*For patients younger than 7 years, diphtheria-tetanus-pertussis vaccine (DTP) (or tetanus
dages (BD Medical, Franklin Lakes, New Jersey), and Coban (3M, St. and diphtheria toxoids, if pertussis vaccine is contraindicated) is preferable to Tt alone. For
Paul, Minnesota). patients 7 years of age or older, Tt alone may be given.
Some wounds are difficult to dress and require special consid- wound before an occlusive dressing does not reduce the infection
eration. For wounds with flaps or questionably viable tissue, com- rate and may promote antibiotic resistance.85 For uncomplicated
pression dressings should not be used, because they may cause traumatic wounds, however, application of bacitracin and neomy-
ischemia. Wounds that cross joints are best dressed with plaster cin ointment results in a significantly lower infection rate than ap-
splints for temporary immobilization; semipermeable films are plication of petrolatum.86 Neomycin-containing ointments reduce
flexible and may also be used in this setting.Wounds with high lev- bacterial counts in partial-thickness wounds in animals, but many
els of exudates may be dressed with hydrocolloids, hydrogels, or other over-the-counter antibiotic ointments are not effective at re-
alginates.78 For large or irregular wounds, negative-pressure ducing bacterial counts in wounds.87
wound therapy (NPWT) with the VAC system (Kinetic Concepts Wounds contaminated by bacteria can be treated with dressings
Inc., San Antonio, Texas) is recommended; VAC dressings con- that contain antibacterial agents such as mafenide, silver nitrate,
form well and remain adherent. Additionally, NPWT uses subat- silver sulfadiazine, or iodine. Mafenide penetrates eschar well, but
mospheric pressure to remove excess wound fluid, stimulates the it can cause pain and has the potential to induce metabolic acido-
formation of granulation tissue, improves peripheral blood flow sis through inhibition of carbonic anhydrase. Silver has microbici-
and tissue oxygenation, and reduces the size of the wound.83,84 dal effects on common wound contaminants and may also be
Use of the VAC system is contraindicated in wounds with exposed affective against methicillin-resistant S. aureus (MRSA).84 Silver
blood vessels or bowel. nitrate does not cause pain, but it can cause hypochloremia, and
it stains fingernails and toenails black. Silver sulfadiazine is fre-
quently used because of its broad antibacterial spectrum, its rela-
Adjunctive Wound Treatment tively low side effect profile (transient leukopenia is occasionally
seen), and its ability to maintain a moist wound environment
PROPHYLACTIC SYSTEMIC ANTIBIOTICS
(thereby speeding healing and epithelialization).88
For most wounds, antibiotic prophylaxis is not indicated.When
TETANUS PROPHYLAXIS
it is called for, the agent or agents to be used should be selected
on the basis of the bacterial species believed to be present. The Tetanus is a nervous system disorder that is caused by Clostri-
anatomic location of a wound may also suggest whether oral flora, dium tetani and is chacracterized by muscle spasm. In the past,
fecal flora, or some less aggressive bacterial contaminant is likely wounds were classified as either tetanus-prone or non–tetanus-
to be present. Gram staining can provide an early clue to the prone on the basis of their severity. It is now clear, however, that
nature of the contamination. Ultimately, the choice of a prophy- wound severity is not directly correlated with tetanus susceptibil-
lactic antibiotic regimen is based on the clinician’s best judgment ity; tetanus has been associated with a wide variety of injury types
regarding which agent or combination of agents will cover the over a broad spectrum of wound severity.89 Accordingly, all wounds,
pathogens likely to be present in the wound on the basis of the regardless of cause or severity, must be considered tetanus prone,
information available. and the patient’s tetanus immunization status must always be con-
As a rule, clean and clean-contaminated wounds are adequately sidered.Tetanus wound prophylaxis should be provided as appro-
treated with irrigation and debridement.There are, however, some priate [see Table 4].89,90
local factors (e.g., impaired circulation and radiation injury) and
RABIES PROPHYLAXIS
systemic factors (e.g., diabetes, AIDS, uremia, and cancer) that
increase the risk of wound infection; in the presence of any of these Rabies is an acute progressive encephalitis that is caused by
factors, prophylactic antibiotics should be considered. In addition, viruses from the family Rhabdoviridae. The rabies virus can be
prophylactic antibiotics should be given to patients with extensive transmitted by any mammal, but viral reservoirs are found only in
injuries to the central area of the face (to prevent spread of infec- carnivores and bats. In North America, raccoons, skunks, bats,
tion through the venous system to the meninges), patients with and foxes are the animals most commonly responsible for trans-
valvular disease (to prevent endocarditis), and patients with pros- mission.91 Bite wounds in which the animal’s saliva penetrates the
theses (to reduce the risk of bacterial seeding of the prosthesis). dermis are the most common cause of exposure.
Lymphedematous extremities are especially prone to cellulitis, and Postexposure treatment consists of wound care, infiltration of
antibiotics are indicated whenever such extremities are wounded. rabies immune globulin into the wound, and administration of
Contaminated and dirty wounds are associated with a higher vaccine.91,92 Wound care involves washing with soap and water, as
risk of infection and are therefore more likely to necessitate anti- well as the use of iodine- or alcohol-based virucidal agents.93
biotic prophylaxis. Human bite wounds, mammalian bite wounds, Guidelines for postexposure prophylaxis have been established
and wounds contaminated with dirt, bodily fluids, or feces are [see Table 5]. The vaccination regimen is determined by the
all prone to infection and must be treated with antibiotics.54,55 patient’s previous vaccination status [see Table 6].
Prophylactic administration of a combination of a β-lactam
antibiotic with a β-lactamase inhibitor (e.g., amoxicillin-clavu-
lanate) is appropriate.57,60 Antibiotic prophylaxis is also indicated Postoperative Wound Care
for mutilating wounds with extensive amounts of devitalized tis- Closed wounds should be kept clean and dry for 24 to 48
sue. Such wounds are often contaminated by a mixture of gram- hours after repair. Epithelialization begins within hours after
positive organisms and gram-negative organisms.40 When antibi- wound approximation and forms a barrier to contamination.
otics are indicated for these injuries, broad-spectrum coverage is Gentle cleansing with running water will help remove bacteria
appropriate. and crusting.The patients should not place tension on the wound
or engage in strenuous activity until the wound has regained suf-
TOPICAL ANTIMICROBIALS
ficient tensile strength. In the first 6 weeks after repair, the
Topical antimicrobials (e.g., antibiotic ointments, iodine prepa- wound’s tensile strength increases rapidly; after this period, ten-
rations, and silver agents) are commonly used to prevent wound sile strength increases more slowly, eventually reaching a maxi-
infection. Application of mupirocin ointment to a clean surgical mum of 75% to 80% of normal skin strength [see Figure 2].
Table 5—Recommendations for Postexposure Rabies Prophylaxis91-93
Animal Type Animal Disposition and Evaluation Prophylaxis
If animal is healthy and available, it is confined for Start vaccination if animal exhibits rabies
10 days of observation symptoms*
If animal is rabid or suspected of being rabid, no

Dogs, cats, ferrets observation is indicated Provide immediate vaccination
If animal’s rabies status is unknown, consultation

Consult public health official
is indicated
Bats, skunks, raccoons, foxes, bobcats, coyotes, Animal is regarded as rabid unless brain laboratory Provide immediate vaccination unless brain labora-
mongooses, and most carnivores tests are negative tory tests are negative
Livestock, small rodents (e.g., squirrels, chipmunks,

rats, hamsters, gerbils, guinea pigs, and mice), Each case is considered indivdually; rabies report- Consult public health officials; almost never require
large rodents (e.g., woodchucks and beavers), ed in large rodents in some areas antirabies treatment
rabbits, hares, and other mammals
*If the isolated animal shows symptoms of rabies, postexposure prophylaxis is started immediately, and the animal is euthanized for laboratory testing. Vaccination prophylaxis is stopped
if laboratory tests are negative for rabies.
Wounds at risk for infection should be assessed by a medical trunk) should remain in place longer, as should sutures in wounds
provider within 48 hours of care. In addition, the patient should sustained by patients who have a condition that hinders healing
be taught to look for signs of infection (e.g., erythema, edema, (e.g., malnutrition). In such cases, suture-mark scars are consid-
pain, purulent drainage, and fever). ered acceptable. The appropriate method of removing a suture is
The timing of suture or staple removal is determined by balanc- first to cut it, then to pull on the knot parallel to or toward, rather
ing the requirements for optimal cosmesis against the need for than away from, the wound.
wound support. On one hand, it is clear that for optimal cosmesis, After suture removal, numerous methods are employed to
sutures should be removed early, before inflammation and epithe- minimize unsightly scar formation. The cosmetic outcome of a
lialization of suture tracts. An epithelialized tract will develop scar is largely determined by the nature and severity of the
around a suture or staple that remains in the skin for longer than wound, which are outside the surgeon’s control. The greatest
7 to 10 days; once the suture or staple is removed, the tract will be impact a surgeon can have on cosmetic outcome is derived from
replaced by scar.94 On the other hand, it takes a number of weeks providing meticulous care when the acute wound is initially
for the wound to gain significant tensile strength, and early encountered. Postoperative wound care measures employed to
removal of wound support can lead to dehiscence of wounds that optimize cosmetic outcome include massage, the use of silicone
are under substantial tension. Early suture removal is warranted bandages or pressure garments, and the application of lotions.
for some wounds. For example, sutures in aesthetically sensitive These interventions appear to help, but prospective trials are
areas (e.g., the face) may be removed on day 4 or 5, and sutures needed to confirm their efficacy and establish treatment guide-
in areas under minimal tension (e.g., in wounds parallel to skin lines.The healing wound is fragile, and topical application of oint-
tension lines) may be removed on day 7. Sutures in wounds sub- ments to achieve an improved scar appearance may actually
ject to greater stress (e.g., wounds in the lower extremities or the achieve the opposite result. For example, vitamin E, which is
commonly applied to healing wounds, can induce contact der-
matitis and cause scars to look worse.95
Table 6—Recommendations for
Postexposure Rabies Vaccination91-93 Factors That May Hinder Wound Healing
Despite a surgeon’s best efforts, healing does not always occur
Dosage in an undisturbed fashion: sometimes, a closed wound dehisces. If
Vaccine No Previous Previous the dehiscence is sudden, the wound is clean, and only skin and
Vaccination Vaccination superficial tissues are involved, then the wound should be
reclosed, and the cause of the dehiscence should be corrected if
Full dose of 20 IU/kg infil- possible. If the dehiscence is slow and the wound is contaminated
trated around wound(s)
Human rabies immune at initial presentation; or infected, then the wound should be allowed to heal secondari-
Not administered
globulin (HRIG) use separate syringe ly, with dressing changes and scar revision to be performed at a
and anatomic site from later date.
vaccine
There are a number of local and systemic factors [see Table 7]
Human diploid cell vaccine that can interfere with wound healing (see below). Accordingly, it
(HDCV), rabies vaccine
1.0 ml IM on days 0, 3, 7,
is essential for clinicians to be aware of and knowledgeable about
adsorbed (RVA), or 1.0 ml IM on
purified chick embryo 14, and 28* days 0 and 3* these factors and, whenever possible, to take appropriate mea-
cell vaccine (PCECV) sures to improve the chances for optimal healing. The use of
nutrients and growth factors to stimulate wound healing may be
*Vaccine administration site for adults is the deltoid; for children, the anterolateral thigh may considered; this measure is currently the subject of extensive
be used. To prevent sciatic nerve injury and reduce adipose depot delivery, the gluteus is
never used. research.
800 that show no perfusion on fluorescein testing is ischemic. Ques-

tionably viable tissue should be monitored closely and debrided
Tensile Strength (g/mm2)
600
when declared nonviable.
Hematoma and Seroma
400 Hematomas and seromas increase the risk of infection and the
likelihood of wound dehiscence. To prevent their formation,
hemostasis at the time of wound closure must be meticulous, and
200 bleeding diatheses must be corrected. Because the rubbing of
wound edges against one another is associated with the formation
of hematomas and seromas, wound edge movement should be
0
1 2 3 4 5 6 7 8 9 10 11 12 minimized and immobilization employed as necessary.Wounds at
Weeks after Wounding significant risk for hematoma or seroma formation should be
closed over a drain.
Figure 2 The tensile strength of skin wounds increases rapidly
for approximately 6 weeks after wounding; it then continues to Large hematomas or seromas that are recognized early, before
increase slowly for 6 to 12 months after wounding, though it never infection develops, should be evacuated, and the wound should be
reaches the tensile strength of unwounded tissue. Collagen is reclosed. Small hematomas or seromas can usually be treated con-
remodeled and replaced with highly cross-linked collagen along servatively until they are reabsorbed, but close observation is
tissue stress lines. The process of collagen replacement and scar required. If a hematoma or seroma is not recognized until late,
remodeling continues for years. when infection has already set in, the wound should be opened,
drained, and allowed to heal secondarily; scar revision may be car-
ried out at a later point.
LOCAL FACTORS
Trauma
Tension
Tissue injury is obviously associated with external trauma, but
Tension—whether from inherent skin tension, poor surgical it can also be iatrogenic. Rough handling of tissue edges with for-
technique, movement of joints, or inadequate wound support— ceps produces minute crush injuries, which promote wound infec-
may lead to separation of wound edges. It should be minimized tion. It is preferable to handle wound edges with hooks, using gen-
by undermining the wound edges during closure to allow easy tle surgical technique.
coaptation.Tissue ellipses from complex wound edges should be
kept as narrow as possible and should be created along relaxed Edema
skin tension lines. Adequate support of the wound after suture Edema results from the accumulation of fluid in the interstitial
removal is critical; many surgeons keep tapes (e.g., Steri-Strips) space. It may occur as an acute process, in which tissue injury
over a wound for 3 weeks, until the strength of the wound equals leads to histamine release, leaky capillaries, and inflammation, or
that of the deep sutures and tapes. Wounds over joints should be as a chronic process, in which venous insufficiency, lymphatic
splinted to reduce tension. insufficiency, and a low plasma oncotic pressure may cause fluid
to collect in the interstitium. In both cases, edema raises tissue
Foreign Body
pressure and inhibits perfusion and healing. The proteinaceous
All foreign bodies that contaminate a wound should be re- and fibrin-rich fluid also forms clot and fibrous tissue, which hin-
moved at the time of initial debridement and before wound clo- der the supply of oxygen and inflammatory cells.97 Clearance of
sure. Retained foreign bodies may cause failed healing, infection, wound edema is necessary for healing and may be successfully
or traumatic tattooing. Iatrogenic foreign bodies may also interfere accomplished by means of compression therapy98 or NPWT with
with wound healing and promote infection. Suture material is a a VAC device.83
foreign body; thus, the number and size of sutures placed in a
wound should be kept to the minimum necessary for coaptation
of the wound edges.
Table 7—Local and Systemic Factors
Infection That Impair Wound Healing
All traumatic wounds are contaminated and should therefore
be irrigated to remove organisms. Infection occurs when bacteria
Local Factors Systemic Factors
are too numerous (>105 organisms/g tissue) or virulent for local
tissue defenses to be able to control them.96 As noted [see Tension Inherited connective tissue disorders
Adjunctive Wound Care, Prophylactic Antibiotics, above], local Foreign body Hypothermia
factors (e.g., impaired circulation and radiation injury) increase Infection Oxygen
the risk of infection, as do various systemic diseases (e.g., diabetes, Ischemia Tobacco smoking
AIDS, uremia, and cancer). Wound cultures should be obtained, Hematoma and seroma Malnutrition
and broad-spectrum antibiotic therapy should be started when Edema Jaundice
infection is diagnosed. The antibiotic regimen is adjusted on the Irradiation Age
basis of culture results and sensitivities. Diabetes mellitus
Uremia
Ischemia Steroids
Chemotherapeutic agents
Ischemic wound tissue readily becomes infected and therefore Other drugs
must be debrided. Tissue with dermal edges that do not bleed or
Irradiation Oxygen
Irradiation damages the skin and can cause wounds to heal Tissue oxygenation is necessary for aerobic metabolism, fibro-
slowly. It also induces chronic skin changes: previously irradiated blast proliferation, collagen synthesis, and the antimicrobial oxida-
tissues demonstrate delayed healing when wounded.99 Irradiated tive burst of inflammatory cells.Transcutaneous oxygen tension is
tissue is characterized by a thickened and fibrotic dermis, a thin directly correlated with wound healing.109 Wound tissue oxygena-
epidermis, pigment changes, telangiectasia, decreased hair, and tion is determined by blood perfusion, hemoglobin dissociation,
increased dryness (as a consequence of damage to sebaceous and local oxygen consumption, fraction of inspired oxygen (FIO2), oxy-
sweat glands). The microvasculature of the skin is obliterated, gen-carrying capacity (as measured by hemoglobin content), arte-
leading to tissue ischemia and impaired healing. Keratinocytes, rial oxygen tension (PaO2), circulating blood volume, cardiac func-
which are necessary for wound epithelialization, exhibit impaired tion, arterial inflow, and venous drainage.106,110 Each of these vari-
mitotic ability and slow progressive desquamation (as a conse- ables should be addressed in promoting wound healing.
quence of their superficial location and high replication rate).97 Supplemental administration of oxygen (inspired or hyperbar-
Collagen bundles become edematous and fibrotic. Fibroblasts, ic) has beneficial effects on wound healing.The incidence of infec-
which are necessary for collagen synthesis, also show diminished tion in surgical wounds can be reduced by improving the FIO2 with
migration and proliferation.100 supplemental oxygen.111 In a study of patients undergoing colon
Because irradiated skin is irreversibly damaged, tissue transfer surgery, for example, the wound infection rate was 50% lower
may be required for repair of wounds in areas subjected to radia- when an FIO2 of 0.8 was maintained intraoperatively and for 2
tion. Vitamin A supplementation can lessen the adverse effects of hours postoperatively than when an FIO2 of 0.3 was maintained.112
irradiation on wound healing.101 Hyperbaric oxygen therapy (i.e., the delivery of oxygen in an envi-
ronment of increased ambient pressure) has been used for treat-
SYSTEMIC FACTORS ment of many types of wounds in which tissue hypoxia may impair
healing.43 It increases tissue oxygen concentrations tenfold while
Inherited Connective Tissue Disorders also causing vasoconstriction, which results in decreased posttrau-
Several inherited connective tissue disorders are known to inter- matic edema and decreased compartment pressures.113 The ele-
fere with normal wound healing. Ehlers-Danlos syndrome exists as vated pressure and hyperoxia induced by hyperbaric oxygen ther-
multiple types that exhibit certain differences, but in general, the apy may promote wound healing; for patients with an acute
syndrome leads to deficient collagen cross-linking, which results in wound, this modality may be a useful adjunct in treating limb-
lax and fragile skin, lax joints, and impaired wound healing. For threatening injury, crush injury, and compartment syndrome.43
Circulating volume can be improved by administering crystal-
example, an Ehlers-Danlos patient who undergoes an elective her-
loids or blood. However, anemia alone is not associated with
nia repair or facelift may have a poor outcome as a consequence of
impaired wound healing unless it is severe enough to limit circu-
deficient collagen formation and poor wound healing.102,103 Osteo-
lating blood volume.114 The vasculature may be compromised
genesis imperfecta is a procollagen formation disorder that is clini-
either systemically (e.g., by diabetes mellitus or peripheral vascu-
cally manifested by brittle bones, increased laxity of ligaments and
lar disease) or locally (e.g., by trauma or scar). Vascular bypasss
skin, bone deformities, and impaired wound healing.104 Marfan syn-
may be necessary to improve tissue oxygenation in patients with
drome is an autosomal dominant disorder characterized by deficient
poor arterial inflow.97
synthesis of fibrillin, which is a key component in elastin formation.
Patients with this syndrome have long extremities and hyperex- Tobacco Smoking
tendable joints; those who are seriously affected have lax ligaments, Tobacco smoking reduces tissue oxygen concentrations, impairs
dissecting aneurysms, dislocated eye lenses, pectus excavatum, and wound healing, and contributes to wound infection and dehis-
scoliosis. Surgical repair of aneurysms and hernias is usually suc- cence.115,116 The effects of smoking are attributable to vasocon-
cessful in this population, though healing difficulties may be en- striction (caused by nicotine), displacement of oxygen binding
countered.103 Cutis laxa is a disease in which an elastase inhibitor (resulting from the high affinity of carbon monoxide for hemoglo-
deficiency gives rise to defective elastic tissue. Patients with this dis- bin), increased platelet aggregation,117 impairment of the inflam-
ease have thick, coarse, and drooping skin, along with hernias, matory cell oxidative burst,118 endothelial damage, and the devel-
aneurysms, heart disease, and emphysema. Unlike patients with the opment of atherosclerosis.115,116,119 All acutely injured patients
other heritable diseases mentioned, cutis laxa patients often show should stop smoking, and ideally, all noninjured patients sched-
no impairment of wound healing.105 uled to undergo surgery should stop smoking at least 3 weeks before
Hypothermia an elective surgical wound is made.118,120 Like smoked tobacco,
transcutaneous nicotine patches alter the inflammatory cell oxida-
Hypothermia may develop as a consequence of administration tive burst and cause vasoconstriction; accordingly, they too should
of anesthetic drugs, exposure to cold, or redistribution of body not be used when a wound is present.118
heat; it leads to peripheral vasconstriction and impaired wound
oxygen delivery.106 Wound tensile strength increases more slowly Malnutrition
when healing occurs in a cold environment. Prevention or correc- On average, hospitalized patients show a 20% increase in ener-
tion of hypothermia reduces the wound infection rate and increas- gy expenditure, and this increase calls for appropriate nutritional
es collagen deposition in patients undergoing abdominal surgery.107 compensation.97 Good nutritional balance and adequate caloric
Preoperative systemic and local warming also reduces the wound intake (including sufficient amounts of protein, carbohydrates, fatty
infection rate in patients undergoing elective operations.108 A warm acids, vitamins, and other nutrients) are necessary for normal
body temperature must be maintained in all wounded patients to wound healing.121
reduce subcutaneous vasoconstriction and maximize wound heal- All patients who have sustained wounds should undergo nutri-
ing potential. tional assessment,122 which typically includes measuring serum
levels of albumin, protein, prealbumin, transferrin, and insulinlike wounds; this measure will improve collagen synthesis, though it
growth factor–1 (IGF-1).97 The serum albumin level is one of the may not have any appreciable effect on the healing rate.143
best predictors of operative mortality and morbidity.123 A value
lower than 2.5 g/dl is considered severely depressed, and a value Age
lower than 3.4 g/dl is associated with higher perioperative mortal- Aging has a deleterious effect on the capacity for wound heal-
ity.124,125 Protein provides an essential supply of the amino acids ing.145 Increasing age is associated with an altered inflammatory
used in collagen synthesis, and hypoproteinemia results in im- response, impaired macrophage phagocytosis, and delayed heal-
paired healing; consequently, it is not surprising that protein ing.146 Nevertheless, even though the wound healing phases begin
replacement and supplementation can improve wound heal- later in elderly persons, proceed more slowly, and often do not
ing.126,127 In particular, supplementation specifically with the amino reach the same level that they would in younger persons, elderly
acids arginine, glutamine, and taurine (which are essential for ana- patients are still able to heal most wounds with ease.147
bolic processes and collagen synthesis) is known to enhance wound
healing.128-130 Glutamine is the most abundant free amino acid in Diabetes Mellitus
the body, and under catabolic conditions, it is released from mus- Diabetes mellitus is associated with poor wound healing and an
cle unless provided as a supplement. increased risk of infection. Diabetic neuropathy leads to sensory
Vitamins C, A, K, and D are essential for normal healing. loss (typically in the extremities) and diminished ability to detect
Vitamin C (ascorbic acid) hydroxylates the amino acids lysine and or prevent injury and wounding. Once present, wounds in diabet-
proline during collagen synthesis and cross-linking. A deficiency ic patients heal slowly. The etiology of this healing impairment is
of this vitamin causes scurvy, marked by failed healing of new multifactorial. Diabetes is associated with impaired granulocyte
wounds and dehiscence of old wounds. Vitamin C supplementa- function and chemotaxis, depressed phagocytic function, altered
tion (100 to 1,000 g/day) can improve wound healing.97,130 Vitamin humoral and cellular immunity, peripheral neuropathy, peripher-
A (retinoic acid) is essential for normal epithelialization, proteo- al vascular disease, and various immunologic disturbances, any of
glycan synthesis, and normal immune function.131-133 Retinoids which may hinder wound healing.148-151 In addition, it is associat-
and topical tretinoin may help foster acute wound healing by ed with a microangiopathy that can limit perfusion and delivery of
accelerating epithelialization of full- and partial-thickness wounds, oxygen, nutrients, and inflammatory cells to the healing wound.152
activating fibroblasts, increasing type III collagen synthesis, and Diabetes-induced impairment of healing, as well as the attendant
decreasing metalloprotease activation.134,135 Oral retinoid treat- morbidity and mortality, may be reduced by tightly controlling
ment significantly increases the decreased hydroxyproline con- blood sugar levels with insulin.153 Diabetic patients must also
tent, tumor growth factor–β (TGF-β) level, and IGF-1 concentra- closely monitor themselves for wounds and provide meticulous
tion associated with corticosteroids.134 In addition, all aspects of care for any wounds present.
corticosteroid-impaired healing—other than wound contrac-
tion—can be reversed by providing supplemental oral vitamin A Uremia
at a recommended dosage of 25,000 IU/day.136 The retinoic acid Uremia and chronic renal failure are associated with weakened
derivative isotretinoin (13-cis-retinoic acid), however, impairs host defenses, an increased risk of infection, and impaired wound
wound epithelialization and delays wound healing.137 Vitamin K is healing.154 Studies using uremic animal models show delayed
a cofactor in the synthesis of coagulation factors II, VII, IX, and healing of intestinal anastomoses and abdominal wounds.155
X, as well as thrombin. Consequently, vitamin K is necessary for Uremic serum also interferes with the proliferation of fibroblasts
clot formation and hemostasis, the first step in acute wound heal- in culture.103,155 Treatment of this wound healing impairment
ing. Vitamin D is required for normal calcium metabolism and includes dialysis.
therefore plays a necessary role in bone healing. Uremic patients with wounds may experience bleeding compli-
Dietary minerals (e.g., zinc and iron) are also essential for cations. In this situation, appropriate evaluation includes determin-
normal healing. Zinc is a necessary cofactor for DNA and RNA ing the prothrombin time (PT), the activated partial thromboplas-
synthesis. A deficiency of this mineral can lead to inhibition cell tin time (aPTT), the platelet count, and the hematocrit. Treat-
proliferation, deficient granulation tissue formation,138 and ment includes dialysis without heparin; administration of desmo-
delayed wound healing.139 Zinc replacement and supplementa- pressin (0.3 μg/kg), cryoprecipitate, conjugated estrogens (0.6
tion can improve wound healing.130 However, daily intake mg/kg/day I.V. for 5 days),156 and erythropoietin; and transfusion
should not exceed 40 mg of elemental zinc, because excess zinc of red blood cells to raise the hematocrit above 30%.157,158
can immobilize macrophages, bind copper, and depress wound Uremic patients with hyperparathyroidism may also exhibit the
healing.140 Iron is also a cofactor for DNA synthesis, as well as uremic gangrene syndrome (calciphylaxis), which involves the
for hydroxylation of proline and lysine in collagen synthesis.97 spontaneous and progressive development of skin and soft tissue
However, iron deficiency anemia does not appear to affect wounds, usually on the lower extremities. Patients with this syn-
wound strength.141 drome typically are dialysis dependent and have secondary or ter-
tiary hyperparathyroidism.Wound biopsies demonstrate fat necro-
Jaundice sis, tissue calcification, and microarterial calcification.159
The effect of jaundice on wound healing is controversial. Treatment includes local wound care, correction of serum phos-
Jaundiced patients appear to have a higher rate of postoperative phate levels with oral phosphate binders,160 correction of calcium
wound healing complications,142 as well as a lower level of collagen levels with dialysis, and subtotal parathyroidectomy.159
synthesis.143 However, obstructive jaundice does not affect healing
of blister wounds in humans.143 Jaundiced animals show a signifi- Drugs
cant delay in collagen accumulation within the wound, but no sig- Steroids Corticosteroids are anti-inflammatory agents that
nificant reduction in the mechanical strength of the wound.144 inhibit all aspects of healing, including inflammation, macrophage
Biliary drainage may be considered in jaundiced patients with migration, fibroblast proliferation, protein and collagen synthesis,
development of breaking strength, wound contraction, and epithe- reduce the synthesis of collagen by fibroblasts, and delay wound
lialization.103,136,161 In the setting of an acute wound that fails to contraction.97 Some cytotoxic drugs (e.g., methotrexate and dox-
heal, corticosteroid doses may be reduced, vitamin A administered orubicin) substantially attenuate the early phases of wound repair
topically or systemically, and anabolic steroids given to restore and reduce wound tear strength.165 The magnitude of these effects
steroid-retarded inflammation.103,136 is influenced by the timing of the chemotherapeutic agent’s deliv-
Unlike corticosteroids, anabolic steroids accelerate normal col- ery in relation to the time when the wound is sustained.
lagen deposition and wound healing. Oxandrolone is an oral ana- Preoperative delivery has a greater adverse effect on healing; for
bolic steroid and testosterone analogue that is employed clinically example, doxorubicin impairs wound healing to a greater extent if
to treat muscle wasting, foster wound healing, and mitigate the given before operation than if treatment is delayed until 2 weeks
catabolism associated with severe burn injury. Supplementation after operation.166 Chemotherapy also results in myelosuppression
with this agent leads to significant improvements in the wound and neutropenia that can decrease resistance to infection, allowing
healing rate.162 In burn patients treated with oral oxandrolone, small wounds to progress to myonecrosis and necrotizing soft tis-
hospital length of stay is significantly reduced, and the number of sue infections.167 In all acutely wounded patients who have recent-
necessary operative procedures is decreased.163 In ventilator- ly been treated with, are currently taking, or will soon begin to take
dependent surgical patients receiving oxandrolone, however, the chemotherapeutic agents, the wounds must be closely observed
course of mechanical ventilation is longer than in those not treat- for poor healing and complications.
ed with oxandrolone. It has been suggested that the very ability of
oxandrolone to enhance wound healing may increase collagen Other drugs Many other commonly used drugs affect wound
deposition and fibrosis in the later stages of ARDS and thereby healing and thus should be avoided in the setting of an acute
prolong recovery.164 Acute elevation of liver enzyme levels has wound. Nicotine, cocaine, ergotomine, and epinephrine all cause
been seen in some patients treated with oxandrolone; accordingly, vasocontriction and tissue hypoxia. Nonsteroidal anti-inflammato-
hepatic transaminase concentrations should be intermittently ry drugs (e.g., ibuprofen and ketorolac) inhibit cyclooxygenase pro-
monitored in all patients treated with this agent.163 duction and reduce wound tensile strength. Colchicine decreases
fibroblast proliferation and degrades newly formed extracellular
Chemotherapeutic agents Both wound healing and tumor matrix. Antiplatelet agents (e.g., aspirin) inhibit platelet aggregation
growth depend on metabolically active and rapidly dividing cells. and arachidonic acid–mediated inflammation. Heparin and war-
Consequently, chemotherapeutic anticancer drugs that hinder farin impair hemostasis by virtue of their effects on fibrin forma-
tumor growth can also impair wound healing.These agents (which tion.84,168,169 As noted [see Malnutrition, above], isotretinoin inhibits
include adrenocorticosteroids, alkylating agents, antiestrogens, wound epithelialization and delays wound healing.137 Vitamin E (α-
antimetabolites, antitumor antibodies, estrogen, progestogens, tocopherol) impairs collagen formation, inflammation, and wound
nitroureas, plant alkaloids, and random synthetics) attenuate the healing170; topical application of this agent can causes contact der-
inflammatory phase of wound healing, decrease fibrin deposition, matitis and worsen the cosmetic appearance of scars.95
Discussion
Physiology of Wound Healing nephrine and norepinephrine) and prostaglandins (e.g., prosta-
Wound healing is not a single event but a continuum of glandin F2α [PGF2α] and thromboxane A2 [TXA2]). As vessels
processes that begin at the moment of injury and continue for contract, platelets aggregate and adhere to the blood vessel colla-
months. These processes take place in much the same way gen exposed by the injury. Aggregating platelets release alpha-
throughout the various tissues of the body and, for the purposes granule proteins, resulting in further platelet aggregation and trig-
of description, may be broadly divided into three phases: (1) gering cytokine release.The cytokines involved in cutaneous wound
inflammation, (2) migration and proliferation, and (3) maturation healing include epidermal growth factors, fibroblast growth fac-
[see Figure 3]. Humans, unlike (for instance) salamanders, lack the tors, transforming growth factor–β, platelet-derived growth factor,
ability to regenerate specialized structures; instead, they heal by vascular endothelial growth factor (VEGF), tumor necrosis fac-
forming a scar that lacks the complex and important skin struc- tor–α (TNF-α), interleukin-1 (IL-1), IGF-1, granulocyte colony-
tures seen in unwounded skin [see Figure 4]. stimulating factor, and granulocyte-macrophage colony-stimulat-
ing factor.171 Some of these cytokines have direct effects early in
INFLAMMATORY PHASE the healing process; others are bound locally and play critical roles
The inflammatory phase of wound healing begins with hemo- in later healing phases. The use of specific cytokines to reverse
stasis, followed by the arrival first of neutrophils and then of ma- healing deficits or promote wound healing appears to be a promis-
crophages.This response is most prominent during the first 24 hours ing clinical tool and is currently the subject of ongoing basic scien-
after a wound is sustained. Signs of inflammation (i.e., erythema, tific and clinical research.172
edema, heat, and pain) are apparent, generated primarily by changes The coagulation cascade also contributes to hemostasis. The
in the venules on the distal side of the capillary bed. In clean extrinsic pathway is essential to hemostasis and is stimulated by
wounds, signs of inflammation dissipate relatively quickly, and few the release of tissue factor from injured tissue; the intrinsic cascade
if any inflammatory cells are seen after 5 to 7 days. In contaminat- is not essential and is triggered by exposure to factor XII. Both
ed wounds, inflammation may persist for a prolonged period. coagulation pathways lead to the generation of fibrin, which acts
Because wounds bleed when blood vessels are injured, hemo- with platelets to form a clot in the injured area [see 1:4 Bleeding and
stasis is essential. In the first 5 to 10 minutes after wounding, vaso- Transfusion]. Fibrin both contributes to hemostasis and is the pri-
constriction contributes to hemostasis, and the skin blanches as a mary component of the provisional matrix [see Migratory and
result. Vasoconstriction is mediated by catecholamines (e.g., epi- Proliferative Phase, Provisional Matrix Formation, below].
Figure 3 Depicted are the phases of wound healing. In the inflammatory phase (top, left), platelets adhere to collagen
exposed by damage to blood vessels to form a plug. The intrinsic and extrinsic pathways of the coagulation cascade gener-
ate fibrin, which combines with platelets to form a clot in the injured area. Initial local vasoconstriction is followed by
vasodilatation mediated by histamine, prostaglandins, serotonin, and kinins. Neutrophils are the predominant inflammato-
ry cells (a polymorphonucleocyte is shown here). In the migratory and proliferative phase (top, right; bottom, left), fibrin
and fibronectin are the primary components of the provisional extracellular matrix. Macrophages, fibroblasts, and other
mesenchymal cells migrate into the wound area. Gradually, macrophages replace neutrophils as the predominant inflam-
matory cells. Angiogenic factors induce the development of new blood vessels as capillaries. Epithelial cells advance across
the wound bed. Wound tensile strength increases as collagen produced by fibroblasts replaces fibrin. Myofibroblasts induce
wound contraction. In the maturational phase (bottom, right), scar remodeling occurs. The overall level of collagen in the
wound plateaus; old collagen is broken down as new collagen is produced. The number of cross-links between collagen mol-
ecules increases, and the new collagen fibers are aligned so as to yield an increase in wound tensile strength.
Vasoconstriction and hemostasis are followed by vasodilatation, tissue and bacteria and digest them. After neutrophils phagocy-
which is associated with the characteristic signs of erythema, edema, tose damaged material, they cease to function and often release
heat, and pain.Vasodilatation is mediated by prostaglandins (e.g., lysosomal contents, which can contribute to tissue damage and a
PGE2 and PGI2 [prostacyclin]), histamine, serotonin, and ki- prolonged inflammatory response. Macrophages, however, are
nins.173,174 As the blood vessels dilate, the endothelial cells separate essential to wound healing and do not cease to function after
from one another, thereby increasing vascular permeability. In- phagocytosing bacteria or damaged material.176 In the wound envi-
flammatory cells initially roll along the endothelial cell lining, sub- ronment, macrophages also secrete collagenase, elastase, and
sequently undergo integrin-mediated adhesion, and finally trans- matrix metalloproteinases (MMPs) that break down damaged tis-
migrate into the extravascular space.175 sue. Macrophages also produce cytokines that mediate wound-
For the first 48 to 72 hours after wounding, neutrophils are the healing processes, as well as IL-1 (which can lead to a systemic
predominant inflammatory cells in the wound. About 48 to 96 response, including fever) and TNF-α.171
hours after wounding, however, monocytes migrate from nearby
MIGRATORY AND PROLIFERATIVE PHASE
tissue and blood and transform into macrophages, and eventual-
ly, macrophages become the predominant inflammatory cells in The migratory and proliferative phase is marked by the attrac-
the wound. Both neutrophils and macrophages engulf damaged tion of epidermal cells, fibroblasts, and endothelial cells to the
Lymphatic
Pacinian Vessel Sweat Gland
Corpuscle and Duct
Meissner
Corpuscle
Hair
Epidermis Sebaceous
Gland
Papillary Dermis
Hair Follicle
Reticular Dermis Approximate

Border of Cone
Blood Vessel
Hypodermis
Fascia
Nerve Fiber
Figure 4 Shown are the key anatomic
components of the skin.
Fat Dome
wound. Cells migrate along the scaffolding of fibrin and fibroblasts and other cells to the provisional extracellular matrix.180 By
nectin. This process involves the upregulation of integrin receptor influencing cellular attachment, fibronectin helps modulate cell mi-
sites on the cell membranes, which allows the cells to bind at dif- gration into the wound.181 In addition, the fibrin-fibronectin lattice
ferent sites in the matrix and pull themselves through the scaffold- binds various cytokines that are released at the time of injury and
ing. Migration through the provisional matrix is facilitated by pro- serves as a reservoir for these factors in the later stages of healing.182
teolytic enzymes. Cytokines and growth factors then stimulate the Fibroblasts then replace the provisional extracellular matrix
proliferation of these cells.171,176 with a collagen matrix, and the wound gains strength. The rate of
collagen synthesis increases greatly after the initial 3 to 5 days and
Epithelialization continues at an increased rate for 21 days before gradually declin-
Within approximately 24 hours of injury, epidermal cells from ing.183 Of the many types of collagen, the ones that are of primary
the wound margin and skin appendages begin to migrate into the importance in the skin are types I and III. Approximately 80% to
wound bed. These migrating epidermal cells dissect the wound, 90% of the collagen in the skin is type I collagen; the remaining
separating desiccated eschar from viable tissue.80 At 24 to 48 hours 10% to 20% is type III.The percentage of type III collagen is high-
after wounding, epidermal cells at the wound margin begin to pro- er in embryonic skin and in skin that is in the early stages of wound
liferate, producing more migrating cells.171 As epidermal migration healing.
is initiated, the desmosomes that link epidermal cells together and Collagen molecules are synthesized by fibroblasts. Lysine and
the hemidesmosomes that link the epidermal cells to the basement proline residues within the collagen molecule become hydroxylat-
membrane disappear.177 Migrating epidermal cells express integrin ed after being incorporated into polypeptide chains. This process
receptors that allow interaction with extracellular matrix proteins, requires specific enzymes, as well as various cofactors (i.e., oxygen,
laminin, collagen, and fibrin clot.178 When epidermal cells migrat- vitamin C, α-ketoglutarate, and ferrous iron).The result is procol-
ing from two areas meet, contact inhibition prevents further migra- lagen, which is released into the extracellular space. Individual col-
tion.The cells making up the epidermal monolayer then differenti- lagen molecules then align and associate with one another to form
ate, divide, and form a multilayer epidermis. fibrils. Covalent cross-links form between various combinations of
the hydroxylated residues (lysine and hydroxylysine) in aligned
Provisional Matrix Formation collagen fibrils, with the strongest links occurring between hydrox-
Formation of the provisional matrix and granulation tissue begins ylysine and hydroxylysine. These cross-links are essential to the
approximately 3 to 4 days after wounding. Fibroblasts synthesize tensile strength of the wound. Cofactor deficiencies (e.g., vitamin
an extracellular matrix of fibrin, fibronectin, and proteoglycans that C deficiency in scurvy) and the use of corticosteroids can lead to
supports epidermal and endothelial cell migration and prolifera- the synthesis of weak, underhydroxylated collagen that is inca-
tion.178,179 Proteoglycans (e.g., dermatan sulfate, heparin, heparan pable of generating strong cross-links.
sulfate, keratan sulfate, and hyaluronic acid) consist of a protein
core that is linked to one or more glycosaminoglycans; they anchor Angiogenesis
proteins and facilitate the alignment of collagen into fibrils. The growth of new blood vessels, which is necessary to support
Fibrin becomes coated with vitronectin and fibronectin, which the wound tissue, begins 2 to 3 days after wounding.This process
are glycoproteins that facilitate the adhesion of migrating fibro- of angiogenesis may be stimulated by the hypoxic and acidic
wound microenvironment, as well as by cytokines (e.g., VEGF) highest at anatomic sites with redundant tissue. Excessive contrac-
derived from epidermal cells and macrophages.171,184 Endothelial tion can lead to contracture, a pathologic scarring that impairs the
cells from surrounding vessels express fibronectin receptors and function and appearance of the scar.
grow into the provisional matrix.These migrating endothelial cells
create paths in the matrix for developing capillaries by releasing Scar Remodeling
plasminogen activator, procollagenase, heparanase, and MMPs, Collagen remodeling begins approximately 3 weeks after wound-
which break down fibrin and basement membranes.171,185 The ing. Collagen synthesis is downregulated, the rates at which colla-
budding capillaries join and initiate blood flow. As the wounded gen is synthesized and broken down reach equilibrium,and the wound
area becomes better vascularized, the capillaries consolidate to becomes less cellular as apoptosis occurs. During this process, the
form larger blood vessels or undergo apoptosis.186 extracellular matrix, including collagen, is continually remodeled
and synthesized in a more organized fashion along stress lines.183
MATURATIONAL PHASE
Collagen breakdown is mediated by MMPs.189 The number of
cross-links between collagen fibers increases,183 and the realigned,
Wound Contraction highly cross-linked collagen is much stronger than the collagen
Myofibroblasts are specialized fibroblasts containing alpha– produced during the earlier phases of healing.The tensile strength
smooth muscle actin microfilaments that contribute to wound of the wound increases rapidly for 6 weeks after injury; accordingly,
contraction.187,188 The wound edges are pulled together by the con- during this period, heavy lifting and any other activity that applies
tractile forces supplied by the myofibroblast. Wound contraction stress across the wound should be avoided. After the initial 6
generally begins in the 4- to 5-day period after wounding and con- weeks, tensile strength increases more slowly for a further 6 to 12
tinues for 12 to 15 days or until the wound edges meet.The rate at months, though it never reaches the tensile strength of unwound-
which contraction occurs varies with the laxity of the tissue and is ed tissue [see Figure 2].
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2 HEAD AND NECK 1 HEAD AND NECK DIAGNOSTIC PROCEDURES — 1
1 HEAD AND NECK DIAGNOSTIC

PROCEDURES
Adam S. Jacobson, M.D., Mark L. Urken, M.D., F.A.C.S., and Marita S.Teng, M.D.
Head and neck surgery deals with a wide range of pathologic con- esophagus. The pharynx is subdivided into the nasopharynx, the
ditions affecting the upper aerodigestive tract and the endocrine oropharynx, and the hypopharynx.
organs of the head and neck. As in other areas of the body, the
causes of these conditions can be inflammatory, infectious, con- Nasopharynx
genital, neoplastic, or traumatic. This chapter discusses the diag- The nasopharynx extends from the posterior choanae to the
nostic approach to head and neck disorders, with particular inferior surface of the soft palate. Malignancies of the nasophar-
attention to cancer. ynx can present as nasal obstruction, epistaxis, tinnitus,
headache, diminished hearing, and facial pain.
Anatomic Considerations Oropharynx
The head and neck can be conceptualized by dividing it into The oropharynx extends from the junction of the hard and soft
the following segments: (1) nasal cavity and paranasal sinuses, (2) palates and the circumvallate papillae to the valleculae. It includes the
oral cavity, (3) pharynx, (4) larynx, (5) salivary glands, and (6) soft palate and uvula, the base of the tongue, the pharyngoepiglottic
thyroid [see Figure 1]. and glossoepiglottic folds, the palatine arch (which includes the ton-
sils and the tonsillar fossae and pillars), the valleculae, and the later-
NASAL CAVITY AND PARANASAL SINUSES
al and posterior oropharyngeal walls. Carcinomas of the oropharynx
The nasal vault and paranasal sinuses are a complex labyrinth can present as pain, sore throat, dysphagia, and referred otalgia.
of interconnected cavities. These cavities are lined with mucous
membranes and are normally well aerated. The nasal vault itself Hypopharynx
is divided into two equal halves by the nasal septum. There are The hypopharynx extends from the superior border of the
three paired turbinates in the nasal cavity, which further subdi- hyoid bone to the inferior border of the cricoid cartilage. It includes
vide the nasal vault from cephalad to caudal, creating the superi- the pyriform sinuses, the hypopharyngeal walls, and the post-
or, middle, and inferior meatuses. cricoid region (i.e., the area of the pharyngoesophageal junction).
The ethmoid sinus is the most complicated of the paranasal Malignancies of the hypopharynx can present as odynophagia,
sinuses; it is also known as the ethmoid labyrinth [see Figure 2]. dysphagia, hoarseness, referred otalgia, and excessive salivation.
The maxillary sinus lies within the body of the maxilla and is the
LARYNX
largest of the paranasal sinuses. The frontal sinus lies within the
frontal bone and is divided into two asymmetrical halves by an The larynx is subdivided into the supraglottis, the glottis, and
intersinus septum. The sphenoid sinus lies posterior to the nasal the subglottis [see Figure 3]. It consists of a framework of carti-
cavity and superior to the nasopharynx. It too is an asymmetri- lages that are held together by extrinsic and intrinsic musculature
cally paired structure that is divided by an intersinus septum.The and lined with a mucous membrane that is topographically
sphenoid sinus remains the most dangerous sinus to manipulate arranged into two characteristic folds (the false and true vocal
surgically because of the surrounding vital structures (i.e., the cords). Neoplasms of the larynx can present as hoarseness, dysp-
carotid artery, the optic nerve, the trigeminal nerve, and the vid- nea, stridor, hemoptysis, odynophagia, dysphagia, and otalgia.
ian nerve).
Tumors within the nasal vault or the paranasal sinuses present Supraglottis
as nasal airway obstruction, epistaxis, pain, and nasal discharge. The supraglottis extends from the tip of the epiglottis to the
They can originate in any of the paranasal sinuses or the nasal junction between respiratory and squamous epithelium on the
cavity proper and often remain silent or are mistakenly treated as floor of the ventricle (the space between the false and true cords).
an infectious or inflammatory condition, with a consequent delay Carcinomas of the supraglottis can present as sore throat,
in the diagnosis. odynophagia, dysphagia, and otalgia.
ORAL CAVITY Glottis
Anatomically, the oral cavity extends from the vermilion bor- The space between the free margin of the true vocal cords is
der to the junction of the hard and soft palates and the circum- the glottis.This structure is bounded by the anterior commissure,
vallate papillae. It includes the lips, the buccal mucosa, the upper the true vocal cords, and the posterior commissure. The most
and lower alveolar ridges, the retromolar trigones, the oral tongue common symptom of carcinoma of the glottis is hoarseness.
(anterior to circumvallate papillae), the hard palate, and the floor
of the mouth. Subglottis
The subglottis extends from the junction of squamous and res-
PHARYNX
piratory epithelium on the undersurface of the true vocal cords
The pharynx is a tubular structure extending from the base of (approximately 5 to 10 mm below the true vocal cords) to the
the skull to the esophageal inlet. Superiorly, it opens into the nasal inferior edge of the cricoid cartilage. The most common symp-
and oral cavities; inferiorly, it opens into the larynx and the tom of carcinoma of the subglottis is hoarseness.
1
Sphenoidal Sinus Superior Sagittal Sinus

Concha Suprema
Frontal Sinus
Superior Concha
Falx Cerebri
Middle Concha
Pharyngeal Orifice
of Auditory Tube
Inferior Concha
Straight Sinus
Oral Part
of Tongue
Sublingual Fold
Pharyngeal Recess
Pharyngeal Part
of Tongue
Salpingopharyngeal Fold
Epiglottis Palatine Tonsil
Hyoid Bone
Oral Part of Pharynx
Laryngeal Part
of Pharynx
Vocal Fold
Thyroid Cartilage
Figure 1 The anatomic structures of
Esophagus the head and neck are shown.
SALIVARY GLANDS Clinical Evaluation

Salivary glands are subdivided into major and minor salivary The diagnostic approach to the upper aerodigestive tract begins
glands.The major salivary glands consist of the parotid glands, the with a thorough history, starting with a detailed evaluation of the
submandibular glands, and the sublingual glands. The minor sali- chief complaint. Once the chief complaint has been defined (e.g.,
vary glands are dispersed throughout the submucosa of the upper neck mass, hoarseness, hemoptysis, or nasal obstruction), it must be
aerodigestive tract. Classically, benign neoplasms present as pain- further characterized. The physician must determine how long the
less, slow-growing masses. A sudden increase in size is usually the problem has been present and whether the patient has any associ-
result of infection, cystic degeneration, hemorrhage into the mass, ated symptoms (e.g., pain, paresthesias, discharge, change in voice,
or malignant transformation. Malignant neoplasms also usually dyspnea, hemoptysis). In addition, it is important to ask about re-
present as a painless swelling or mass. However, certain features cent infection (e.g., of the ear, mouth, teeth, or lungs) and previous
are strongly suspicious for a malignancy, such as overlying skin medical treatment. Once a complete history of the chief complaint
involvement, fixation of the mass to the underlying structures, has been obtained, the physician should elicit a more comprehen-
pain, facial nerve paralysis, ipsilateral weakness or numbness of the sive general medical history from the patient, including pertinent
tongue, and cervical lymphadenopathy. past medical history, past surgical history, medications, allergies,
social history (tobacco, ethanol, I.V. drug use), and family history.
THYROID
After completion of the history, the next step is to perform a
The thyroid gland performs a vital role in regulating metabol- comprehensive physical examination. This begins with a thor-
ic function. It is susceptible to benign conditions (e.g., nodule, ough inspection of the entire surface of the head and neck, with
goiter, and cyst), inflammatory disease (e.g., thyroiditis), and malig- a focus on gross lesions, areas that are topographically abnor-
nancies. Additionally, congenital anomalies of the thyroid, such mal, and old scars from previous injuries or procedures. The
as a thyroglossal duct cyst, can present later in life.Thyroid lesions examination should proceed in an orderly fashion from superi-
can present as pain, hoarseness, dyspnea, or dysphagia. or to inferior. Next, the inspection focuses on the mucosal sur-
On the posterior aspect of the thyroid gland reside the four faces of the upper aerodigestive tract.
parathyroid glands. These glands play a vital role in maintaining Although an accurate history and careful physical examination of
calcium balance. Parathyroid adenomas and, rarely, carcinomas the head, neck, and mucosal surfaces are the most important steps
can develop. in evaluating a lesion in this part of the body, this clinical evaluation
Frontal Sinus
Ethmoid Sinuses
Turbinate Ostium
Bones
Maxillary
Sinus
Nasal
Airway Figure 2 The paranasal
sinuses are shown.
usually provides only a working diagnosis.The head and neck sur- 60º, and 90º), which allow for visualization of structures that are in-
geon must then proceed in a stepwise fashion to further clarify the accessible by simple anterior rhinoscopy. Rigid nasal endoscopy is
diagnosis and, in the case of neoplasm, to perform an accurate staging. especially useful for visualizing deeper structures and structures that
Radiographic techniques allow the head and neck surgeon to vi- are not in a straight axis from the nasal aperture.
sualize the mass and determine its characteristics (i.e., to differenti-
ate between solid and cystic lesions), as well as determine its
anatomic associations. Ultrasonography, magnetic resonance imag- Indirect Laryngoscopy
ing, and computed tomography each provides a unique view of the Indirect laryngoscopy has been used since the 1800s for visualiz-
pathology in question and thereby helps narrow the differential di- ing the pharynx and larynx. In this technique, the head light source
agnosis. Acquisition of a tissue specimen for cytologic or histologic illuminates the mirror, which in turn illuminates the laryngophar-
analysis, or both, is the next step. Fine-needle aspiration (FNA) is ynx [see Figure 5].The patient is seated in the sniffing position and
often utilized at this stage in the workup, provided that the location protrudes the tongue while a warmed laryngeal mirror is intro-
of the mass lends itself to a safe procedure. If the lesion is located duced firmly against the soft palate in the midline to elevate the
deep in the neck near vital structures, image-guided FNA can be at- uvula out of the field (gently, so as not to elicit the gag reflex).The
tempted before resorting to an open biopsy. If the lesion is on a mu- image seen on the mirror can be used to assess vocal cord mobility,
cosal surface of the upper aerodigestive tract, an endoscopic biopsy as well as to inspect for a mass or foreign body of the larynx or phar-
is performed. Often, a panendoscopic procedure is performed at ynx.This technique can be performed rapidly and is inexpensive.
this point to accurately map the lesion, obtain a tissue specimen,
and, in patients with cancer, assess the rest of the upper aerodiges-
tive tract for a synchronous primary tumor. Endoscopic Procedures
After a histologic diagnosis has been made and correlated with Endoscopic evaluation of the upper aerodigestive tract is cru-
the imaging information, the patient and physician can have a com- cial in establishing a definitive diagnosis. The equipment used
prehensive discussion of the pathology, the stage of the disease, and consists of both rigid and flexible laryngoscopes, bronchoscopes,
the selection of therapy. and esophagoscopes. Many of these techniques can be performed
in the office setting, providing the surgeon with an array of meth-
ods for gaining the information necessary for a working diagnosis
Nasal Diagnostic Procedures and, in some cases, for performing a therapeutic intervention.
Operative endoscopy is performed to obtain a definitive diagno-
ANTERIOR RHINOSCOPY
sis, to stage tumors, and to rule out synchronous lesions.There is
Using a variety of different light sources that provide both illu- no substitute for thorough examination and biopsy of a lesion
mination and coaxial vision, the head and neck surgeon can view with the patient under general anesthesia. Regardless of the endo-
the nasal vault through a nasal speculum [see Figure 4].This tech- scopic method used, an adequate biopsy specimen must be
nique is performed both before and after nasal decongestion, with obtained for a histologic diagnosis.
particular attention to mucosal color, edema, and discharge and
FLEXIBLE RHINOLARYNGOSCOPY
the effect of vasoconstriction. Limited visualization of the nasal
septum, the turbinates, and the vault is also possible with this Flexible rhinolaryngoscopy is currently one of the most com-
technique. monly used techniques for visualizing the nasal cavity, the sinus-
es, the pharynx, and the larynx. The technique utilizes a small-
RIGID NASAL ENDOSCOPY
caliber flexible endoscope and can be performed in an office set-
The rigid nasal endoscope comes with a variety of lens angles (0º, ting [see Figure 6]. Before the procedure, the patient’s nasal cavity
Epiglottis ESOPHAGOSCOPY
Esophagoscopy plays an important role in the evaluation of

Vestibule of
patients with dysphagia, odynophagia, caustic ingestion, trauma,
Hyoid the Larynx ingested foreign bodies, suspected anomalies, and upper aerodi-
Bone gestive tract malignancies. This procedure may be performed
with either a flexible or a rigid scope.
Vestibular Flexible Esophagoscopy
Fold
The primary application for flexible esophagoscopy is diagno-
sis. The procedure is particularly useful in elderly patients with
limited spinal mobility and in patients with short, thick necks.
The flexible esophagoscope is used with local anesthesia and
Vocal sedation in a monitored setting.To facilitate control of secretions
Fold and the passage of the instrument, the patient is placed in a flexed
Thyroid position and lying on one side. Using insufflation, the surgeon
Cartilage visualizes and enters the cricopharyngeus and carries out a safe
Vocal
Muscle and detailed visual study of the esophagus. If a malignancy is sus-
pected, either a brush specimen is sent for cytology or a cup for-
ceps is used to acquire a specimen for histologic analysis.
Infraglottic
Rigid Esophagoscopy
Cricoid
Cartilage Space Rigid esophagoscopy can be used to treat a variety of problems,
including foreign bodies, hemorrhage (e.g., from esophageal
varices), and endobronchial tumors. Rigid esophagoscopes [see Fig-
ure 8] are used with the patient under general anesthesia.The pa-
Trachea tient is placed in the supine position with the neck extended. The
esophagoscope is then passed along the right side of the tongue,
with the endoscopist using the left hand to cradle the instrument.
The right hand is used for stabilization of the proximal end of the
Figure 3 Cross-sectional anatomy of the larynx is shown. scope, suctioning, and insertion of instruments through the lumen
of the esophagoscope. The lip of the esophagoscope is positioned
anteriorly for manipulation of the epiglottis and visualization of the
is decongested and anesthetized for maximum visualization and pyriform sinus and the arytenoids.The scope is then passed along
minimal discomfort. In the procedure, the examiner threads the the pyriform sinus into the cricopharyngeus (i.e., the superior
end of the scope into the nasal aperture along the floor of the esophageal valve). The left thumb is then used to advance the in-
nasal cavity. As the scope is advanced, the examiner can visualize strument down the esophagus. If no major lesions are noted on in-
the nasal cavity proper for any evidence of lesions or masses. sertion of the esophagoscope, a careful inspection of the mucosa
Once the scope approaches the nasopharynx, it is directed inferi- should be made during withdrawal of the instrument.
orly and advanced slowly, allowing direct visualization of the
entire pharynx and larynx.
DIRECT LARYNGOSCOPY
Direct laryngoscopy has the advantage of permitting both diag-

nostic and therapeutic intervention [see Figure 7]. It is performed
with the patient under general anesthesia and intubated.The pro-
cedure allows for direct visualization of the pharynx and the larynx
and permits the surgeon to perform biopsies and remove small le-
sions. At the same time, the surgeon has the opportunity to palpate
the structures of the oral cavity, the oropharynx, and the hypo-
pharynx, which cannot be properly palpated in an awake patient.
The laryngoscope can also be suspended from a table-mount-
ed Mayo stand (for hands-free use), and a microscope can be
maneuvered into focal distance to allow magnified visualization of
the glottis and subglottis. During a microscopic direct laryn-
goscopy, small lesions or topographic abnormalities can be better
characterized and removed if desired. Some examples of lesions
that can be diagnosed by direct laryngoscopy are vocal cord
polyps, leukoplakia, intubation granulomas, contact ulcers, webs,
nodules, hematomas, and papillomatosis. Additionally, small
malignant lesions of the vocal cords can be examined and ablat-
ed or extirpated by using a CO2 laser under direct microlaryngo-
scopic guidance. Figure 4 Shown is an assortment of nasal specula.
Figure 5 Shown is a laryngeal mirror.

Such an instrument is used for indirect
laryngoscopy.
BRONCHOSCOPY visualized, the instrument is threaded anteriorly to allow visualiza-

Bronchoscopy provides clinically useful information by direct tion of the glottis. The bronchoscope is then passed between the
inspection of the tracheobronchial tree. Like esophagoscopes, vocal cords and into the trachea. At this point, ventilation may be
bronchoscopes come in both flexible and rigid forms. The flexi- resumed either by positive pressure or by jet ventilation techniques
ble bronchoscope is used primarily for diagnosis.The value of the (ventilating bronchoscopes have a side port for attachment of the
rigid bronchoscope lies in its therapeutic applications, which tubing from the ventilator).The patient’s head is manipulated with
include foreign-body removal, removal of bulky tumors, intro- the endoscopist’s right hand so as to direct the tip of the broncho-
duction of radioactive materials, and placement of stents. scope and permit bilateral exploration of the major airways.
Flexible Bronchoscopy PANENDOSCOPY
The flexible fiberoptic bronchoscope is usually used with local The term panendoscopy refers to the combination of direct
anesthesia and sedation in a monitored setting (e.g., an operating laryngoscopy (with or without microscopic assistance), esopha-
suite). After local anesthesia and decongestion of the nasal vault goscopy, and bronchoscopy. Together, these three procedures
with topical tetracaine and 1% phenylephrine, the flexible scope is provide a complete examination of the entire upper aerodigestive
gently passed along the nasal floor into the nasopharynx, where tract. In cancer patients, this combination of procedures allows
the tip of the scope is angled inferiorly to permit visualization of the examiner to create a detailed map of the tumor, as well as to
the pharynx.The instrument is then advanced slowly into the glot- rule out synchronous primary tumors.
tis (between the true vocal folds) and into the tracheobronchial
tree. After a visual inspection of the airway has been completed, a Biopsy Procedures
specimen can be retrieved by means of brush biopsy, broncho-
alveolar lavage, or a biopsy forceps. FINE-NEEDLE ASPIRATION
Rigid Bronchoscopy FNA is often used to make an initial tissue diagnosis of a neck
Rigid bronchoscopy [see Figure 9] is performed with the patient mass. The advantages of this technique include high sensitivity
under general anesthesia. The patient is placed in the supine posi- and specificity; however, 5% to 17% of FNAs are nondiagnostic.
tion with the neck hyperextended. The bronchoscope is then Another advantage of FNA is speed: If a cytologist or a patholo-
passed along the right side of the tongue, with the endoscopist gist is available, diagnosis can often be made within minutes of
using the left hand to cradle the instrument.The instrument is ini- the biopsy.
tially held almost vertically until it reaches the posterior pharyngeal FNA is performed with a 10 ml syringe with an attached 21-
wall, at which point it is slowly guided into a more horizontal posi- to 25-gauge needle. Larger needles are more likely to result in
tion.While advancing the scope, the endoscopist cradles the instru- tumor seeding.The patient is positioned to allow for optimal pal-
ment with the fingers of the left hand, providing guidance and pro- pation of the mass. The skin overlying the mass is prepared with
tecting the patient’s lips and teeth. Once the tip of the epiglottis is a sterile alcohol prep sponge. Local anesthesia is not necessary.
The mass is grasped and held in a fixed and stable position. The
needle is introduced just under the skin surface. As the needle is
advanced, the plunger of the syringe is pulled back, to create suc-
tion. Once the mass is entered, multiple passes are made without
exiting the skin surface; this maneuver is critical in maximizing
specimen yield. After the final pass is completed, the suction on
the syringe is released and the needle withdrawn from the skin. If
a cyst is encountered, it should be completely evacuated and the
fluid sent for cytologic analysis.
A drop of aspirated fluid is placed on a glass slide. A smear is
made by laying another glass slide on top of the drop of fluid and
pulling the slides apart to spread the fluid. Fixative spray is then
applied. Alternatively, wet smears are placed in 95% ethyl alcohol
and treated with the Papanicolaou technique and stains.
FNA has several advantages over excisional biopsy. An FNA
requires only an office visit, with minimal loss of time from work
for the patient. In contrast, excisional biopsy is commonly per-
formed in an operating room, so the patient must undergo pre-
operative testing. Patients with a significant medical history may
require formal medical clearance. An excisional biopsy exposes
Figure 6 A small-caliber flexible laryngoscope is used for rhino- the patient to the risks of anesthesia, postoperative wound infec-
laryngoscopy. tion, and tumor seeding.
a b
Figure 7 Shown are (a) normal vocal folds directly visualized via (b) a rigid laryngoscope.
ULTRASOUND-GUIDED FNA neck. Palpable masses in the neck [see 2:3 Neck Mass] can be
Ultrasonographic guidance of FNA enables the surgeon to ob- assessed for changes in size, for association with other local struc-
tain a cytologic specimen of deeper or nonpalpable masses that are tures, and for character (i.e., solid, cystic, or complex). Applica-
not amenable to standard FNA. Real-time imaging of the needle’s tions of ultrasonography include assessment of masses such as
passage allows the surgeon to plot a more accurate trajectory and thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, sali-
avoid underlying vital structures. Furthermore, it provides an image vary gland tumors, abscesses, carotid body tumors, vascular
of the mass, allowing its characterization as solid, cystic, or hetero- tumors, and thyroid masses. Additionally, ultrasonography com-
geneous.With cystic or complex masses, it is imperative to place the bined with FNA and cytologic evaluation can provide both a
tip of the needle into the wall to increase specimen yield. detailed visual description and an accurate cytologic evaluation of
masses in the neck [see Ultrasound-Guided FNA, above].
CT-GUIDED FNA
COMPUTED TOMOGRAPHY
CT-guided FNA is most commonly employed to diagnose poor-
ly accessible or deep-seated lesions of the head and neck. Like ultra- A CT scan with intravenous contrast is often the first-line
sound-guided FNA, CT-guided FNA provides visualization of the imaging technique used to evaluate a mass of the neck and to as-
needle as it is passed through the tissue and into the underlying sess for pathologic adenopathy. CT has proved to be an effective
structures, thus allowing a more accurate needle trajectory and method for primary staging of tumors and lymph nodes. Addition-
avoidance of underlying vital structures. Additionally, visual guid- ally, it has been shown to be effective in studying capsular pene-
ance of the needle greatly increases the likelihood of obtaining a tration and extranodal extension. It is clearly superior to MRI in
specimen from the mass rather than the surrounding tissues. evaluating bone cortex erosion, given that MRI cannot assess
bone cortex status at all. CT scans are also widely used for post-
treatment surveillance in cancer patients.
Imaging Procedures
MAGNETIC RESONANCE IMAGING
Because many of the deep structures of the head and neck are
inaccessible to either direct evaluation by palpation or indirect MRI avoids exposing the patient to radiation and provides the
evaluation via endoscopy, further information must be obtained investigator with superior definition of soft tissue. For example,
by radiography. Imaging procedures such as CT, MRI, ultra- MRI can differentiate mucous membrane from tumor, as well as
sound, and positron emission tomography (PET) scanning per- detect neoplastic invasion of bone marrow. In patients with nasal
mit the diagnosis and analysis of pathologic conditions affecting cavity tumors, MRI can distinguish between neoplastic, inflam-
these deep structures, including the temporal bone, skull base, matory, and obstructive processes. MRI is also valuable in assess-
paranasal sinuses, soft tissues of the neck, and larynx. ing the superior extent of metastatic cervical lymphadenopathy
(i.e., intracranial extension). A disadvantage of MRI is its limited
ULTRASONOGRAPHY
ability to show bone detail; it therefore cannot detect invasion of
Ultrasonography is a safe and inexpensive method of gaining bone cortex by a neoplasm. Furthermore, an MRI scan is signif-
high-resolution real-time images of the structures of the head and icantly more expensive than a CT scan.
Figure 8 Shown is a rigid endoscope.

Figure 9 (a) Rigid bronchoscopes incorporate stainless-steel tubes of varying length and
diameter. The beveled distal end of this Hopkins bronchoscope facilitates mobilization of the
epiglottis during intubation; the side ports permit ventilation and use of suction catheters.
(b) Illumination is provided by fiberoptic rods that are inserted into the bronchoscope.
POSITRON EMISSION TOMOGRAPHY False negative scans occur when tumor deposits are very small
PET scanning is a functional imaging technique that measures (i.e., 3 to 4 mm or less in diameter). Thus, micrometastases are
tissue metabolic activity through the use of radioisotopically not reliably detected using an FDG-PET image. Furthermore, a
tagged cellular building blocks, such as glucose precursors. A false negative scan can occur if the PET scan is performed too
range of physiologic tracers has been developed for PET imag- soon after radiation therapy.
ing, with the glucose analogue 2-deoxy-2-[(18)F]fluoro-D-glu- The role of PET imaging in head and neck oncology is rapid-
cose (FDG) the most commonly used. FDG has a half-life of 110 ly expanding. Currently, the majority of PET imaging used in
minutes. Once given to the patient, FDG is taken up by glucose head and neck oncology is FDG based. FDG-PET is actively
transporters and is phosphorylated by hexokinase to become being used to look for unknown primary lesions and second pri-
FDG-6-phosphate (FDG-6-P). Further metabolism of FDG-6- maries, to stage disease before therapy, to detect residual or
P is blocked by the presence of an extra hydroxyl moiety, which recurrent disease after surgery or radiation therapy, to assess the
allows FDG-6-P to accumulate in the cell and serve as a marker response to organ preservation therapy, and to detect distant
for glucose metabolism and utilization. metastases. Because false positive and false negative PET scans
Because neoplastic cells have higher rates of glycolysis, localized do occur, accurate interpretation of PET scans requires a thor-
areas of increased cellular activity on PET scans may represent neo- ough understanding of the potential confounding factors.
plastic tissue. In this respect, PET is very different from CT and MRI,
PET/CT
which depict tissue structure rather than tissue metabolic activity.
Because FDG is nonspecifically accumulated in glycolytically PET/CT is essentially an FDG-PET scan that has been coreg-
active cells, it demarcates areas of inflammation as well as neo- istered with a simultaneous CT scan to allow the radiologist to
plastic tissue, which can lead to a false positive scan. Muscular precisely correlate the area of increased cellular activity with the
activity during the scan can also lead to areas of increased uptake anatomic structure. This technique removes some of the guess-
in nonneoplastic tissue. Furthermore, healing bone, foreign body work involved with interpreting an area of increased activity on a
granulomas, and paranasal sinus inflammation can produce false simple PET scan and provides the physician with a morphologic
positive results. correlate for the area of increased uptake.
Recommended Reading
AJCC Cancer Staging Manual, 5th ed. Lippincott Cummings C: Otolaryngology Head and Neck Cancer Institute, National Institutes of Health, 2004.
Raven, Philadelphia, 1997 Surgery, 3rd ed. Mosby – Year Book St. Louis, 1998 http://seer.cancer.gov/
Bailey B: Head and Neck Surgery – Otolaryngology, Som P: Head and Neck Imaging, 4th ed. Mosby, St. Acknowledgments
3rd ed. Lippincott Williams & Wilkins, Philadelphia, Louis, 2003 Figure 1 Tom Moore.
2001 Surveillance Epidemiology and End Results. National Figures 2 and 3 Alice Y. Chen.
2 HEAD AND NECK 2 ORAL CAVITY LESIONS — 1
2 ORAL CAVITY LESIONS

David P. Goldstein, M.D., Henry T. Hoffman, M.D., F.A.C.S., John W. Hellstein, D.D.S., and
Gerry F. Funk, M.D., F.A.C.S.
Approach to Oral Cavity Lesions

The oral cavity is a complex structure that plays a role in many that involve the oral mucosa: for instance, well over 100 medica-
important functions, including mastication, swallowing, speech, tions are associated with lichenoid drug reaction, and even more
and respiration. It extends from the vermilion border of the lips are associated with xerostomia. Use of alcohol or tobacco is a
to the oropharynx and is separated from the oropharynx by the notable risk factor for the development of oral cavity carcinoma,
anterior tonsillar pillars, the junction of the hard and soft palates, as is a previous head and neck carcinoma. The quantity of alco-
and the junction between the base of the tongue and the oral hol or tobacco consumed should be determined because a dose-
tongue at the circumvallate papillae. response relationship exists between the level of use and the risk
In most cases, lesions of the oral cavity reflect locally confined of cancer. Other risk factors for oral cavity carcinoma include sun
processes, but on occasion, they are manifestations of systemic exposure (lip cancer), human papillomavirus infection, and nutri-
disease. The cause of an oral cavity lesion can usually be identi- tional deficiencies. Radiation exposure is a risk factor for soft tis-
fied by the history and the physical examination; however, it is sue sarcoma, lymphoma, and minor salivary gland tumors, and
most often determined definitively by either a response to a ther- HIV infection is a risk factor for Kaposi sarcoma.
apeutic trial or a biopsy. A systematic classification of oral cavity
PHYSICAL EXAMINATION
lesions facilitates the development of a differential diagnosis. One
approach to classification is based on the appearance of the lesion The head and neck should be examined in an organized and
(e.g., white, red, pigmented, ulcerative, vesiculobullous, raised, or systematic manner. Illumination with a headlight or a reflecting
cystic). Another approach is first to categorize the lesion as either mirror facilitates oral examination by freeing the examiner’s
neoplastic or nonneoplastic and then to further divide the non- hands for use in retracting the cheeks and the tongue.
neoplastic lesions into various subcategories (e.g., infectious, The mucosa of the oral cavity is evaluated at each of the oral
inflammatory, vascular, traumatic, and tumorlike) [see Table 1]. In subsites [see Figure 1]. Any trismus should be noted, as should the
the following discussion, we adopt the second approach. general health of the teeth and the gingiva. Percussion of carious
teeth with pulpitis often elicits pain, though this is not always the
case if caries is shallow or pulpal necrosis is present. Palpation of
Clinical Evaluation the tongue, the floor of the mouth, and the oral vestibule is an
essential component of oral examination. Palpation of the sub-
HISTORY
mandibular and submental regions is best performed bimanually.
The onset, duration, and Oral lesions should be characterized in terms of color, depth,
growth rate of the oral lesion location, texture, fixation, and other applicable attributes. When
should be determined. In- cancer is present, tenderness, induration, and fixation are com-
flammatory lesions usually mon. Invasion of surrounding structures (e.g., the mandible, the
have an acute onset and are self-limited, and they may be recur- parotid duct, or the teeth) by a malignant lesion should be noted.
rent. Neoplasms tend to exhibit progressive enlargement; a rapid Physical examination is not a definitive means of detecting mandi-
growth rate is suggestive of malignancy. It is often possible to bular invasion, because tumor fixation can be secondary to other
identify specific events (e.g., upper respiratory tract infection, oral factors and cortical invasion can occur with minimal fixation.2 In
trauma, or medications) that precipitated the lesions. Both malig- addition, lesions in some areas of the oral cavity (e.g., the hard
nancies and inflammatory conditions may be associated with var- palate and the attached gingiva) almost always appear to be fixed.
ious nonspecific symptoms, including pain and dysphagia. A history of otalgia warrants otoscopic examination. Otalgia in
Symptoms suggestive of malignancy include trismus, bleeding, a the absence of any identifiable pathologic condition of the ear
change in denture fit or occlusion, facial sensory changes, and often represents referred pain from a malignancy of the upper
referred otalgia. Fever, night sweats, and weight loss may occur in aerodigestive tract. The presence of otalgia in a middle-aged per-
various settings but are particularly associated with lymphomas son should always trigger a search for an underlying cause. The
and systemic inflammatory conditions. Some oral lesions are nasal cavity should be examined with a speculum to rule out
identified without presenting signs or symptoms as incidental tumor extension in lesions of the hard palate, and transnasal
findings noted during a general dental or medical examination.1 fiberoptic pharyngoscopy and laryngoscopy should be done if a
A review of systems may uncover signs (e.g., rashes or arthri- malignant neoplasm is a possibility or if a systemic condition is
tis) that suggest a possible autoimmune disorder. The medical suspected that may also affect the nasal or pharyngeal mucosa.
history should always address previous or current connective tis- Examination of the neck may reveal enlarged lymph nodes.
sue diseases, malignancies, radiation therapy, chemotherapy, and Lymphadenopathy in an adult should be considered to represent
HIV infection. It is especially important to elicit a medication his- metastatic cancer until proved otherwise. A benign ulcer in the
tory because many classes of medications cause drug eruptions oral cavity may cause a reactive adenopathy as a consequence of
Approach to Oral Cavity Lesions
Perform head and neck exam.

Patient presents with oral cavity lesion
•Visual assessment of mucosa of oral cavity
subsites
Obtain clinical history. •Color, depth, location, texture, and fixation
•Onset, duration, progression, precipitating of lesions
events, previous oral lesions •Ear exam, especially for otalgia
•Associated symptoms •Neck exam for adenopathy
•Review of systems •Nasal exam for palatal or upper alveolar
•Risk factors for malignancy lesions or systemic diseases
•Exam of oropharynx, larynx, and hypopharynx
if malignancy suspected
Diagnosis is probable
Estimate likelihood of malignancy.
Index of suspicion for malignancy is low Lesion is suspected of being premalignant

(leukoplakia or erythroplakia)
Further investigation with culture and sensitivity, lab tests,
or imaging may be warranted, depending on working diagnosis. •Small lesions: perform excisional biopsy.
Generally, these conditions can be managed with •Larger lesions: perform incisional biopsy.
observation, symptomatic treatment, or therapeutic trial. Treat specific lesion.
Inflammatory lesion Tumorlike lesion Benign neoplasm Hyperkeratosis
Infectious •Torus: intervention only if Treat with local Observe; repeat biopsy
•Viral: symptomatic treatment, antivirals if denture fit affected excision. if changes noted.
patient is immunocompromised •Cyst: observation or
•Bacterial: antibiotics excision
•Fungal: antifungals, usually topical (systemic •Fibroma: observation or
for persistent infection) excision
•Oral hairy leukoplakia or unusual infection: •Odontogenic cyst:
rule out HIV infection, refer patient to excision or debridement;
infectious disease specialist tooth extraction for
Noninfectious dentigerous cyst
•Aphthous ulcer: symptomatic treatment,
topical anti-inflammatories
•Traumatic ulcer: symptomatic treatment
•Autoimmune: symptomatic treatment, topical
or systemic steroids
•Necrotizing sialometaplasia: observation,
biopsy to rule out cancer
If lesion persists or therapeutic trial

fails, perform biopsy.
Formulate initial diagnostic impressions.
Diagnosis is uncertain
Investigate further with culture and sensitivity, imaging,

or lab tests.
Consult dermatologist or hematologist as appropriate.
Perform biopsy if malignancy is possible.
Treat identified condition as appropriate (see below).
Index of suspicion for malignancy

is high
Perform biopsy.
Treat specific malignancy.
Dysplasia or CIS Invasive cancer
Assess margins. If clear, Ensure adequate margins.

consider reexcision with wider Consider reexcision with
margins or observation; if close frozen-section control.
or positive, perform reexcision
with frozen-section control.
Minor salivary gland malignancy Mucosal melanoma Squamous cell carcinoma Kaposi sarcoma
Stage with CT, MRI, or PET. Stage with CT, MRI, PET, or Consider referral to medical
Assess with CT or MRI.
Perform wide local excision. panendoscopy. oncologist or infectious
Perform wide local excision.
•Clinically positive neck: •Stage 1 and 2: surgery disease specialist.
•Clinically positive neck: neck dissection.
•Clinically negative neck: consider neck dissection. or irradiation Rule out systemic disease.
selective neck dissection if tumor is •Clinically negative neck: •Stage 3 and 4: surgery with If asymptomatic, observe;
high grade. consider selective neck postoperative irradiation if symptomatic, consider
dissection. Perform neck dissection local or systemic treatment.
Consider postoperative irradiation for
Consider postoperative as indicated.
high-grade tumor or perineural spread.
irradiation.
the associated inflammation, but in the setting of cervical lymph-

adenopathy, the initial diagnostic assumptions should emphasize Hard
the strong possibility of a primary oral cancer with metastases to Upper Palate
the neck. Asymmetrical enlargement of the parotid or subman- Alveolus
dibular glands may result either from obstruction of the ducts by
Retromolar
an oral cavity mass or from enlargement of nodes intimately asso- Trigone
ciated with the glands. Symmetrical enlargement suggests a sys-
temic process (e.g., Sjögren syndrome or HIV infection). The
Table 1 Differential Diagnosis of Oral Cavity

Lesions Based on Etiology
Infectious
Viral
Herpes simplex
Herpes zoster
Cytomegalovirus
Herpangina
Hand, foot, and mouth disease
Oral hairy leukoplakia (Epstein-Barr virus)
Bacterial Buccal
Mycobacterial infection Mucosa Oral
Syphilis Tongue
Gingivostomatitis
Fungal
Inflammatory Candidiasis
lesions Coccidioidomycosis Lower Floor of
Alveolus Mouth
Noninfectious
Recurrent aphthous stomatitis
Traumatic ulcer
Lip
Autoimmune disorders
Behçet syndrome
SLE Figure 1 Depicted are the major anatomic subsites of the oral
Wegener granulomatosis cavity.
Sarcoidosis
Amyloidosis
Pemphigus and pemphigoid cranial nerves should be examined, with particular attention
Pyogenic granuloma focused on the trigeminal, facial, and hypoglossal nerves.
Necrotizing sialometaplasia
Lichen planus
Investigative Studies
Mucocele
Ranula The history and physical
Tumorlike
lesions Tori examination should narrow
Fibroma down the differential diag-
Odontogenic cysts nosis and lead to a working
Benign diagnosis. If a benign local
Squamous papilloma process (e.g., aphthous sto-
Minor salivary gland neoplasms matitis, traumatic ulcer, or viral infection) is suspected, no fur-
Ameloblastoma ther investigation, other than reevaluation, may be needed. If the
Hemangioma lesion persists or progresses, further investigation is warranted.
Granular cell tumor
Brown tumor LABORATORY TESTS
Neuroma, schwannoma, neurofibroma
Laboratory studies are usually not beneficial in the initial
Osteoma, chondroma
Neoplasms Malignant
workup of oral cavity lesions. If a connective tissue disease is sus-
Squamous cell carcinoma pected, serologic tests [see Table 2] and referral to a rheumatolo-
Verrucous carcinoma gist or another appropriate specialist may be considered.
Minor salivary gland malignancies
IMAGING
Mucoepidermoid carcinoma
Adenoid cystic carcinoma The value of advanced imaging with computed tomography,
Polymorphous low-grade adenocarcinoma magnetic resonance imaging, or both in the management of oral
Mucosal melanoma cavity lesions has not been firmly established. Accordingly, judg-
Kaposi sarcoma ment must be exercised. There is evidence to suggest that early
Lymphoma
oral cavity malignancies can be managed without either CT or
Osteosarcoma
MRI. Nevertheless, many clinicians obtain these studies in all
cases of malignancy and in most cases of suspected malignancy. bacterial, or viral infection is suspected, a small portion of a spec-
CT and MRI can help assess the size and location of the lesion imen may be sent separately for culture. If there is an associated
and determine the degree to which surrounding structures are neck mass [see 2:3 Neck Mass], fine-needle aspiration (FNA) may
involved. In patients with oral cavity carcinoma, imaging facili- be performed to rule out metastatic disease. In general, FNA is
tates the staging of tumors and the planning of treatment. In not useful for biopsy of oral lesions: incisional biopsy is often tech-
patients with cervical metastases, physical examination augment- nically easier and provides more tissue.
ed by MRI and CT has a better diagnostic yield than physical
EXAMINATION UNDER ANESTHESIA AND PANENDOSCOPY
examination alone. Bone-window CT scans are particularly help-
ful for assessing invasion of the mandible, the maxilla, the cervi- In patients with oral carcinoma, examination under anesthesia
cal spine, and the base of the skull. CT scans are highly sensitive (EUA) and panendoscopy may be performed either before or
and specific for detecting mandibular invasion.2,3 MRI provides during operation to assess the extent of the primary tumor and
better soft tissue delineation than CT, with fewer dental artifacts, identify any synchronous tumors. Both EUA and panendoscopy
and therefore is particularly valuable for assessing malignancies of are commonly performed in the operating room with the patient
the tongue, the floor of the mouth, and the salivary glands. Loss under general anesthesia. Panendoscopy involves endoscopic
of the usual marrow enhancement on T1-weighted MRI images examination of the larynx, the oropharynx, the hypopharynx, the
suggests bone invasion, though this is not a specific finding. Chest esophagus, and, occasionally, the nasopharynx. As a rule, assess-
x-ray, CT, or both may be employed to search for lung metastases ment of the tumor and neck is more accurately performed when
or a second primary tumor. the patient is relaxed under a general anesthetic. With improved
Positron emission tomography (PET) is playing an increasing- imaging techniques and the wider availability of office endo-
ly important role in the workup of patients with head and neck scopes, the role of panendoscopy is decreasing.
carcinoma or mucosal melanoma. PET is useful for confirming
the presence of a malignancy, as well as for assessing cervical and
distant metastases4-6; it is particularly valuable for detecting recur- Diagnosis and
rent or persistent disease.7 Drawbacks include frequent false pos- Management of Specific
itive results with active inflammation, high cost, and limited avail- Oral Cavity Lesions
ability. In addition, the quality of the PET images obtained and
INFLAMMATORY LESIONS
the level of technical experience available vary considerably
among institutions. Although broad guidelines have been devel-
oped for certifying physicians in the use of PET, the specific Infectious
expertise needed for optimal imaging of the complexities of the Viral stomatitis may be caused by a number of different virus-
head and neck is not easily acquired. es, including herpes simplex virus (type 1 or type 2), varicella-
zoster virus, and coxsackievirus [see Figures 2a and 2b].8 It is most
BIOPSY
common in children and immunocompromised patients. The
For oral cavity lesions that are suggestive of malignancy or are lesions of viral stomatitis are generally vesicular, occur in the oral
probably of neoplastic origin, biopsy is usually required. A brief cavity and the oropharynx, and erupt over the course of several
observation period to allow reevaluation, with biopsy withheld, days to form painful ulcers. Eruption may be preceded by local
may be warranted if a response to therapy or spontaneous resolu- symptoms (e.g., burning, itching, or tingling) or systemic symp-
tion is possible. The potential morbidity associated with a biopsy toms (e.g., fever, rash, malaise, or lymphadenopathy). The diag-
done in a previously irradiated region should be considered in nosis is usually established by the history and the physical exami-
deciding whether biopsy is advisable. Specimens are usually sent nation and may be confirmed by means of biopsy or viral culture.
to the pathologist in 10% buffered formalin, but there are notable Treatment of viral stomatitis primarily involves managing
exceptions. If a lymphoma is suspected, specimens should be sent symptoms with oral rinses, topical anesthetics, hydration, and
without formalin for genetic testing and flow cytometry. If an antipyretics. Systemic antiviral medications may shorten the
autoimmune disease is suspected, special tests requiring immuno- course of herpetic stomatitis and are indicated in immunocom-
fluorescence are indicated, and specimens should be sent either promised patients.9
fresh or in Michel solution. In addition, if fungal, mycobacterial, Candidiasis is a common fungal infection of the oral cavity [see
Figures 2c and 2d]. Candida albicans is the species most common-
ly responsible; however, other Candida species can cause this con-
Table 2 Serologic Tests for Diagnosing Connective dition as well, with C. glabrata emerging as a growing problem in
immunocompromised hosts. Factors predisposing to oral candi-
Tissue Disease
dal infection include immunosupression, use of broad-spectrum
antibiotics, diabetes, prolonged use of local or systemic steroids,
Connective Tissue Disease Serologic Tests
and xerostomia.10 Oral candidiasis presents in several different
CBC, antinuclear antibody, anti–double- forms [see Table 3], of which pseudomembranous candidiasis
SLE
stranded DNA antibody, anti-Smith antibody (thrush) is the most common. This form is characterized by
white, curdlike plaques on the oral mucosa that may be wiped off
Antinuclear antibody, rheumatoid factor, anti-
Sjögren syndrome Ro (SS-A), and anti-La (SS-B) antibodies (with difficulty) to leave an erythematous, painful base (the
Auspitz sign). Widespread oral and pharyngeal involvement is
cANCA, serum creatinine level, urine common.The diagnosis is based on the clinical appearance of the
Wegener granulomatosis microscopy
lesion and on evaluation of scrapings with the potassium hydrox-
Sarcoidosis Serum calcium and ACE levels ide (KOH) test. Culture is generally not useful, because Candida
ACE—angiotensin-converting enzyme cANCA—cytoplasmic antineutrophil cytoplasmic is a common commensal oral organism.11
antibodies CBC—complete blood count SLE—systemic lupus erythematosus Ideally, initial management of oral candidiasis is aimed at
a b
c d
Figure 2 Shown are infectious lesions of the oral cavity: (a) primary herpes stomatitis of
the buccal mucosa and soft palate; (b) primary herpes stomatitis of the tongue (in the
same patient as in frame a); (c) oral candidiasis (pseudomembranous form); and (d) oral
candidiasis (erythematous form).
reversing the underlying condition, though this is not always pos- ulcers are the most common [see Table 4].9 The diagnosis is made
sible. Treatment typically involves either topically administered on the basis of the history and the physical examination; biopsy is
antifungal agents or, if infection is severe or topical therapy fails, reserved for lesions that do not heal or that grow in size.
systemically administered antifungals. Patients who are immuno- Numerous therapies have been tried for recurrent aphthous
compromised or have xerostomia may benefit from long-term stomatitis, most with only minimal success. The majority of aph-
prophylaxis. thous ulcers heal within 10 to 14 days and require no treatment;
however, patients with severe symptoms may require medical
Noninfectious intervention. Temporary pain relief can be obtained with topical
Recurrent aphthous stomatitis Aphthous stomatitis is a anesthetic agents (e.g., viscous lidocaine). Tetracycline oral sus-
common idiopathic ulcerative condition of the oral cavity [see pension and antiseptic mouthwashes have also been used, with
Figures 3a and 3b].The ulcers are typically painful and may occur varying success.9 Topical steroids are the mainstay of therapy and
anywhere in the oral cavity and the oropharynx but are rarely may shorten the duration of the ulcers if applied during the early
found on the hard palate, the dorsal tongue, and the attached gin- phase.11 These agents may be applied either in a solution (e.g.,
giva.9 Affected patients often have a history of lesions, beginning dexamethasone oral suspension, 0.5 mg/5 ml) or in an ointment
before adolescence. There are three different clinical presenta- (e.g., fluocinolone or clobetasol). Ointments work much better in
tions of recurrent aphthous stomatitis, of which minor aphthous the oral cavity than creams or gels do. Systemic steroids are indi-
cated when the number of ulcers is large or when the outbreak
has persisted for a long time.
Table 3 Clinical Presentation of Oral Candidiasis
Necrotizing sialometaplasia Necrotizing sialometaplasia
is a rare benign inflammatory lesion of the minor salivary glands
Type of Oral Candidiasis Presentation
that resembles carcinoma clinically and histologically and is read-
White, curdlike plaques on oral mucosa that ily mistaken for it [see Figure 3c].12 This condition most common-
Pseudomembranous when wiped off (with difficulty) leave erythe- ly develops in white males in the form of a deep, sudden ulcer of
matous, painful base
the hard palate.The presumed cause is ischemia of the minor sali-
Thick white plaques on oral mucosa that can- vary glands resulting from infection, trauma, surgery, irradiation,
Hyperplastic not be rubbed off or irritation caused by ill-fitting dentures.9 Biopsy is usually nec-
Red, atrophic areas on palate or dorsum of essary to rule out squamous cell carcinoma or a minor salivary
Erythematous tongue gland malignancy. Review of the tissue by a pathologist well versed
Cracking and fissuring at oral commissures
in head and neck pathology is essential. Characteristic histologic
Angular cheilitis
findings include coagulation necrosis of the salivary gland acini,
a b c
d e f
g h i
Figure 3 Shown are noninfectious inflammatory lesions of the oral cavity: (a) minor apthous ulcer of the lower lip; (b)
minor apthous ulcer of the upper lip; (c) necrotizing sialotmetaplasia of the hard palate; (d) resolution of necrotizing
sialometaplasia without treatment (in the same patient as in frame c); (e) pyogenic granuloma of the upper alveolus;
(f) reticular lichen planus involving the buccal mucosa; (g) lichen planus of the lateral tongue; (h) pemphigus vulgaris of
the oral cavity, with an erythematous base after rupture of bullae (involving the left lateral tongue, the buccal mucosa, and
the lip); and (i) traumatic ulcer of the tongue secondary to dental trauma.
ductal squamous metaplasia, preservation of the lobular architec- tant is the recommended treatment.The classic presentation is in
ture, and a nonmalignant appearance of squamous nests.12,13 a pregnant woman, and hormonal influences may have an addi-
Lesions resolve without treatment within 6 to 10 weeks [see tional influence on recurrence.
Figure 3d].
Lichen planus Lichen planus is a common immune-medi-
Pyogenic granuloma A pyogenic granuloma is an aggrega- ated inflammatory mucocutaneous disease [see Figures 3f and 3g].15
tion of proliferating endothelial tissue [see Figure 3e] that occurs Clinically, idiopathic lichen planus is indistinguishable from
in response to chronic persistent irritation (e.g., from a calculus lichenoid drug reaction. The reticular form of lichen planus is the
or a foreign body) or trauma.10 The lesion appears as a raised, most common one and presents as interlacing white keratotic stri-
soft, sessile or pedunculated mass with a smooth, red surface that ae on the buccal mucosa, the lateral tongue, and the palate.15
bleeds easily and can grow rapidly.14 Surface ulceration may Lichen planus is usually bilateral, symmetrical, and asympto-
occur, but the ulcers are not invasive. The gingiva is the most matic.16 The symptomatic phases may wax and wane, with erythe-
common location, but any of the oral tissues may be involved. matous and ulcerative changes being the primary signs. Cutaneous
Conservative excision with management of the underlying irri- lesions occur less frequently and appear as small, violaceous, pru-
ritic papules.The diagnosis is generally made on the basis of the his- helpful in establishing the diagnosis. Circulating antibodies may be
tory and the physical examination; biopsy is not always necessary. present in either condition but are more common in pemphigus.
For asymptomatic lesions, no treatment is required other than Serologic tests may suffice to establish the diagnosis, without any
observation.17 For painful lesions, which are more common with need for biopsy. Management involves administration of immuno-
the erosive form of the disease, either topical or systemic steroids suppressive agents, often in conjunction with a dermatologist.
are appropriate.17 There is some controversy regarding the risk of
malignant transformation; however, long-term follow-up is still Traumatic ulcer Trauma (e.g., from tooth abrasion, tooth
recommended.16,18 The main risk posed by lichen planus may be brushing, poor denture fit, or burns) is a common cause of oral
the masking effect that the white striae cause, which can prevent mucosal ulceration [see Figure 3i]. The ulcers usually are painful
the clinician from observing the early leukoplakic and erythro- but typically are self-limited and resolve without treatment.Topical
plakic changes associated with epithelial dysplasia. anesthetic agents may be beneficial if pain is severe enough to limit
oral intake.
Ulcer from autoimmune disease Oral ulcers may be the
first manifestation of a systemic illness.The most common oral mani-
festation of systemic lupus erythematosus (SLE) is the appearance Tumorlike Lesions
of painful oral ulcers in women of childbearing age. Patients with
TORUS MANDIBULARIS AND TORUS PALATINUS
Behçet disease present with the characteristic triad of painful oral
ulcers, genital ulcers, and associated iritis or uveitis. Patients with Palatal and mandibular tori are benign focal overgrowths of cor-
Crohn disease or Wegener granulomatosis frequently manifest oral tical bone [see Figures 4a and 4b].10 They appear as slow-growing,
ulceration during the course of the illness. These disorders should asymptomatic, firm, submucosal bony masses developing on the
be managed in conjunction with a rheumatologist. lingual surface of the mandible or the midline of the hard palate.14
Mucous membrane pemphigoid and pemphigus vulgaris are When these lesions occur on the labial or buccal aspect of the
chronic vesiculobullous autoimmune diseases that frequently affect mandible and the maxilla, they are termed exostosis.20 Torus
the oral mucosa [see Figure 3h]. In mucous membrane pemphigoid, mandibularis tends to occur bilaterally, whereas torus palatinus
the antibodies are directed at the mucosal basement membrane, arises as a singular, often lobulated mass in the midline of the hard
resulting in subepithelial bullae.16 These bullae rupture after 1 to 2 palate. Surgical management is required only if the tori are inter-
days to form painful ulcers, which may heal over a period of 1 to 2 fering with denture fit.
weeks but often do not display a predictable periodicity. Oral pain
MUCOCELE AND MUCOUS RETENTION CYST
is often the chief complaint, but there may be undetected ocular
involvement that can lead to entropion and blindness. A mucocele is a pseudocyst that develops when injury to a
Pemphigus vulgaris is a more severe disease than mucous mem- minor salivary gland duct causes extravasation of mucous, sur-
brane pemphigoid. In this condition, the antibodies are directed at rounding inflammation, and formation of a pseudocapsule [see
intraepithelial adhesion molecules, leading to the formation of Figures 4c and 4d].14 Mucoceles are soft, compressible, bluish or
intraepithelial bullae.9 The blisters are painful and easily ruptured translucent masses that may fluctuate in size.They are most com-
and tend to occur throughout the oral cavity and the pharynx.19 The monly seen on the lower lip but also may develop on the buccal
Nikolsky sign (i.e., vesicle formation or sloughing when a lateral mucosa, anterior ventral tongue, and floor of the mouth. Only
shearing force is applied to uninvolved oral mucosa or skin) is pres- very rarely do they involve the upper lip; masses in the upper lip,
ent in both pemphigus and pemphigoid. In most cases, biopsy with even if they are fluctuant, should be assumed to be neoplastic,
pathologic evaluation (including immunofluorescence studies) is developmental, or infectious. Treatment involves excision of the
mucocele and its associated minor salivary gland.
A ranula (from a diminutive form of the Latin word for frog)
Table 4 Clinical Presentation of Aphthous Stomatitis is a mucocele that develops in the floor of the mouth as a conse-
quence of obstruction of the sublingual duct,16 secondary either
to trauma or to sublingual gland sialoliths. If the ranula extends
Type of Aphthous Presentation Time to
Ulcer Resolution through the mylohyoid muscle into the neck, it is referred to as a
plunging ranula. A plunging ranula may present as a submental
Multiple painful, well-demarcated or submandibular neck mass. Imaging helps delineate the extent
ulcers, < 1.0 cm in diameter, are
noted, with yellow fibrinoid base and
of the mass and may confirm the presence of a sialolith. The
Minor surrounding erythema; typically 7–10 days, with- recommended treatment is excision of the ranula with removal
involve mobile mucosa, with tongue, out scarring
of the sublingual gland and often the adjacent submandibular
palate, and anterior tonsillar pillar the
most common sites gland. Marsupialization is an option but is associated with a rela-
tively high recurrence rate.21
Ulcers, often multiple, may range in A mucous retention cyst (salivary duct cyst) is usually the result
size from a few millimeters to 3 cm
and may penetrate deeply with ele- of partial obstruction of a salivary gland duct accompanied by
Major (Sutton 4–6 wk, with
disease)
vated margins; typically involve
scarring
mucous accumulation and ductal dilatation [see Figure 4e].21 It is
mobile mucosa, with tongue, palate,
and anterior tonsillar pillar the most
a soft, compressible mass that may occur at any location in the oral
common sites cavity where minor salivary glands are present.Treatment involves
surgical excision with removal of the associated minor salivary
Small (1–3 mm) ulcers occur in
“crops” but are still limited to mov- gland.
Herpetiform able mucosal surfaces; gingival 1–2 wk
involvement, if present, is caused by FIBROMA
extension from nonkeratinizing
crevicular epithelium A fibroma is a hyperplastic response to inflammation or trau-
ma [see Figures 4f and 4g].22 It is a pedunculated soft or firm mass
a b c
d e f
g h
Figure 4 Shown are tumorlike lesions of the oral cavity: (a) torus mandibularis, with
bilateral bony protuberances on the lingual surface of the mandible; (b) mandibular
exostosis, with a unilateral bony protuberance on the labial-buccal surface of the
mandible; (c) mucocele of the lip (note the bluish hue of the cystic lesion; cf. frame e);
(d) mucocele of the floor of the mouth associated with the sublingual gland (ranula);
(e) mucous retention cyst of the lower lip (presenting much like mucocele, but appear-
ing more transparent); (f) fibroma of the hard palate resulting from denture trauma;
(g) fibroma of the lower lip; and (h) dentigerous cyst (a unilocular radiolucency sur-
rounding the crown of an unerupted tooth, with no bone destruction).
with a smooth mucosal surface that may be located anywhere in pressure resorption and to inflammation caused by retained ker-
the mouth. Such lesions are managed with either observation or atin. Management involves either excision or debridement and
local excision. creation of a well-ventilated and easily maintained cavity.24
ODONTOGENIC CYST
Neoplastic Lesions
A dentigerous cyst is an epithelium-lined cyst that, by defini-
BENIGN
tion, is associated with the crown of an unerupted tooth [see
Figure 4h]. Such cysts cause painless expansion of the mandible
or the maxilla. Treatment involves enucleation of the cyst and its Squamous Papilloma
lining and extraction of the associated tooth.23 Squamous papilloma is one of the most common benign neo-
An odontogenic keratocyst is a squamous epithelium–lined plasms of the oral cavity [see Figures 5a and 5b].13 It usually pre-
cyst that produces keratin. Bone resorption occurs secondary to sents as a solitary, slow-growing, asymptomatic lesion, typically
a b c
d e
f
Figure 5 Shown are benign neoplasms of the oral cavity: (a) squamous papil-
loma of the frenulum; (b) squamous papilloma of the ventral tongue; (c) pleo-
morphic adenoma of the hard palate; (d) pleomorphic adenoma of the hard
palate on coronal CT (note the soft tissue thickening along the left hard palate,
with no bone erosion or destruction); (e) ameloblastoma of the left angle and
ramus of the mandible (a multilocular radiolucency); and (f) ameloblastoma on
CT, with a soft tissue mass in the left mandible and erosion of the lingual plate
of the mandible.
hematoma that leads to bony expansion and giant cell prolifera-

tion.26 Eventually, erosion of the buccal cortex may occur with the
development of facial swelling.
Management involves enucleation and curettage.26 The surgeon
should be prepared for bleeding during treatment. The use of cal-
citonin or intralesional steroid injections is gaining popularity.
Minor Salivary Gland Neoplasms
The minor salivary glands are small mucus-secreting glands
that are distributed throughout the upper aerodigestive tract, with
less than 1 cm in diameter. It is well circumscribed and peduncu- the largest proportion concentrated in the oral cavity. Minor sali-
lated and has a warty appearance.16 The palate and tongue are the vary gland neoplasms are uncommon, but when they do occur,
sites most frequently affected13; occasionally, multiple sites are they are most likely to develop in the oral cavity. Within the oral
involved. The presumed cause is a viral infection, most likely cavity, the hard palate and the soft palate are the most common
human papillomavirus.25 sites of minor salivary gland neoplasms; however, tumors involv-
Papillomas are managed with complete excision, including the ing the tongue, the lips, the buccal mucosa, and the gingivae have
base of the stalk. been described. Approximately 30% of minor salivary gland neo-
plasms are benign. Of these benign lesions, the most common is
Giant Cell Lesions pleomorphic adenoma, which presents as a painless, slow-grow-
Central giant cell granulomas, brown tumors of hyperparathy- ing submucosal mass [see Figures 5c and 5d].13,27
roidism, aneurysmal bone cysts, and lesions associated with genet- Pleomorphic adenoma is managed with complete surgical exci-
ic diseases (e.g., cherubism) may all be seen in the jaws. Of partic- sion to clear margins. This tumor exhibits small pseudopodlike
ular note is the aneurysmal bone cyst that may occur at sites of extensions that may persist and cause recurrence if enucleation
trauma, which, in theory, is the consequence of an organizing around an apparent capsule is attempted.
6 VASCULAR SYSTEM 11 REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSMS — 11
problems. Both CTA and contrast biplane angiography are used and 0.035-in. guide wires are placed bilaterally under fluoroscop-
for this purpose. Of the two, spiral CTA is currently preferred.This ic guidance; 10 French sheaths are then placed over the two guide
imaging modality is capable of obtaining high-quality images of wires and advanced into the aneurysm under fluoroscopic guid-
the vascular anatomy and reconfiguring them into detailed three- ance. A superstiff 0.035-in. guide wire 260 cm in length is insert-
dimensional images. For optimal evaluation, images should be ed into the thoracic aorta, usually from the right limb. In the con-
obtained at 1.5 to 3 mm intervals from the celiac artery to the tralateral iliac artery, a pigtail catheter is placed just above the level
femoral arteries. Spiral CTA accurately defines the proximal and of the renal arteries, and an initial roadmapping aortogram is
distal characteristics of the AAA, as well as detects any significant obtained.The 10 French sheath in the right femoral artery is then
renal, visceral, or iliac occlusive disease. It is particularly helpful in exchanged for the device, which is placed over the superstiff guide
defining the infrarenal neck between the renal arteries and the wire and carefully advanced into the proximal infrarenal aorta
proximal portion of the aneurysm. under fluoroscopic guidance, then into the perirenal aorta [see
Angiography is employed as a complement to spiral CTA in this Figure 11a]. A second aortogram is performed to verify the posi-
setting. An arteriogram is useful in that it helps define renal, tion of the renal arteries. Under fluoroscopic guidance, the stent-
mesenteric, and distal arterial anatomy; helps characterize tortu- graft is then gradually deployed by retracting the outer sheath and
osity, calcification, and stenoses in access arteries; and helps deter- allowing the graft to expand, and it is positioned directly below the
mine the angles between the aorta, the proximal neck, and the level of the renal arteries [see Figure 11b].
aneurysm. Once the main bifurcation module has been deployed, the 10
Intravascular ultrasonography (IVUS) is a useful intraoperative French sheath in the contralateral iliac artery is pulled back, and a
imaging adjunct in the process of sizing and selecting endograft 0.035-in. angled hydrophilic wire and a guide catheter are insert-
components. It can be used to measure vessel diameters and land- ed into the contralateral limb of the bifurcation module.The hydro-
ing zone lengths, as well as to determine the amount of mural philic wire is then exchanged for a superstiff guide wire, over which
thrombus in the aneurysm neck. In patients with severe renal the contralateral limb is then advanced through the sheath into the
insufficiency, IVUS is used primarily to identify the renal and contralateral vessel and deployed [see Figure 11c]. A final aorto-
hypogastric arteries, allowing the endograft to be deployed with gram is then performed to confirm that a satisfactory technical
minimal or no resort to angiography. result has been achieved [see Figure 11d]. Proximal and distal ex-
Proper patient selection is mandatory for successful outcome. tender cuffs may be placed if necessary.The femoral arteriotomies
The common femoral arteries must be large enough to accept a are repaired, and lower-extremity perfusion is reestablished.
delivery system larger than 21 French. The proximal infrarenal
OUTCOME EVALUATION
aortic neck must be suitable for device implantation—that is, its
diameter must be between 16 and 28 mm, and its length should EVAR is significantly less invasive than open surgical repair and
be at least 15 mm. The common iliac artery implantation should consequently is associated with a significant reduction in major
be carried out as close to the iliac bifurcation as possible to procedure-related morbidity. Prospective clinical trials comparing
increase the columnar strength of the implanted device. The iliac open AAA repair with EVAR have consistently found that patients
artery diameter must be between 8 and 20 mm. In patients with undergoing the latter experience less intraoperative blood loss,
iliac artery aneurysms, it is possible to land the end of the stent in need less postoperative ICU care, have shorter lengths of stay, and
the external iliac artery and thereby exclude one internal iliac regain normal function earlier.25,26 Procedure-related mortality
artery. Exclusion of both internal iliac arteries should be avoided after EVAR is 1% to 2%, which is essentially equivalent to that
so as to prevent ischemic sequelae (e.g., buttock claudication, reported after open repair in prospective clinical trials but lower
colon ischemia, and erectile dysfunction). Coil embolization may than the 5% mortality reported after open repair in most multi-
be performed in conjunction with EVAR to treat internal iliac center studies.27,28
aneurysms. However, a waiting period of several weeks between In the past few years, two randomized, controlled trials com-
coil embolization of a hypogastric artery on one side and the same paring EVAR with open AAA repair have been published. The
procedure on the other side should be considered to allow recruit- Dutch Randomized Endovascular Aneurysm Management
ment of collateral vessels and reduce the incidence of pelvic (DREAM) trial found EVAR to have a significant advantage in the
ischemia. first 30 days, with reduced mortality and a lower incidence of
severe complications.29 This survival advantage was not sustained,
TECHNIQUE
however, and at 1 year, there was no difference between EVAR and
The methods and technical principles we briefly describe here open AAA repair. The EVAR 1 trial, carried out in the United
derive from the personal experience of two surgeons (F.R.A and Kingdom, found EVAR to yield a similar reduction in 30-day mor-
C.K.Z) with more than 1,000 modular implants. The ensuing tality.30 Again, this survival advantage was not sustained, and at 4
technical description is not intended to be exhaustive, nor is it years, there was no difference between EVAR and open repair in
meant as a substitute for the instructions provided by any of the terms of overall mortality or health-related quality of life. EVAR
manufacturers. did, however, have a significant advantage over open AAA repair
The patient is placed under epidural or general anesthesia. with regard to 4-year aneurysm-related mortality. The impact of
Bilateral femoral artery cutdowns are performed through trans- this advantage will continue to be assessed as this trial’s follow-up
verse groin incisions to allow exposure of the common femoral period lengthens.
artery from the inguinal ligament to the femoral bifurcation. On occasion, EVAR fails to exclude blood flow from the
Proximal control of the femoral arteries is obtained with umbilical aneurysm sac completely.This condition, known as endoleak, may
tapes. Systemic anticoagulation with I.V. heparin is instituted to arise from an incomplete seal at the site where the endograft is
prolong the activated clotting time (ACT) to greater than 250 sec- affixed to the aortic neck or the iliac arteries (type I endoleak),
onds.The ACT is monitored and maintained at this level through- from retrograde flow into the aneurysm from the inferior mesen-
out the procedure, and additional heparin is given as needed. teric artery or the lumbar arteries (type II endoleak), or from the
The femoral arteries are cannulated with an 18-gauge needle, graft or modular junction site (type III endoleak).Type I and type
6 VASCULAR SYSTEM 11 REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSMS — 12
III endoleaks call for secondary treatment to prevent possible or, possibly, open surgical repair). New endovascular devices are
aneurysm rupture.The significance of type II endoleaks is less cer- currently being designed and evaluated in clinical trials, and
tain. There is no clear evidence that type II endoleaks lead to endovascular treatment strategies continue to evolve and improve.
aneurysm rupture; however, most such endoleaks are treated if Clinical follow-up of patients treated during the initial prospec-
they are associated with aneurysm enlargement. tive clinical trials now extends to more than 7 years, and EVAR
Although numerous studies have shown that endovascular AAA continues to show favorable results. The largest multicenter
repair results in less morbidity and perioperative mortality than endovascular clinical trial to date, involving 1,193 patients who
open repair,31-34 reports describing endograft migration over time, were followed for as long as 6 years, found that prevention of
aneurysm enlargement, and occasional aneurysm rupture have aneurysm rupture (the primary objective) was achieved in 99% of
raised questions about the long-term durability of the proce- patients, whereas procedure-, aneurysm-, or graft-related death
dure.35,36 These adverse events, though uncommon, serve as was avoided in 97%.37,38 These results are consistent with the
reminders that EVAR is still a new technology, one whose long- favorable overall outcomes reported from a European registry of
term outcome is unknown. Accordingly, close patient monitoring EVAR using a variety of endovascular devices.39 Thus, the midterm
and follow-up surveillance are warranted, and secondary treat- results of EVAR are favorable and support the consideration of this
ments may be required (e.g., additional endovascular procedures approach for most patients who are candidates for the procedure.
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346:1445, 2002 23. Crawford JL, Stowe CL, Safi HJ, et al: Inflamma- minimum follow-up period of 2 years. J Vasc
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Am 69:755, 1989 4:232, 1997 Acknowledgment
14. Stokes J, Butcher HR: Abdominal aortic 29. Prinssen M,Verhoeven ELG, Buth J, et al: A ran-
aneurysms: factors influencing operative mortal- domized trial comparing conventional and Figures 4 through 11 Susan Brust, C.M.I.
© 2003 WebMD Corp. All rights reserved. ACS Surgery: Principles and Practice
6 Vascular System 12 AORTOILIAC RECONSTRUCTION — 1
12 AORTOILIAC RECONSTRUCTION
Mark K. Eskandari, M.D.

Symptomatic aortoiliac occlusive disease is the consequence of a Minneapolis, Minnesota) or a Bookwalter (Cardinal Health, V.
diffuse atherosclerotic process that is exacerbated by smoking, Mueller, McGaw Park, Illinois), is often helpful. The retroperi-
hypertension, hypercholesterolemia, and diabetes.1-4 The resul- toneum overlying the aortic bifurcation is then incised in the mid-
tant narrowing of the aorta and the iliac vessels impairs circula- line, and the aorta is exposed to the level of the inferior mesenteric
tion into the pelvis and the lower extremities, thereby causing artery [see 6:11 Repair of Infrarenal Abdominal Aortic Aneurysms].
myriad patient complaints. Manifestations range from impo- Both common iliac arteries are exposed, with care taken not to
tence, claudication (in the buttock, the thigh, or the calf), and damage the underlying iliac veins and the overlying ureters, which
rest pain (in the forefoot) to ulceration or gangrene. normally cross at the iliac bifurcation.
Hemodynamically significant obstruction of blood flow arising Given that this procedure is best suited for treatment of local-
from aortoiliac occlusion may be either segmental or diffuse. ized disease, exposure beyond the iliac bifurcation is rarely nec-
Fortunately, there are a number of different vascular reconstruc- essary. If it appears that the disease process extends into the
tions that can be performed to reestablish sufficient flow to the external iliac arteries or more proximally in the infrarenal aorta,
lower body.The choice of a surgical revascularization approach is another form of treatment, such as aortobifemoral bypass (see
based on two factors: (1) anatomic constraints and (2) comorbid below), may be indicated.
conditions. Regardless of which technique is selected, preopera-
tive workup and planning are essentially the same. Step 3: Aortoiliac Endarterectomy
Once the aorta and the iliac vessels are exposed, I.V. heparin is
given for systemic anticoagulation. The vessels are then con-
Preoperative Evaluation trolled with vascular clamps. As a rule, the iliac vessels should be
Once it has been established that a patient’s symptoms (e.g., clamped first to reduce the risk of distal embolization during
claudication, rest pain, or a nonhealing wound) are attributable placement of the aortic cross-clamp. These vessels should be
to hemodynamically significant aortoiliac occlusive disease, a clamped only enough to prevent retrograde bleeding. They must
thorough preoperative evaluation is initiated. Such evaluation not be repeatedly clamped and unclamped, because they are
typically includes obtaining objective physiologic documentation prone to the development of flow-limiting intimal flaps or frac-
of the extent of occlusive disease by measuring lower-extremity tured atherosclerotic plaques.
blood flow with arterial waveforms and ankle-brachial indices. Next, the aorta is incised longitudinally from a point just above
An imaging study is also required to guide revascularization. the bifurcation (where the aorta is soft) down into the common
Percutaneous diagnostic angiography is widely used for this pur- iliac artery in which the disease process extends further.
pose; however, technological advancements may allow magnetic Sometimes, the middle sacral or lower lumbar arteries must be
resonance angiography (MRA) to supplant traditional contrast oversewn to control back-bleeding. A dissection plane is devel-
arteriography.5-7 If an extra-anatomic bypass is anticipated, ancil- oped between the media and the adventitia, and a standard
lary tests, including bilateral arm blood pressure measurements endarterectomy of the infrarenal aorta and the more diseased
and computed tomography scans of the chest, abdomen, or iliac artery is performed. The endarterectomy of the contralater-
pelvis, may be necessary. A standard cardiac risk assessment is al iliac artery is performed by means of eversion through the aor-
mandatory before any form of revascularization, and the extent totomy [see Figure 1]. If the distal termination points in the iliac
of testing is tailored to the level of cardiac risk. vessels are irregular or have a significant step-off, the plaque
should be tacked down with two or three 6-0 polypropylene
sutures, with the knots tied on the outside of the vessel wall.
Operative Technique
Troubleshooting Occasionally, endarterectomy results in a
AORTOILIAC ENDARTERECTOMY
very thin residual wall, or the distal termination points are too
Although localized aortoiliac endarterectomy is less common- steep to fix with tacking sutures alone. In such cases, the best
ly performed today than it once was, it remains useful for a sub- recourse is to replace this section of the aorta and the common
group of patients with focal aortic bifurcation disease. The clas- iliac vessels with a short standard bifurcated prosthetic interposi-
sic candidate for this procedure has minimal disease of the tion graft. Proximally, the graft is sewn to the infrarenal aorta in
infrarenal abdominal aorta and the external iliac arteries but a an end-to-end fashion. Distally, the two limbs are sewn to the
severely diseased and narrowed aortic bifurcation. two common iliac arteries in the same manner.
Step 1: Incision and Approach Step 4: Repair of Arteriotomy
A standard lower midline transperitoneal incision allows rapid, The arteriotomy can be closed either primarily or with a patch,
direct access. Usually, the incision can be made below the umbili- depending on the size of the aorta and the iliac vessels. Primary
cus and extended to the pubis. closure is preferred, but if it appears that such closure will signif-
icantly narrow the aorta or the iliac artery, a patch (either pros-
Step 2: Exposure and Control of Aorta and Iliac Arteries thetic or autogenous) should be used instead. Before closure is
Upon entry into the abdominal cavity, exposure of the aortic completed, the vessels should be flushed and back-bled to dimin-
bifurcation is achieved by retracting the small bowel cephalad. A ish the risk of distal embolization to the legs upon reestablish-
self-retaining retractor, such as an Omni (Omni-Tract Surgical, ment of inline flow. The adequacy of the repair is confirmed pri-
through a lower-quadrant retroperitoneal incision positioned

medial to the lateral border of the rectus muscle. The femoral
artery is approached through a standard vertical groin incision.
Step 2: Exposure of Iliac and Femoral Arteries
Once the retroperitoneum is entered, the visceral contents
and the ureter are bluntly dissected away from the psoas muscle
medially. This dissection, which takes place through a mostly
bloodless field, yields full exposure of the targeted common iliac
artery and its bifurcation into the external and internal iliac
arteries. It should proceed far enough to allow control of the
arteries with vascular clamps. Care must be taken not to damage
the underlying iliac veins. In particular, no attempt should be
made to isolate these vessels circumferentially, which can lead to
troublesome bleeding.
The vertical incision in the groin permits full exposure of the
common femoral artery and its bifurcation into the superficial
femoral artery and the profunda femoris. Unlike the iliac arter-
ies, the femoral artery and its branches may be circumferential-
ly dissected.
Step 3:Tunneling of Bypass Graft
Once the inflow and outflow vessels are adequately exposed,
the bypass graft is tunneled from the retroperitoneum to the
groin, passing beneath the ureter and the inguinal ligament.
During tunneling, care must be taken not to avulse the bridging
epigastric vein found just cephalad and posterior to the inguinal
ligament. Typically, a prosthetic graft 6 to 8 mm in diameter is
used; however, autogenous material (e.g., a segment of the
greater saphenous vein) may be used if desired.
Step 4: Proximal Anastomosis to Iliac Artery

With the bypass graft in position, the patient undergoes sys-
temic anticoagulation with I.V. heparin. The common, external,
and internal iliac arteries are controlled with vascular clamps.
The proximal anastomosis is then performed to the selected
common iliac artery. If practicable, the anastomosis should be an
Figure 1 Aortoiliac endarterectomy. Plaque is end-to-side one so as to preserve antegrade flow into the inter-
removed through a longitudinal aortotomy. nal iliac artery.
Troubleshooting Occasionally, the common iliac artery is

marily by the palpation of normal femoral pulses in the groins. too diseased to clamp or to use as an inflow source. In such
cases, the infrarenal aorta may be clamped instead or used as the
Step 5: Closure of Retroperitoneum site of the proximal anastomosis.
Before abdominal closure, the retroperitoneum is closed with
Step 5: Distal Anastomosis to Femoral Artery
an absorbable suture so as to isolate the repair from the GI tract.
This step reduces the risk of an aortoenteric fistula. Vascular clamps are placed on the common femoral artery
and its branches, and the distal anastomosis is performed in an
ILIOFEMORAL BYPASS end-to-side manner. The configuration of the longitudinal arte-
Iliofemoral bypass, already an uncommon procedure, has now riotomy depends on the presence and extent of disease in the
largely been supplanted by advances in percutaneous endolumi- femoral arteries. If both the superficial femoral artery and the
nal techniques. Nevertheless, it is still used on occasion and thus profunda femoris are relatively free of disease, the arteriotomy
is worth knowing. One limitation on the application of iliofemoral should extend from the common femoral artery into the super-
bypass is that aortoiliac occlusive disease typically causes diffuse ficial femoral artery. If, however, the superficial femoral artery is
aortic and bilateral iliac artery narrowing. For this operation to be occluded or heavily diseased, the arteriotomy should extend
successful, there must be a relatively disease-free common iliac down into the profunda femoris [see Figure 3]. In either case, an
artery that can provide unimpeded inflow. Accordingly, ilio- end-to-side anastomosis is fashioned. Before completion of the
femoral bypass is most suitable for those rare patients who have bypass, the inflow vessel is flushed and the outflow vessel back-
isolated unilateral external iliac artery disease. bled to reduce the risk of distal embolization to the legs.
Step 1: Incision and Approach AORTOFEMORAL BYPASS
The patient is placed in the supine position, and two incisions Before the application of percutaneous balloon angioplasty
are made [see Figure 2]. The common iliac artery is approached and stenting, aortofemoral bypass grafting was the revascular-
ization operation of choice for patients with diffuse aortoiliac Endarterectomy, above], this dissection is primarily between the
occlusive disease. This operation is still favored by many, and it renal arteries and the inferior mesenteric artery. In most cases,
yields excellent long-term patency. the dissection need not be extended downward below the aortic
bifurcation into the iliac arteries.
Step 1: Incision and Approach When this operation is performed through a left retroperi-
Typically, the patient is placed in the supine position, and the toneal incision, the external and internal oblique muscles and the
operation is performed through a midline laparotomy and two transversus abdominis are divided, and the retroperitoneum is
longitudinal groin incisions. A self-retaining retractor is recom- entered. Complete exposure of the infrarenal aorta is obtained by
mended to facilitate exposure of the infrarenal aorta. mobilizing the abdominal contents, the left kidney, and the left
Alternatively, the infrarenal aorta may be exposed via a left ureter medially after blunt dissection along the anterior border of
retroperitoneal incision extending obliquely from the lateral bor- the psoas muscle.
der of the rectus muscle, at the level of the umbilicus, to the tip
of the 11th rib. For this approach, the patient is placed in a right Troubleshooting In those cases in which aortofemoral by-
semilateral decubitus position with the assistance of an inflatable pass is being done for a patient with complete infrarenal aortic
beanbag. The hips are rotated so that they are flat on the bed, occlusion, the operative approach is modified to allow placement
providing easy access to the groins. of a vascular clamp above the renal arteries.The dissection is car-
ried cephalad by retracting the small bowel mesentery and the
Step 2: Exposure of Aorta superior mesenteric artery to the right. The left renal vein is
Upon entry into the abdominal cavity, the fourth portion of found anterior to the aorta at the level of the renal arteries.
the duodenum is dissected free of its retroperitoneal attach- Generally, this vein need not be divided to expose the suprarenal
ments, and the small bowel is retracted to the right of the aorta. aorta. Rather, it should be thoroughly dissected and encircled
The self-retaining retractor may then be placed to facilitate expo- with a vessel loop so that it can be retracted cephalad and cau-
sure. Next, the retroperitoneum overlying the infrarenal aorta is dad. Sometimes, an adrenal or gonadal vein draining into the left
incised in the midline to expose the vessel, ideally in a location renal vein must be ligated and divided to give the renal vein
that is not heavily diseased or calcified. Unlike the dissection added mobility. With the left renal vein retracted caudad, the
required in a localized endarterectomy [see Aortoiliac suprarenal aorta is dissected.
Step 3: Exposure of Femoral Artery

A vertical groin incision provides full exposure of the common
femoral artery and its bifurcation into the superficial femoral
artery and the profunda femoris. The femoral artery and its
branches should be circumferentially dissected to give the sur-
geon an unobstructed view for placement of the vascular clamps.
a b Step 4:Tunneling of Bypass Graft

Once the inflow and outflow vessels are adequately exposed,
the bypass graft—typically, a bifurcated prosthetic graft measur-
ing 14 × 7 mm or 16 × 8 mm—is tunneled from the abdomen to
the groins. Its course should pass beneath the ureter and the
inguinal ligament. To create the tunnel, one index finger, orient-
ed so that its dorsum faces the vessel wall, is inserted in the mid-
line incision and advanced caudad down to the groin.
Simultaneously, the other index finger, oriented so that its volar
aspect faces the common femoral artery, is inserted into a groin
incision and advanced cephalad until the two fingers meet. As
with an iliofemoral bypass graft, care must be taken not to avulse
the bridging epigastric vein found just cephalad and posterior to
the inguinal ligament. With one of the two fingers held in place,
a Silastic tube or vessel loop is passed through the tunnel. The
limbs of the graft are attached to the tube or loop and passed
through the tunnel down to the groins.
Step 5: Proximal Anastomosis to Aorta

The proximal aortic anastomosis can be done in either an end-
to-end or an end-to-side configuration. An end-to-side beveled
anastomosis is preferable for (1) patients with a small (< 1.5 cm)
infrarenal aorta and (2) patients with severe occlusive disease of
both external iliac arteries in whom it is desirable to preserve flow
into the pelvic circulation via the internal iliac arteries. An end-
Figure 2 Iliofemoral bypass. (a) A low retroperitoneal incision to-end anastomosis is preferable for (1) patients with occlusive
and an ipsilateral groin incision are made for exposure of the iliac disease and a concomitant aortic aneurysm and (2) patients
inflow and outflow bypass vessels. (b) The graft is tunneled undergoing revascularization for chronic total aortic occlusion.
beneath the ureter and the inguinal ligament. The latter configuration is also less bulky and easier to cover and
a b c
Figure 3 Iliofemoral bypass. (a) When concomitatnt superficial femoral artery disease is present, the
distal anastomosis is performed to a longitudinal arteriotomy that extends onto the proximal profunda
femoris. (b) The heel of the hood of the graft is anastomosed to the common femoral artery. (c) The tip of
the graft is extended down the profunda femoris.
isolate from the GI tract at the conclusion of the operation.

Once a configuration for the anastomosis has been chosen,
I.V. heparin is given for systemic anticoagulation. The graft is
trimmed so that its bifurcation lies close to the proximal anasto-
mosis.The infrarenal aorta is controlled, most commonly with vas-
cular clamps above and below the site of the intended anastomosis.
Control of the aorta with a partially occluding vascular clamp may
be attempted, but the size of the vessel and the coexistence of aor-
tic disease typically make this difficult or impossible to accomplish.
If an end-to-side anastomosis is to be performed, a longitudi-
nal aortotomy is made and the graft sewn in place in a spatulat-
ed fashion.The toe of the graft is oriented cephalad [see Figure 4].
The anastomosis should be spatulated steeply so that it is not too
bulky in the retroperitoneum and can be covered at the end of
the procedure. Before completion of the anastomosis, the graft is
flushed and back-bled.
If an end-to-end anastomosis is to be performed, a small por-
tion of the aorta is resected to allow the graft to fit neatly into the
retroperitoneum. In some cases, back-bleeding lumbar arteries in
the region of the resected aorta must be oversewn. The distal
stump is oversewn with 2-0 or 3-0 polypropylene in two rows; the
first row is done with a continuous suture in a horizontal mattress
stitch, the second with a continuous suture in a baseball stitch
[see Figure 5].
Troubleshooting Vascular control of the aorta is achieved

differently when chronic infrarenal aortic occlusion is present. In
this setting, placement of a vascular clamp just below the renal
arteries may squeeze atherosclerotic debris up into the renal
arteries. To prevent this, the vascular clamp should be placed
between the superior mesenteric artery and the renal arteries.
Once the distal clamp is in place, the aorta is opened below the
renal arteries and the atherosclerotic plug removed. The supra-
renal clamp can then be moved to just below the renal arteries,
and the proximal anastomosis can be fashioned as already
described (see above). Figure 4 Aortofemoral bypass. Shown is an end-to-side
A heavily calcified infrarenal aorta encountered at the time of proximal anastomosis.
a b c
Figure 5 Aortofemoral bypass. Shown is an end-to-end proximal

anastomosis. (a) A segment of diseased aorta is resected, and the
distal aortic stump is oversewn. (b) The proximal end of the graft is
sutured to the open infrarenal aorta. (c) The distal anastomoses are
completed in an end-to-side fashion.
operation presents a difficult problem. In most cases, the infra- visualized and preserved. Careless closure of the retroperitoneum
renal aorta can still be used, but the proximal anastomosis should can lead to laceration or entrapment of the ureter, particularly
be performed in an end-to-end configuration. Even in the most the right ureter. Every attempt should be made to cover the graft.
calcified aortas, the region 1 to 2 cm below the renal arteries is If the retroperitoneum is too thin or the graft too bulky, an omen-
often soft enough to allow an anastomosis to be fashioned. If this tal pedicle flap may be used.
is not the case, there are two alternatives: (1) suprarenal aortic
THORACOFEMORAL BYPASS
control and endarterectomy of the infrarenal aorta just below the
renal ostia before the proximal anastomosis and (2) conversion to A thoracofemoral bypass is ideal for a small subgroup of
a thoracofemoral bypass graft [seeThoracofemoral Bypass, below]. patients, comprising (1) those with an occluded old aortofemoral
bypass graft, (2) those with a so-called lead-pipe calcified infra-
Step 6: Distal Anastomosis to Femoral Artery renal aorta that is unusable as an inflow source, and (3) those
Vascular clamps are placed on the common femoral artery and with a so-called hostile abdomen (i.e., those with an ileal conduit,
its branches, and the distal anastomosis is performed. As with an an ileostomy or colostomy, or a previous aortic graft infection).
iliofemoral bypass, the configuration of the longitudinal arteri- Candidates for this procedure must have adequate pulmonary
otomy depends on the existence of disease in the femoral arter- reserve and be able to tolerate a thoracotomy. They must also be
ies. If both the superficial femoral artery and the profunda informed of and accept the low but real risk of paralysis.
femoris are relatively free of disease, the arteriotomy should The patient is placed in a right semilateral decubitus position
extend from the common femoral artery into the superficial so that the hips are nearly flat on the table and the torso is slight-
femoral artery. If, however, the superficial femoral artery is ly rotated to the patient’s right [see Figure 6]. An axillary roll and
occluded or heavily diseased, the arteriotomy should extend an inflatable beanbag will help maintain this position. Because
downward into the profunda femoris. In either case, an end-to- single-lung ventilation will be necessary when the proximal anas-
side anastomosis is indicated. Before completion of the bypass, tomosis is done, either a double-lumen endotracheal tube or a
the inflow vessel is flushed and the outflow vessel back-bled to bronchial blocker must be used. Placement of an orogastric tube
diminish the risk of distal embolization to the legs. to decompress the stomach helps keep the diaphragm down dur-
ing exposure of the descending thoracic aorta.
Step 7: Closure of Retroperitoneum
Before abdominal closure, the retroperitoneum is closed with Step 1: Incision and Exposure of Descending Thoracic Aorta
an absorbable suture to isolate the repair from the GI tract and The descending thoracic aorta is approached through a left
reduce the risk of an aortoenteric fistula. The ureters should be posterior lateral thoracotomy at the level of the 7th or 8th inter-

space. Additional exposure can be gained by resecting part of the
rib and using a self-retaining table-mounted retractor. With the Vascular clamps are placed on the common femoral artery and
left lung decompressed, the parietal pleura overlying the des- its branches, and an end-to-side anastomosis is fashioned distal-
cending thoracic aorta is incised. The aorta is cleanly dissected, ly. Again, the configuration of the longitudinal arteriotomy de-
with care taken not to damage the esophagus, which lies medial- pends on the existence of disease in the femoral arteries. If both
ly. Having an orogastric tube in place is advantageous in this the superficial femoral artery and the profunda femoris are rela-
regard: the esophagus can easily be located by palpating the tube. tively free of disease, the arteriotomy should extend from the
Any intercostal vessels in the region of the anticipated aortotomy common femoral artery into the superficial femoral artery. If,
can be preserved and controlled at the time of the anastomosis. however, the superficial femoral artery is occluded or heavily dis-
eased, the arteriotomy should extend downward into the profun-
Step 2: Exposure of Femoral Artery da femoris. Before completion of the bypass, the inflow vessel is
Full exposure of the common femoral artery and its bifurca- flushed and the outflow vessel back-bled.
tion into the superficial femoral artery and the profunda femoris
is obtained via a standard groin incision. Step 6: Closure of Chest
Once the proximal anastomosis is complete, the left lung is
Step 3:Tunneling of Bypass Graft reinflated. At the conclusion of the operation, the chest is closed
The tunnel for the prosthetic graft has two components: (1) a in a standard fashion over two chest tubes. The proximal anas-
left retroperitoneal tunnel and (2) a subcutaneous tunnel over tomosis should be covered with either a prosthetic patch or
the pubis. Usually, a tube prosthetic graft is sutured to a bifur- bovine pericardium to diminish the risk of an aortopulmonary
cated graft before being tunneled through the retroperitoneum. fistula.
The retroperitoneal tunnel is started in the chest by making a 1
AXILLOFEMORAL BYPASS
cm hole in the posterior lateral aspect of the left diaphragm. An
index finger is inserted through this hole and advanced caudad Axillofemoral bypass is ideally suited to elderly patients who
into the retroperitoneum as far as it can go. The other index fin- cannot tolerate an aortic operation. The hemodynamic changes
ger is inserted through the left groin incision, oriented directly occurring during the operation are minimal, and recovery from
over the external iliac artery, and advanced cephalad into the the three small incisions used is substantially quicker than that
retroperitoneum [see Figure 7]. Care is taken not to avulse the from a laparotomy or a thoracotomy.
bridging epigastric vein found posterior and inferior to the Because hemodynamically significant occlusive disease is less
inguinal ligament. In most cases, the left retroperitoneal tunnel common in the right innominate artery than in the left subcla-
must then be completed by using a long, hollow metal tunneling vian artery, the right axillary is more often used as the inflow ves-
device such as the Gore Tunneler (W. L. Gore & Associates, Inc., sel than the left axillary artery is. Such occlusion can easily be
Tempe, Ariz.). Once this tunnel is completed, the graft is passed identified preoperatively by measuring blood pressure in both
through it in such a way that the bifurcated limbs are brought arms. The sterile field includes both groins, the appropriate side
caudad down into the left groin wound. of the chest (usually the right) up to the neck, and the appropri-
Next, the subcutaneous tunnel from the left groin to the right ate flank (again, usually the right). It need not include the entire
groin is bluntly fashioned anterior to the pubis. It should not be inflow arm; however, the arm should be abducted 90o and posi-
oriented superior to the pubis because of the risk of injury to an tioned on an arm board.
overdistended bladder. To minimize this risk, an indwelling uri-
nary catheter is advocated. The subcutaneous tunnel is used to Step 1: Incision and Exposure of Axillary Artery
pass the right limb of the graft over to the right groin. It is not The patient is placed in the supine position.The axillary artery
uncommon for the bifurcation of the prosthetic graft to lie just is approached through a horizontal 6 cm infraclavicular incision
cephalad to the left groin wound. placed approximately 2 cm below the inferior border of the clav-
icle. Dissection is carried through the subcutaneous tissue, the
Step 4: Proximal Anastomosis to Descending Thoracic Aorta fascia overlying the pectoralis major is incised, and the muscle is
Once the graft has been tunneled, the patient undergoes sys- bluntly dissected along the length of its fibers. The dissection
temic anticoagulation with I.V. heparin. The descending thoracic plane should remain medial to the pectoralis minor.
aorta is controlled either with a side-biting clamp or with two Next, the axillary vein is encountered and retracted caudad,
completely occluding aortic clamps placed in close proximity to and the underlying axillary artery is visualized.The axillary artery
each other. In the latter case, one or two intercostal arteries may is cleanly dissected, with care taken not to retract or damage the
have to be temporarily controlled as well. A longitudinal aortoto- brachial plexus lying deep and superior to the artery. For full
my is then made along the left lateral aspect of the thoracic aorta, exposure of the axillary artery, the thoracoacromial artery may
and a beveled end-to-side anastomosis is fashioned. Exposure can have to be ligated at its origin. For easier retraction, the axillary
be enhanced by ventilating the right lung and attaching the oro- artery may be encircled with vessel loops.
gastric tube to suction to decompress the stomach. Before com-
pletion of the anastomosis, the aorta is flushed and back-bled. Step 2: Exposure of Femoral Artery
The femoral artery and its bifurcation into the superficial
Troubleshooting Partial aortic control with a side-biting femoral and profunda femoris arteries are approached through a
vascular clamp is successful in most cases, but it is not recom- standard groin incision.
mended when the descending thoracic aorta is heavily diseased
and calcified or when preoperative imaging studies show throm- Step 3:Tunneling of Bypass Graft
bus in this location. If an intercostal artery cannot be temporari- Once the inflow and outflow vessels are adequately exposed, a
ly controlled with clamps, it can be oversewn from the inside of prosthetic graft 80 to 100 cm long and 8 or 10 mm in diameter
the aorta to prevent nuisance back-bleeding. is tunneled from the axillary incision, beneath the pectoralis
Figure 6 Thoracofemoral bypass. The patient is positioned so that the hips are flat but
the torso is slightly rotated to the patient’s right. Three incisions are made: a left postero-
lateral thoracotomy and two groin incisions.
minor, and down to the flank. The use of a long, hollow metal to provide additional exposure. The axillary artery is controlled
tunneler is recommended at this point. To facilitate tunneling, a with vascular clamps, with care taken not to include any part of
single counterincision is made in the midaxillary line over the the brachial plexus lying nearby. A longitudinal arteriotomy is
sixth or seventh intercostal space. From this counterincision, the made along the length of the axillary artery. The proximal anas-
graft is tunneled along the flank, over the iliac crest, anterior to tomosis is then fashioned in an end-to-side configuration. The
the anterior superior iliac process, and into the ipsilateral groin anastomosis must lie medial to the pectoralis minor. This is crit-
wound. Except for the portions in the axilla and the groin, the ical for preventing avulsion of the graft from the axillary artery
entire graft should lie in a subcutaneous plane. when the patient fully abducts the arm. Before the anastomosis is
Next, a subcutaneous tunnel from the ipsilateral groin to the completed, it is flushed and back-bled. Once blood flow to the
contralateral groin is bluntly fashioned anterior to the pubis to arm is reestablished, the graft should be positioned so that it lies
allow passage of a second prosthetic graft (a short crossover graft parallel to the axillary artery for a length of 2 to 3 cm before div-
8 mm in diameter).This tunnel should not be oriented superior to ing deep and caudad.
the pubis because of the risk of injury to an overdistended bladder.
Step 4: Proximal Anastomosis to Axillary Artery The distal anastomosis to the femoral arteries is performed as
With the long graft in place, I.V. heparin is given for systemic described earlier [see Thoracofemoral Bypass, above]. There re-
anticoagulation. The pectoralis minor may be retracted laterally mains some controversy over the formation of the short crossover
Figure 7 Thoracofemoral bypass. A left retroperitoneal tunnel is fashioned for passage

of the prosthetic graft downward to the groin. (The right arm of the graft is subsequently
passed to the right groin via a subcutaneous tunnel anterior to the pubis.)
graft from the axillary bypass graft to the contralateral femoral

artery. My practice is to place the proximal anastomosis of the
crossover femorofemoral anastomosis on the hood (or distal anas-
tomosis) of the axillofemoral bypass graft [see Figure 8]. Others
prefer to use a commercially available bifurcated axillofemoral
prosthetic graft or to place the crossover graft more proximally
along the length of the axillofemoral graft.
FEMOROFEMORAL BYPASS
A femorofemoral crossover bypass is well suited to patients

who have unilateral complete occlusion or a diffusely diseased
iliac system but have a relatively normal contralateral iliac sys-
tem. It is performed with the patient supine and is conducted in
essentially the same fashion as an axillofemoral bypass, but with-
out the axillary anastomosis.
ENDOVASCULAR THERAPY
The use of percutaneous balloon angioplasty and stenting for

the treatment of peripheral vascular disease has grown exponen-
tially since its introduction in the 1990s. As regards short-term
results, patients clearly experience less pain, recover more quick-
ly, and regain function earlier. Initially, there was some question
about the durability of stenting; however, data from longer fol-
low-up periods indicate that this approach is an acceptable alter-
native for patients with focal aortoiliac occlusive disease.8-10
Complications
Figure 8 Axillofemoral bypass. Shown is the recommended
Certain complications are associated with all of the revascu- configuration for the short femorofemoral crossover graft orig-
larization procedures discussed, such as bleeding, distal embo- inating from the long axillofemoral graft. The femorofemoral
lization, graft thrombosis, and graft infection. Late graft infec- graft originated from the hood of the axillofemoral graft.
tion, recurrent disease, and pseudoaneurysm formation are
known long-term complications as well. In addition, the follow-
ing complications are unique to one or more of the procedures during exposure of the axillary artery (thoracofemoral by-
but do not arise with the others. pass, axillofemoral bypass).
1. Injury to the ureters, resulting from their position overlying

the iliac vessels (aortoiliac endarterectomy, iliofemoral by- Outcome Evaluation
pass, axillofemoral bypass). Regardless of which operation is performed to treat aortoil-
2. Impotence, resulting from damage to the autonomic nerve iac occlusive disease, the subsequent outcome should be im-
fibers around the origin of the left common iliac artery (aor- mediate relief of presenting symptoms—for example, reduced
toiliac endarterectomy, iliofemoral bypass, axillofemoral by- claudication, resolution of rest pain, or improved distal wound
pass). healing. Unfortunately, overall long-term survival in patients
3. Bleeding or deep venous thrombosis, related to trauma to with symptomatic aortoiliac occlusive disease is not improved
the underlying iliac venous structures (all). by operative management and is typically 10 to 15 years less
4. Paraplegia, resulting from the sacrifice of intercostal vessels than that in a normal age-matched group. Not surprisingly, by
supplying the anterior spinal artery (thoracofemoral bypass). far the most significant long-term cause of death in these
5. Colonic ischemia or infarction, resulting from hindered pri- patients is atherosclerotic cardiac disease, which underscores
mary flow via the inferior mesenteric artery or collateral ves- the importance of a thorough preoperative cardiac evaluation.
sels from the hypogastric arteries (axillofemoral bypass). In general, direct aortoiliac reconstructions (i.e., endarterecto-
6. Buttock claudication, resulting from disruption of inline my, aortofemoral bypass, and thoracofemoral bypass) have an
flow to the pelvic circulation (axillofemoral bypass). expected patency rate of 85% to 90% at 5 years and 70% to 75%
7. Aortoduodenal fistula, resulting from incomplete coverage at 10 years.11-13 When these operations are performed at experi-
of an aortic graft (axillofemoral bypass). enced centers on patients who are considered to be good risk
8. Renal failure, resulting from acute tubular necrosis or candidates, mortality is typically less than 3%.14,15 Femoro-
embolization when a suprarenal aortic clamp is used (thora- femoral bypass and axillobifemoral bypass have expected 5-year
cofemoral bypass, axillofemoral bypass). patency rates of 70% to 75% and 60% to 85%, respectively.16-19
9. Arm paralysis, resulting from injury to the deep and superi- Coexistent superficial femoral artery disease in the recipient ves-
orly oriented brachial plexus (axillofemoral bypass). sels has a detrimental effect on the long-term patency of these
10. Respiratory failure resulting from effusion or hemothorax bypasses.20 Long-term anticoagulation may improve the patency
after a left thoracotomy or from inadvertent pneumothorax for an axillobifemoral bypass graft.
References
1. Witteman JC, Grobbee DE, Valkenburg HA, et patients. AJR Am J Roentgenol 179:1013, 2002 bifurcation grafts for aortoiliac occlusive disease:
al: Cigarette smoking and the development and 7. Pandharipande PV, Lee VS, Reuss PM, et al:Two- a meta-analysis. J Vasc Surg 26:558, 1997
progression of aortic atherosclerosis: a 9-year station bolus-chase MR angiography with a sta- 15. Passman MA, Taylor LM, Moneta GL, et al:
population-based follow-up study in women. tionery table: a simple alternative to automated- Comparison of axillofemoral and aortofemoral
Circulation 88:2156, 1993 table techniques. AJR Am J Roentgenol 179:1583, bypass for aortoiliac occlusive disease. J Vasc
2. McGill HC Jr, McMahan CA, Malcom GT, et 2002 Surg 23:263, 1996
al: Effects of serum lipoproteins and smoking on 8. Back MR, Novotney M, Roth SM, et al: Utility 16. Martin D, Katz SG: Axillofemoral bypass for aor-
atherosclerosis in young men and women. The of duplex surveillance following iliac artery toiliac occlusive disease. Am J Surg 180:100, 2000
PDAY Research Group. Pathobiological deter- angioplasty and primary stenting. J Endovasc
minants of atherosclerosis in youth. Arterioscler 17. Taylor LM Jr, Moneta GL, McConnell D, et al:
Ther 8:629, 2001 Axillofemoral grafting with externally supported
Thromb Vasc Biol 17:95, 1997
9. Sanchez LA, Wain RA, Veith FJ, et al: polytetrafluoroethylene. Arch Surg 129:588, 1994
3. Van Der Meer IM, De Maat MP, Hak AE, et al: Endovascular grafting for aortoiliac occlusive dis-
C-reactive protein predicts progression of ather- 18. Rutherford RB, Patt A, Pearce WH: Extra-
ease. Semin Vasc Surg 10:297, 1997 anatomic bypass: a closer view. J Vasc Surg
osclerosis measured at various sites in the arteri-
al tree: the Rotterdam study. Stroke 33:2750, 10. Gray BH, Sullivan TM: Aortoiliac occlusive dis- 6:437, 1987
2002 ease: surgical versus interventional therapy. Curr 19. Naylor AR, Ah-See AK, Engeset J: Axillofemoral
Interv Cardiol Rep 3:109, 2001 bypass as a limb salvage procedure in high risk
4. Faries PL, LoGerfo FW, Hook SC, et al: The
impact of diabetes on arterial reconstructions for 11. Kalman PG: Thoracofemoral bypass: proximal patients with aortoiliac disease. Br J Surg
multilevel arterial occlusive disease. Am J Surg exposure and tunneling. Semin Vasc Surg 13:65, 77:659, 1990
181:251, 2001 2000 20. Criado E, Burnham SJ, Tinsley EA Jr, et al:
5. Morasch MD, Collins J, Pereles FS, et al: Lower 12. Nash T: Aortoiliac occlusive vascular disease: a Femorofemoral bypass graft: analysis of patency
extremity stepping-table magnetic resonance prospective study of patients treated by and factors influencing long-term outcome. J
angiography with multilevel contrast timing and endarterectomy and bypass procedures. Aust N Z Vasc Surg 18:495, 1993
segmented contrast infusion. J Vasc Surg 37:62, J Surg 49:223, 1979
2003 13. Brewster DC: Clinical and anatomical consider-
6. Loewe C, Schoder M, Rand T, et al: Peripheral ations for surgery in aortoiliac disease and
vascular occlusive disease: evaluation with con- results of surgical treatment. Circulation 83:I42,
trast-enhanced moving-bed MR angiography 1991 Acknowledgments
versus digital subtraction angiography in 106 14. de Vries SO, Hunink MG: Results of aortic Figures 1 through 8 Alice Y. Chen.
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 1
13 SURGICAL TREATMENT OF THE

INFECTED AORTIC GRAFT
Victor J. D’Addio, M.D., F.A.C.S., and G. Patrick Clagett, M.D., F.A.C.S.
In dealing with an infected aortic graft, the primary goal of treat- mortality was associated with this method of treatment.2 In addi-
ment is to save life and limb. This goal is best accomplished by tion, many survivors experience significant problems, including
eradicating all infected graft material and maintaining adequate early or late allograft rupture and late aortic graft dilation.3
circulation with appropriate vascular reconstruction. Secondary Reinfection of allografts may also occur and usually proves fatal
goals are to minimize morbidity, to restore normal function, and to when it does. Complications may be reduced by using cryopre-
maintain long-term function without the need for repeated inter- served allografts instead of fresh ones, but at present, the data are
vention or amputation. insufficient to determine whether one type of allograft is clearly
Before definitive reconstruction, all infected graft material must superior to the other overall. Currently, aortic allografts are avail-
be debrided, along with any grossly infected vascular tissue and able in the United States only on a limited basis; accordingly, this
surrounding soft tissue. Once debridement is complete, there are technique is not a useful option in emergency situations.
several options for reconstruction, including (1) extra-anatomic
ANTIBIOTIC-TREATED PROSTHETIC GRAFT
bypass, (2) use of an arterial allograft, (3) placement of vascular
prostheses treated with or soaked in antibiotic solutions, and (4) Use of antibiotic-treated prosthetic graft material for recon-
in situ replacement with a femoral-popliteal vein (FPV) graft.The struction has the advantage of permitting an expeditious recon-
choice among these options is made on the basis of the specific struction that leaves no aortic stump.2,4-8 However, the reinfection
clinical situation present. The primary focus of the technical rate is high and unpredictable, and patients must undergo lifelong
description in this chapter, however, will be on the fourth option antibiotic therapy. Typically, the new prosthetic graft is soaked in
[see Operative Technique, below]. rifampin, 60 mg/ml, for 15 minutes before implantation.6,7
IN SITU AUTOGENOUS RECONSTRUCTION
Choice of Procedure Dissatisfaction with the long-term patency of extra-anatomic
bypass led to the development of in situ autogenous venous recon-
EXTRA-ANATOMIC BYPASS
struction.9-11 Early reconstructive attempts that made use of
Extra-anatomic bypass, usually performed as an axillobifemoral greater saphenous vein grafts proved unsuccessful because the
bypass [see Figure 1 and 6:12 Aortoiliac Reconstruction], is a good small caliber of the venous conduit resulted in low patency rates.
option for treatment of an infected aortic graft when groin infec- Subsequent attempts that made use of larger-caliber FPV grafts,
tion is absent and lower-extremity runoff is good. The primary however, proved highly successful.
advantages of extra-anatomic bypass are that it minimizes lower- FPV grafts have excellent long-term patency and are resistant
extremity ischemic time and that it is less of a physiologic insult to reinfection. In addition, they are ideal conduits for patients with
than an aorta-based bypass procedure (mainly because it is typi- extensive multilevel occlusive disease, in whom venous grafts the-
cally done in a staged fashion). The primary disadvantages are oretically would have better patency than prosthetic grafts. (An
that long-term patency is poor and that there is a significant risk analogy would be the superior durability of venous grafts for
of reinfection. In addition, if groin infection is present, the bypass femoropopliteal bypass in comparison with prosthetic grafts.) The
is compromised even further by the need to use vessels such as the 5-year patency rates for aortoiliac/aortofemoral reconstructions
profunda femoris artery or the popliteal artery for distal targets. using FPV grafts range from 85% to 100%.11,12 Long-term ampu-
Bilateral axillofemoral bypasses are often required in this situation. tation rates are correspondingly low.
Because of these factors, the durability of an extra-anatomic bypass The primary disadvantage of reconstruction with FPV grafts is
may be limited despite aggressive antithrombotic treatment. that the procedure is time consuming and technically demanding.
Extra-anatomic bypasses are plagued by sudden thrombotic In our experience, the mean operating time is about 8 hours.The
occlusion, and amputation rates are high. In one large series, one lower-extremity ischemic time is longer than that in patients
third of patients required a major amputation during long-term undergoing extra-anatomic bypass, but it can be minimized by
follow-up.1 Reinfection also is a major concern when prosthetic sequencing the operation so as to shorten cross-clamp time and
grafts are employed in patients with ongoing infection: it occurs in by using a two-team approach. An additional disadvantage of
10% to 20% of such patients and often proves lethal. A final major using FPV grafts is the associated short-term venous morbidity.
concern in patients who undergo excision of an infected aortic Approximately 20% of patients who undergo FPV harvesting will
graft and extra-anatomic bypass is the possibility of blowout of the require fasciotomy, typically performed at the time of the harvest.
aortic stump.This is an infrequent occurrence (incidence < 10%) The fasciotomy rate is highest in patients who undergo concur-
but one that is typically fatal. rent greater saphenous vein harvesting and in those who have
severe lower-extremity ischemia (ankle-brachial index [ABI]
AORTIC ALLOGRAFT
< 0.4).13 Long-term venous morbidity appears to be low, with no
In situ aortic allografting has been employed to treat aortic graft known cases of venous ulceration or venous claudication.14 Mild
infections, with somewhat mixed results. In one report, a 20% to moderate chronic edema develops in approximately 30% of
Figure 1 Standard treatment of aortic graft

infection involves axillobifemoral bypass, removal
of the infected prosthesis, and oversewing of the
aortic stump. This procedure can be performed in
either one or two stages. It is most useful in
patients who do not have infection extending into
the femoral area.
patients. Aneurysmal degeneration of the vein grafts is a theoreti- nance angiography can also be a helpful adjunct, particularly in
cal risk, but in practice, it is rare. patients with renal insufficiency.
When autogenous reconstruction with deep vein grafts is being
considered, preoperative assessment of the adequacy of the vein seg-
Preoperative Evaluation ments must also be performed.This is accomplished by means of ve-
The preoperative workup should assess the extent of infection, nous duplex ultrasonography. Duplex examination of the lower-ex-
look for concomitant occlusive disease (indicating a possible need tremity venous system establishes the diameter and the available
for infrainguinal, visceral, or renal reconstruction), and determine length of the deep veins. In addition, the duplex scan can evaluate
whether there are other associated infectious complications that acute or chronic thrombosis of the deep veins, any recanalization
must be treated surgically (e.g., a psoas abscess, an entrapped changes, the congenital absence or duplication of venous segments,
ureter with hydronephrosis, or duodenal erosion necessitating and unusually small deep veins.When the FPV is small (< 5 mm),
duodenal repair). In patients who have previously undergone absent, or incomplete, a dominant profunda femoris vein is usually
prosthetic aortofemoral bypass, infection may be limited to one present.This vein courses posteriorly through the thigh to connect
limb of the graft, and it may be treatable by replacing only that with the popliteal vein and can also be used as a venous autograft.
limb. In patients who have previously undergone prosthetic Duplex vein mapping of the greater saphenous system is also rou-
infrainguinal bypass, the prosthetic graft may have to be removed tinely performed and may provide useful information in the event
and replaced with an autogenous graft. that concomitant infrainguinal reconstruction is planned or may
Traditionally, the mainstay of the preoperative workup was arte- have to be performed unexpectedly.
riography complemented by computed tomography, but current-
ly, the workup is increasingly being performed with CT angiogra-
phy alone. CT angiography is often capable of evaluating the Operative Planning
extent of infection, visualizing the sites of previous prosthetic anas- Removal of an infected aortic graft and autogenous reconstruc-
tomoses, and delineating the arterial anatomy. Magnetic reso- tion require prolonged exposure of large portions of the body sur-
Care must also be taken to preserve major branches of the

superficial femoral artery when this vessel is occluded or severely
diseased. Interruption of these branches, which may supply collat-
eral circulation to distal beds, may result in unexpected critical
ischemia of the lower extremity after completion of the proximal
reconstruction, and further infrainguinal arterial reconstruction
may be necessary.
STEP 2: DISSECTION OF FPV
The FPV has many large and small side branches. Careful, metic-
ulous and unhurried ligation of these branches is critical. Most are
doubly ligated, with suture ligation reserved for the larger ones.
Failure to ligate a branch adequately will result in exsanguinating
hemorrhage if a tie loosens and pops off when exposed to aortic
pressure. Although as a rule, the FPV is larger and sturdier than the
typical greater saphenous vein, it is thin-walled in some areas where
branches are present. If a branch is avulsed during dissection, suture
repair with 6-0 or 7-0 polypropylene is necessary. Branch ligation
during FPV harvesting differs from the typical branch ligation dur-
Figure 2 The FPV (thin black arrow), the superficial femoral ing saphenous vein harvesting.The branches of the FPV are ligated
artery (thick white arrow), and the saphenous nerve (thin white close to their bases because this is where the vein wall tends to be
arrow) lie deep to the sartorius (thick black arrow) in the sub-
thin; the larger caliber of the FPV makes this technique possible. In
sartorial canal. The sartorius is reflected medially to expose
these structures. The adductor magnus tendon is divided to
contrast, the branches of the greater saphenous vein, which is of
expose these structures as they traverse Hunter’s canal. smaller caliber, are ligated slightly away from the vessel wall to
ensure that the lumen of the vein is not encroached on.
The extent of the harvest depends on the length of venous con-
face. Significant drops in core body temperature, combined with duit required for reconstruction. Proximally, dissection extends to
blood loss and resuscitation, may lead to metabolic acidosis, coag- the level of the junction of the femoral and profunda femoris veins.
ulopathy, cardiac dysrhythmia, and immune compromise. These veins join to form the common femoral vein, which is also
Accordingly, core body temperature should be kept above 36° C exposed in the dissection.The profunda femoris vein is easily rec-
(96.8° F) by applying heated-air warming blankets to the upper ognizable as a large posteriorly penetrating vein in the proximal
body, using warmed fluid for resuscitation, and maintaining a thigh. Distally, dissection is carried through the adductor hiatus by
warm ambient temperature in the operating room. dividing the tendon of the adductor magnus; this measure allows
To minimize ischemic time with cross-clamping, the major easy access to the proximal portion of the popliteal vein. The
tasks involved in excision of an infected aortic graft and in situ popliteal segment of the vein has multiple large branches, which
autogenous reconstruction should be sequenced as follows: (1) must be carefully ligated.The dissection can easily be taken down
dissection of FPVs, which are left in situ until needed; (2) isola- to the level of the knee joint. The veins are left in situ until the
tion and control of the femoral vessels; (3) entry into the abdomen required length of conduit can be determined.
and control of the aorta; (4) removal of the infected prosthesis;
and (5) reconstruction with the deep vein grafts.15 STEP 3: DISSECTION AND CONTROL OF FEMORAL VESSELS
The femoral vessels can usually be dissected by extending the vein

Operative Technique harvest incision cephalad along the lateral border of the sartorius to
STEP 1: THIGH INCISION AND EXPOSURE OF FEMORAL VESSELS
The patient is placed in the supine position with the legs “frog-
legged” and supported under the thighs. An incision is made on
the thigh along the lateral border of the sartorius muscle.This lat-
eral incision not only facilitates vein harvesting but also allows the
surgeon to expose the femoral vessels while avoiding the infected
femoral incision medially in the groins.
The sartorius is reflected medially so as to preserve the medi-
al segmental blood supply.The subsartorial canal is entered, and
the femoral vessels are exposed. The femoral vein is usually
located posterior to and slightly medial or lateral to the artery at
this level. The deep venous system is then exposed from the dis-
tal common femoral vein downward, including the proximal
profunda femoris vein through Hunter’s canal to the mid-
popliteal level [see Figure 2]. The saphenous nerve is located in
this canal and is intimately associated with the femoral vessels. Figure 3 Use of a valvulotome typically results in incomplete
Care must be taken not to injure this nerve either directly or valve lysis. It is preferable to evert the entire venous graft and
through excessive traction; such injury will cause irritating post- excise the valves (which usually number 3 or 4) completely with
operative saphenous neuralgia. scissors.
a b c
d e
Figure 4 Multiple anatomic reconstructions have been used to recreate the aorto-iliac-femoral anato-
my. (a) Shown is an aortounifemoral bypass with a femorofemoral crossover. (b) Instead of a femoro-
femoral bypass, the second limb may be brought off the midportion of the first limb in an end-to-side
manner. (c) If infection is limited to one limb of an aortofemoral bypass, an FPV graft may be used to
replace only the infected portion. (d) One segment of vein may be used to replace both segments of an
aortoiliac or aortofemoral graft. (e) In some instances, it may be easier to approach the paraceliac
aorta via a retroperitoneal approach for the proximal anastomosis.
STEP 5: REMOVAL AND PREPARATION OF VENOUS GRAFTS

the level of the anterior superior iliac spine. Through this incision,
control of the superficial femoral, profunda femoris, and common Before cross-clamping, the vein grafts are removed and pre-
femoral vessels is gained. In addition, the distal limbs of the existing pared. The length of the grafts is determined by measuring from
aortofemoral graft can be controlled. Occasionally, control is difficult the aortic anastomosis to the femoral anastomoses on both sides.
to obtain from a position lateral to the sartorius, in which case the The femoral vein is divided flush with the profunda femoris vein
medial aspect of the muscle may be dissected from the subcutaneous and oversewn with a 5-0 polypropylene suture. This creates a
tissue to afford improved exposure. Only rarely is a more medial inci- smooth transition point from the profunda femoris vein to the
sion required. As noted [see Step 1, above], the lateral approach al- common femoral vein and leaves no stump in which blood can
lows the surgeon to avoid entering the previous incision, where there stagnate and create thrombus. The grafts are then distended in a
may be a draining sinus or cellulitis. 4° C solution containing lactated Ringer solution (1 L), heparin
(5,000 U), albumin (25 g), and papaverine (60 mg). Any leaks are
STEP 4: ABDOMINAL INCISION AND DISSECTION OF AORTA repaired either with additional silk ties or with figure-eight fine
The abdomen is then entered either through a midline abdomi- polypropylene sutures. Any adventitial bands that distort the
nal incision or via a retroperitoneal approach; the latter is particu- lumen are lysed.
larly helpful in avoiding tedious abdominal adhesions. Dissection Next, the valves in the grafts must be lysed.This is a critical step
for control of the aorta above the aortic anastomosis is performed. because the grafts are placed in a nonreversed fashion to optimize
The anastomosis may be near the level of the renal arteries, in which size matching with the aorta for the proximal anastomosis.
case suprarenal or supraceliac aortic control may be required. Valvulotomes have been used for valve lysis in these large-caliber
veins, but the results have been unsatisfactory: lysis is often incom- formed so as to cut down on the blood loss that typically occurs
plete, and the remnants of the valves may become sites of graft when the limbs are removed from their tunnels.
stenosis. Our current practice is to evert venous grafts completely Multiple configurations have been successfully employed to
and to excise all valves under direct vision [see Figure 3]. reconstruct the distal aortic and iliac-femoral vasculature [see
Figure 4].The proximal anastomosis is performed with a continu-
STEP 6: REMOVAL OF BODY OF PREVIOUS GRAFT AND
ous 4-0 polypropylene suture. The diameter of the FPV graft is
PROXIMAL ANASTOMOSIS OF NEW GRAFT TO AORTA
typically about 1.5 cm or a little greater, and the mismatch in
The patient is heparinized, and the aorta above the anastomo- diameter between the graft and the aorta is dealt with by taking
sis and both limbs of the graft are cross-clamped.The body of the slightly more advancement (i.e., placing sutures slightly farther
graft is then excised, with the limbs left in place. All prosthetic apart) on the aortic wall than on the graft wall [see Figure 5a]. If
material, including sutures, is removed. The previous aortic anas- the caliber discrepancy between the two structures is too large,
tomosis may have been done in either an end-to-end or an end- another technique must be employed, such as plication of the
to-side fashion. If it was an end-to-side anastomosis, the distal end aorta, joining of the venous grafts in a pantaloon configuration, or
of the aorta will have to be oversewn with a large suture (e.g., 0 or placement of a triangular patch at the proximal aspect of the graft
No. 1 polypropylene). Balloon occlusion of the distal lumen is a [see Figures 5b through 5d].
helpful adjunctive measure before ligation. Regardless of how the After the proximal anastomosis is complete, the venous graft is
previous aortic anastomosis was done, the new anastomosis is typ- distended under aortic pressure, and the side branches are care-
ically constructed in an end-to-end fashion.The distal limbs of the fully examined to confirm that all ligatures are securely placed.
existing graft are left in place while the aortic anastomosis is per- Any questionable areas are repaired. Anastomotic leakage is also
repaired with the aorta clamped to ensure that the venous graft is
not torn during repair.
a b STEP 7: REMOVAL OF LIMBS OF PREVIOUS GRAFT AND DISTAL
ANASTOMOSES OF NEW GRAFTS TO FEMORAL ARTERIES
The femoral limbs of the prosthetic aortobifemoral grafts are
then removed by pulling them through the groin incisions. When
the FPV grafts are tunneled to the groins, care must be taken to
ensure that ligated side branches are not torn or dislodged.
Because it may be difficult to create new tunnels through the
scarred retroperitoneum, the vein grafts may be tunneled through
the existing tunnels. In many cases, the existing tunnels are small-
er in caliber than the new vein grafts, and careful digital dilation
of the tunnels is required.
The femoral anastomoses are fashioned in a standard manner.
Once again, all prosthetic material and all surrounding infected
tissue must be debrided from the groins. On occasion, profun-
c d daplasty or reimplantation of the profunda femoris may be re-
quired. If possible, the femoral anastomoses should be done in an
end-to-side manner to preserve retrograde pelvic perfusion.
Perfusion of the extremities must be assessed before the leg
wounds are closed. If Doppler arterial signals are absent at the
level of the ankle, a femoropopliteal or distal bypass may be nec-
essary [see 6:18 Infrainguinal Arterial Procedures]. Because the
popliteal artery is exposed during FPV harvesting, adjunctive
femoropopliteal bypass is easily accomplished in this setting.
STEP 8: CLOSURE
After reversal of heparinization, the thigh wounds are copious-

ly irrigated and closed over closed suction drains. Placement of
drains prevents postoperative seromas and subsequent wound
complications. Even though these wounds are contaminated as a
consequence of the proximity of the infected graft in the groin
wound, infection is rare. Often, there are draining sinuses medial
to the vein harvest incisions, which are debrided and left open.
Figure 5 (a) An end-to-end proximal anastomosis is usually
possible if the diameter of the FPV graft is large enough and the
aorta is of normal size. (b) If the end of the aorta is significantly Postoperative Care
larger in diameter than the venous graft, plication of the aorta
can be performed. (c) A pantaloon technique may also be used to Parenteral antibiotics are continued for 5 to 7 days, and antibi-
deal with a size mismatch between the aorta and the FPV graft. otic coverage is modified on the basis of intraoperative cultures of
This technique effectively doubles the circumference of the vein. the graft material and wound swabs. Intermittent pneumatic
(d) The proximal anastomosis can also be facilitated by incorpo- compression and low-dose subcutaneous heparin (5,000 U every
rating a wedge-shaped portion of vein into the proximal end of 8 to 12 hours) are employed for prevention of deep vein thrombo-
the graft. sis.Thrombosis of the residual popliteal vein is common, and ag-
gressive prophylaxis may prevent extension of the thrombus into ical examination of the legs.We specifically assess progressive com-
the calf veins. With the FPV absent, the risk of pulmonary em- partment swelling and firmness on serial examination after reper-
bolism is low. fusion of the lower extremities.We also consider risk factors in mak-
ing this decision. Two specific risk factors for fasciotomy are (1) a
low preoperative ABI (< 0.4) and (2) concurrent greater saphenous
Complications vein harvesting.13 Other factors may also help determine the need
The incidence of chronic venous morbidity after FPV harvesting for fasciotomy, including the indication for operation, the length of
is low, but the fasciotomy rate is approximately 20%. In our prac- vein harvested, the duration of arterial cross-clamping, and the
tice, the decision to perform a fasciotomy is based primarily on clin- amount of fluid administered intraoperatively.
References
1. Quinones-Baldrich WJ, Hernandez JJ, Moore WS: 1998). J Vasc Surg 30:92, 1999 12. Jackson M, Ali A, Bell C, et al: Aortofemoral bypass in
Long-term results following surgical management of 7. Young RM, Cherry KJ, Davis PM, et al:The results of young patients with premature atherosclerosis: is su-
aortic graft infection. Arch Surg 126:507, 1991 in situ prosthetic replacement for infected aortic perficial femoral vein superior to Dacron? J Vasc Surg
2. Speziale F, Rizzo L, Sbarigia E, et al: Bacterial and grafts. Am J Surg 178:136, 1999 40:17, 2004
clinical criteria relating to the outcome of patients un- 8. Batt M, Magne JL, Alric P, et al: In situ revasculariza- 13. Modrall JG, Sadjadi J, Ali A, et al: Deep vein harvest:
dergoing in situ replacement of infected abdominal tion with silver-coated polyester grafts to treat aortic predicting need for fasciotomy. J Vasc Surg 39:387,
aortic grafts. Eur J Vasc Endovasc Surg 13:127, 1997 infection: early and midterm results. J Vasc Surg 2004
3. Kieffer E, Gomes D, Chiche L, et al: Allograft replace- 38:983, 2003 14. Wells JK, Hagino RT, Bargmann KM, et al: Venous
ment for infrarenal aortic graft infection: early and late 9. Clagett GP, Bowers BL, Lopez-Viego MA, et al: Cre- morbidity after superficial femoral-popliteal vein har-
results in 179 patients. J Vasc Surg 39:1009, 2004 ation of a neo-aortoiliac system from lower extremity vest. J Vasc Surg 29:282, 1999
4. Bandyk DF, Novotney ML, Back MR, et al: Expand- deep and superficial veins. Ann Surg 218:239, 1993
15. Clagett GP: Treatment of aortic graft infection. Cur-
ed application of in situ replacement for prosthetic 10. Nevelsteen A, Lacroix H, Suy R: Autogenous recon-
graft infection. J Vasc Surg 32:451, 2000 rent Therapy in Vascular Surgery, 4th ed. Ernst CB,
struction with the lower extremity deep veins: an alter- Stanley JC, Eds. CV Mosby, Philadelphia, 2001, p 422
5. Walker WE, Cooley DA, Duncan JM, et al:The man- native treatment of prosthetic infection after recon-
agement of aortoduodenal fistula by in situ replace- structive surgery for aortoiliac disease. J Vasc Surg
ment of the infected abdominal aortic graft. Ann Surg 22:129, 1995
205:727, 1987 11. Clagett GP, Valentine RJ, Hagino RT: Autogenous
6. Hayes PD, Nasim A, London NJM, et al: In situ re- aortoiliac/femoral reconstruction from superficial Acknowledgment
placement of infected aortic grafts with rifampin- femoral-popliteal veins: feasibility and durability. J Vasc
bonded prostheses: the Leicester experience (1992 to Surg 25:255, 1997 Figures 1, 4, and 5 Alice Y. Chen.
6 VASCULAR SYSTEM 14 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 1
14 OPEN PROCEDURES FOR

RENOVASCULAR DISEASE
Matthew S. Edwards, M.D., Juan Ayerdi, M.D., and Kimberley J. Hansen, M.D., F.A.C.S.
Until comparatively recently, intervention for renovascular disease Disease] is liberally used as an alternative to open renal artery
focused entirely on hypertension. However, the introduction of revascularization, but the data currently available suggest that it
potent new antihypertensive agents and percutaneous endovascu- should be employed selectively.The best results with PTRA alone
lar methods of management has led to substantial changes in atti- have been achieved with nonostial atherosclerotic renal artery
tudes to and indications for management of renovascular disease. lesions and medial fibroplasia of the main renal artery. Suboptimal
Today, open surgical repair is commonly reserved for (1) patients results have been achieved with hypoplastic (i.e., developmental)
who have severe hypertension despite optimal medical therapy, (2) lesions, fibrodysplasia of the intimal and perimedial variety, ostial
patients in whom percutaneous transluminal renal artery angio- atherosclerotic renal artery lesions, and renal artery occlusions.
plasty (PTRA) fails or who have disease patterns that are not For ostial renal artery atherosclerosis, some surgeons have advo-
amenable to PTRA, and (3) patients who have renovascular dis- cated PTRA with primary endoluminal stenting in an effort to
ease associated with excretory renal insufficiency (i.e., ischemic improve results; however, the results of PTRA and primary stent-
nephropathy).1 ing in this setting have been inferior to those of open operative
The experience of our center (Wake Forest University School of repair. Consequently, in the majority of cases of ostial atheroscle-
Medicine) in the management of more than 850 patients over a rosis in combination with renal insufficiency, we advise operative
16-year period indicates that atherosclerotic renovascular disease intervention for good-risk patients.
frequently exists in combination with diffuse extrarenal athero- These recommendations are not absolute. Decisions regarding
sclerosis and renal insufficiency. In one study, bilateral atheroscle- therapy for renovascular disease must be individualized. Factors
rotic renal artery lesions were present in two thirds of patients, and contributing to the choice of treatment include the expected mor-
complete renal artery occlusion was present in more than one bidity and mortality of operative repair and the presence of pre-
third.2 Although practitioners frequently cite selected data to sup- dictors of death and dialysis dependence at follow-up. In this
port a particular management scheme in this setting, the question regard, severe left ventricular dysfunction with clinical congestive
of what constitutes optimal management of atherosclerotic reno- heart failure, diabetes mellitus, and uncorrectable azotemia have
vascular disease responsible for either hypertension or renal insuf- all been shown to be significant and independent predictors of
ficiency is still unanswerable.To date, there have been no prospec- reduced dialysis-free survival.2,3
tive, randomized trials that compare the best medical manage-
ment with PTRA and with open surgical repair.
Operative Planning
Preoperative Evaluation SURGICAL STRATEGY
Evaluation and diagnosis of renovascular hypertension and reno- Our use of open surgical methods to treat atherosclerotic reno-
vascular renal insufficiency (i.e., ischemic nephropathy) are discussed vascular disease is based on several guiding principles [see Table 1].
in more detail elsewhere, as are general issues related to the We consider severe hypertension a prerequisite for open operative
question of medical versus surgical therapy. management and do not perform prophylactic renal artery repair
INDICATIONS FOR INTERVENTION
The recognition of both the progressive nature of the athero- Table 1—Recommended Principles for
sclerotic renovascular lesions seen in combination with severe Contemporary Surgical Management of
hypertension and the deterioration of renal function seen in select- Renovascular Disease10
ed patients who are managed medically lends support to the idea
that renal artery intervention is indicated when either renovascu- Renal artery repair is done on an empirical, but not prophylactic, basis
lar hypertension or ischemic nephropathy is present. In our view, Complete renal artery repair is done in one operation when feasible;
bilateral ex vivo reconstruction may be staged
renal artery intervention is appropriate in patients with severe Direct aortorenal methods of reconstruction are preferred
hypertension and, specifically, in all patients who have severe hy- Nephrectomy is reserved for nonreconstructable disease in a
pertension in combination with excretory renal insufficiency (i.e., nonfunctioning kidney
ischemic nephropathy). Open operative management is preferred Combined aortic reconstruction is limited to clinically significant
disease
for children and young adults and for patients with bilateral reno-
Intraoperative duplex sonography is performed to assess technical
vascular disease, especially if renal artery occlusion is present.2 success
PTRA [see 6:16 Endovascular Procedures for Renovascular
a b
Figure 1 Aortorenal bypass.8 Technique for end-to-side (a, b) and end-to-end (c) aortorenal bypass
grafting. The length of arteriotomy is at least three times the diameter of the artery to prevent recur-
rent anastomotic stenosis. For the anastomosis, 6-0 or 7-0 monofilament polypropylene sutures are
used in continuous fashion, under loupe magnification. If the apex sutures are placed too deeply or
with excess advancement, stenosis can be created, posing a risk of late graft thrombosis.
Operative Technique
in patients who are not hypertensive. Although we employ renal
vein renin assays to guide management of unilateral lesions in many Various open surgical techniques are used to correct athero-
cases, we typically perform empirical renal artery repair without sclerotic renovascular disease; however, no single repair technique
functional studies when the hypertension is severe or uncontrolled is optimal for all renovascular lesions. The best approach to renal
and when renal artery disease is bilateral or involves a solitary kid- artery reconstruction in any given case depends on patient char-
ney. We attempt to correct all hemodynamically significant reno- acteristics, the pattern of renal artery disease, and the presence or
vascular disease in a single operation; we perform staged repair only absence of associated aortic lesions that may have to be corrected
in cases in which the disease necessitates bilateral ex vivo recon- simultaneously. The open procedures most commonly performed
struction. Because the lower limit of renal function retrieval is not to treat renovascular disease are (1) aortorenal bypass, (2) renal
known but improved renal function is known to be the strongest artery thromboendarterectomy, and (3) renal artery reimplanta-
predictor of dialysis-free survival, we reserve nephrectomy for tion. In general, aortorenal bypass is the most versatile of these
patients who have an unreconstructable lesion in a renal artery sup- procedures.Transaortic thromboendarterectomy may be especial-
plying a nonfunctioning kidney (i.e., a kidney providing less than ly useful when ostial atherosclerosis ends within 1 cm of the origin
10% glomerular filtration on renography).4 In the majority of open of the renal artery and involves multiple renal arteries. Renal
operative repairs, we employ direct aortorenal reconstruction artery reimplantation is often particularly appropriate for the cor-
methods; we seldom use indirect (splanchnorenal) methods, rection of renovascular disease in children and adolescents, in that
because celiac axis stenosis is present in 40% to 50% of patients concerns regarding graft material are eliminated.
and bilateral repair is required in more than 50%.2 Regardless of With all of these reconstruction techniques, multiple small
the method of reconstruction employed, we perform intraoperative doses of mannitol are administered intravenously during perirenal
renal duplex sonography as a completion study to look for any aortic and renal artery dissection. Mannitol is given both before
technical errors in the repair that might lead to restenosis or occlu- and after periods of warm renal ischemia up to a total dose of 1
sion. Failed renal artery repair has been associated with a signifi- g/kg. During cross-clamping of the aorta and the renal artery, the
cant and independent risk of eventual dependence on dialysis.5 patient is given heparin, 100 U/kg, to establish systemic anticoag-
ulation. When a purely autogenous reconstruction is performed, eter of the smallest conduit, and the ends of the conduit should be
antibiotics are unnecessary; however, when a prosthetic graft is widely spatulated to guard against late suture line stenosis. The
employed, administration of a first-generation cephalosporin is proximal anastomosis is usually made with a continuous 6-0
begun 2 hours before operation and continued for 24 hours. monofilament polypropylene suture, and the distal anastomosis is
created with a continuous 7-0 or 8-0 monofilament polypropylene
AORTORENAL BYPASS
suture.
Aortorenal bypass [see Figure 1] may be performed with either
THROMBOENDARTERECTOMY
an autogenous conduit or a prosthetic graft. If an entirely autoge-
nous repair is possible, we prefer to use a reversed segment of the Thromboendarterectomy of the renal arteries and the perirenal
greater saphenous vein as the conduit. If the saphenous vein is too aorta may be performed via either a transrenal or a transaortic
narrow (i.e., < 4 mm in diameter) or of inadequate quality, a 6 approach. When the renal artery atheroma extends 1 cm or less
mm thin-walled polytetrafluoroethylene (PTFE) graft is used from the ostium and involves both or multiple renal arteries, the
instead. In either case, the infrarenal aorta is dissected and transaortic technique [see Figure 2] is especially useful. With both
clamped proximally and distally, and a longitudinal elliptical open- endarterectomy techniques, extensive aortic exposure is required.
ing is created anterolaterally in the aortic wall (e.g., with two or The aorta proximal to the origin of the superior mesenteric artery
three applications of a 5.2 mm aortic punch). If required, a local (SMA) is exposed and controlled. This exposure is facilitated by
endarterectomy at the site of the anastomosis may be performed partially dividing the aortic crura and controlling the SMA with a
through this opening. Silastic loop.
The proximal and distal anastomoses are then created. Currently, the majority of aortorenal endarterectomies are per-
Although end-to-side distal renal artery anastomoses were com- formed through a longitudinal aortotomy extending from a point
monly performed at one time, current aortorenal bypass tech- 2 to 3 cm below the renal arteries to the base of the SMA. A sleeve
niques typically employ end-to-end distal renal artery anasto- of aortic atheroma is created, then divided sharply at the base of
moses. For both the proximal and the distal anastomosis, the the SMA proximally and well below the most inferior renal artery
length of the arteriotomy should be at least three times the diam- distally. After the aortic endarterectomy is completed, an eversion-
a b
Left
Renal
Artery
SMA
SMA
IMA
Figure 2 Thromboendarterectomy.8 Exposure for a longitudinal transaortic endarterectomy is

obtained via the standard transperitoneal approach. The duodenum is mobilized from the aorta later-
ally in the standard fashion; alternatively, for more complete exposure, the ascending colon and the
small bowel are mobilized. (a) Dotted line shows the location of the aortotomy. (b) The plaque is
transected proximally and distally, the renal arteries are everted, and the atherosclerotic plaque is
removed from each renal ostium. The aortotomy is typically closed with a continuous 4-0 or 5-0
polypropylene suture. (IMA—inferior mesenteric artery)
a b c
Figure 3 Renal artery reimplantation.9 (a)

When the renal artery is redundant and the
disease involves the orifice of the renal artery,
it is usually possible to reimplant the vessel at
a lower level. Dotted lines indicate the location
of the aortotomy and the point where the renal
artery is divided. (b) An elliptical opening is
created in the aortic wall, and a local
endarterectomy is done as required. (c) A
monofilament suture is placed in the aortic
wall. (d) The native renal artery is ligated,
proximally spatulated, and reimplanted.
type endarterectomy is performed for each of the renal arteries. Although this technique has only limited applicability to the
The surgical assistant retracts the anterior lip of the aortic wall and treatment of atherosclerotic renovascular disease in adults, it may
inverts the renal artery into the aorta, and the operating surgeon be particularly useful for this purpose in children and young ado-
retracts the renal artery atheroma while gently pushing the lescents, who often have congenital or developmental lesions that
remaining renal artery away with a dissector. In this manner, the involve the renal artery orifice. The main advantage of reimplan-
end point of the endarterectomy can easily be visualized to con- tation is that it obviates concerns regarding the durability of the
firm that the endarterectomy is complete.The endarterectomy site renal artery conduit.
is then irrigated with heparinized saline, and the longitudinal aor-
SPLANCHNORENAL BYPASS
totomy is closed with a continuous 4-0 or 5-0 monofilament
polypropylene suture. Indirect, or splanchnorenal, bypass [see Figure 4] is an uncom-
Both transrenal and transaortic thromboendarterectomy are mon procedure at our center. In large part, its relative rarity is a
contraindicated if aneurysmal degeneration of the perirenal aorta reflection of the frequent presence of simultaneous disease of the
is present or if there is transmural calcification at the site of celiac axis and the frequent need for bilateral renal artery recon-
endarterectomy. struction in combination with aortic repair. In addition, we believe
that this approach does not yield long-term patency equivalent to
RENAL ARTERY REIMPLANTATION
that provided by direct aortorenal reconstruction. Consequently,
In the course of renal artery exposure, the vessel is dissected these indirect bypass techniques are reserved for a selected sub-
from its aortic origin to its primary bifurcation. On occasion, after group of high-risk patients.
complete dissection, the vessel is found to have sufficient redun- Hepatorenal bypass is most frequently performed through a
dancy to allow tension-free reimplantation into the infrarenal right subcostal incision, splenorenal bypass through a left sub-
aorta [see Figure 3]. As in a renal artery bypass [see Aortorenal costal incision. In either procedure, the patient is positioned with
Bypass, above], an elliptical section of the aortic wall is resected, a roll beneath the ipsilateral flank, with the operating table flexed
and a widely spatulated aortorenal anastomosis is fashioned. and the ipsilateral arm padded and tucked to the side.The incision
may be extended to the contralateral semilunar line and into the function in 60% of occluded renal arteries that underwent opera-
ipsilateral flank as necessary for exposure. In a hepatorenal bypass, tive repair.4
a greater saphenous vein graft is usually employed, originating
INTRAOPERATIVE RENAL DUPLEX ULTRASONOGRAPHY
from the common hepatic artery and coursing posterior to the
portal triad and anterior to the vena cava before the end-to-end The surgeon’s technique plays a dominant role in determining
renal artery anastomosis [see Figure 4]. A splenorenal bypass may patency after renal artery reconstruction. To look for technical
be created either in a similar fashion (i.e., with a greater saphenous errors at the time of operation, we employ intraoperative renal
vein graft) or by anastomosing the transected splenic artery direct- duplex ultrasonography. A 10.0/5.0 mHz compact linear array
ly to the left renal artery [see Figure 5]. If the latter approach is probe with Doppler color-flow capability is placed within a sterile
taken, the collateral circulation to the spleen is sufficient to main- sheath that has a latex tip containing sterile gel.The operative field
tain splenic viability. is flooded with warm saline solution, and B-scan images are
obtained from the sites of aortic control and of renal artery repair.
NEPHRECTOMY All defects noted on the B-scan images are then examined in both
In patients with renovascular renal insufficiency or ischemic longitudinal and transverse projections. Doppler samples are
nephropathy, an incremental increase in excretory renal function obtained proximal and distal to the lesions to determine their
after operation is the dominant determinant of dialysis-free sur- hemodynamic significance.6 In 249 consecutive renal artery
vival. As noted [see Operative Planning, Surgical Strategy, above], repairs with anatomic follow-up, 10% had a focal increase in peak
we reserve nephrectomy for patients in whom an unrecon- systolic velocities consistent with residual stenosis.2 Each defect
structable renal artery is supplying a nonfunctioning kidney.When was revised immediately, and in each case, a significant defect was
the renal artery is occluded, reconstruction is performed if the dis- found. At 12 months after operation, primary patency of the renal
tal renal artery is normal at the time of surgical exploration. Past reconstruction was observed in 97% of repairs.This product-limit
recommendations regarding the management of renal artery oc- estimate of patency is stable up to 8 years after operation.
clusion have emphasized kidney length, distal renal artery recon-
stitution, and the appearance of a nephrogram during angiography
Outcome Evaluation
as criteria for determining whether reconstruction is indicated.
Our practice, however, has been to perform renal artery recon- Surgical repair of atherosclerotic renovascular disease can be
struction whenever a normal distal renal artery is demonstrated. accomplished with a high rate of success and sustained long-term
In a study employing this strategy, we reported retrieval of renal patency. With proper patient selection, the majority of patients
a b
Figure 4 Hepatorenal bypass.9 (a) Shown is exposure of the

common hepatic artery and the proximal gastroduodenal artery
in the hepatoduodenal ligament in preparation for hepatorenal
bypass (typically through a right subcostal skin incision). (b,c)
The reconstruction is completed by placing a greater saphenous
vein interposition graft between the side of the hepatic artery
and the distal end of the transected right renal artery.
Splenic Artery
a b
Left Renal
Artery
Figure 5 Splenorenal bypass.9 (a) Shown is exposure of the left renal

hilum in preparation for splenorenal bypass (typically obtained through
a left subcostal incision). The pancreas has been mobilized along its
inferior margin and retracted superiorly. (b) The transected splenic
artery is anastomosed to the transected left renal artery in an end-to-
end manner. A splenectomy is not routinely performed.
demonstrate beneficial blood pressure response and renal function perioperative mortality demonstrated significant and independent
response, albeit with perioperative mortality and morbidity that associations with advanced age and clinical congestive heart fail-
vary according to the complexity of the procedure. ure. The estimated primary patency rate for all 720 renal artery
In a 2002 report, we reviewed our center’s experience with 500 reconstructions was 97% at 8 years’ follow-up.
consecutive patients who underwent open surgical repair for treat-
ment of atherosclerotic renovascular disease between January HYPERTENSION RESPONSE
1987 and December 1999.2 These patients included 254 women Early blood pressure response was estimated on the basis of
and 246 men, with a mean age of 65 ± 9 years. Each patient had ambulatory blood pressure values and medication requirements
severe hypertension.The mean preoperative blood pressure for the determined at least 1 month after operative repair. Among surgi-
group was 200 ± 35/104 ± 21 mm Hg. Most of the patients had cal survivors, 12% were considered cured, 73% were considered
diffuse extrarenal atherosclerosis. A total of 81% had at least one
improved, and 15% were considered failed [see Table 3].
manifestation of cardiac disease; 34% had a history of significant
cerebrovascular disease; and 78% were considered to have at least RENAL FUNCTION RESPONSE
mild renal insufficiency, as evidenced by a serum creatinine con-
centration of 1.3 mg/dl or greater. Ischemic nephropathy was seen A significant change in excretory renal function was defined
in 244 patients (49%), including 40 patients who were dependent as a change of at least 20% in the estimated glomerular filtration
on dialysis before operation. rate (EGFR), measured at least 3 weeks after repair. Of patients
Angiographic evaluation demonstrated the presence of bilater-
al renal artery disease in 60% of these atherosclerotic patients.The
renal artery lesion was considered ostial in 97% of cases, and 16% Table 2 Summary of Operative Management of
of renal arteries were completely occluded. A total of 720 renal Atherosclerotic Renovascular Disease2
artery reconstructions were performed [see Table 2]. Aortorenal by-
pass was performed in two thirds of the repairs, and two thirds of Total renal reconstructions 720
these bypasses were done with venous grafts.Thromboendarterec- Aortorenal bypass 384
tomy was performed in almost one third of the cases. Renal artery Venous graft 204
reimplantation was performed in 56 instances, splanchnorenal by- PTFE graft 159
pass in only 13 instances. Although there were 124 renal artery oc- Dacron graft 21
clusions, only 56 of these were treated by means of nephrectomy. Reimplantation 56
Twenty-three patients (4.6%) died in the hospital or within 30 Thromboendarterectomy 267
days of renal reconstruction. Mortality varied significantly with Splanchnorenal bypass 13
the magnitude of procedure. Mortality after isolated renal artery Total nephrectomies 56
repair was substantially lower than mortality after combined aor-
tic and bilateral renal artery repair (0.8% versus 6.9%). Moreover, Total kidneys operated on 776
100
Table 3 Results of Operative Treatment of
Atherosclerotic Renovascular Disease among 90
472 Surgical Survivors2
80
Result Rate (%)
70
Dialysis-Free Survival (%)

Perioperative mortality 4.6
Hypertension response 60
Cured 12
Improved 73 50
Failed 15
Renal function response* 40

Improved 58
Unchanged 35 30
Worsened 7
20
*For 220 patients with preoperative serum creatinine concentrations ≥ 1.8 mg/dl; a
significant change is defined as a ≥ 20% change in EGFR.
10
0
with preoperative ischemic nephropathy, 58% showed improve- 0 20 40 60 80 100 120 140
ments in renal function, including 30 patients removed from
dialysis dependence [see Table 3]. In contrast to previous reports Follow-up (months)
that suggested the existence of a lower limit of renal dysfunction EGFR EGFR EGFR
beyond which recovery could not be observed, the percentage of Improved Unchanged Worsened
patients who showed improvement rose with increasing preop- Figure 7 Illustrated are product-limit estimates of time to death
erative serum creatinine concentration. Overall, 75% of dialysis- or dialysis, stratified according to postoperative renal function
dependent patients were permanently removed from dialysis response for patients with a preoperative EGFR of 25 ml/min/m2.
after renal artery repair. In addition, the site of disease and the The interaction between preoperative EGFR and renal function
extent of repair were found to influence increases in the EGFR. response for dialysis-free survival was significant and independent.2
100 Although each subgroup of patients who underwent operation

demonstrated some improvement in renal function, the greatest
90 incremental increase in the EGFR was observed in those who
underwent bilateral renal reconstruction for significant bilateral
80 disease.3,7
RELATIONSHIP OF HYPERTENSION RESPONSE AND RENAL
70
Dialysis-Free Survival (%)
FUNCTION RESPONSE TO DIALYSIS-FREE SURVIVAL
60 At a mean follow-up of 56 months, 171 patient deaths had

occurred.When outcomes were considered in terms of the blood
50 pressure response to operative intervention, only hypertension
cured was found to be significantly and independently associat-
40
ed with survival or dialysis dependence: patients whose hyper-
tension was cured experienced improved dialysis-free survival
30
[see Figure 6]. In contrast, all outcome categories for the renal
function response influenced both survival and eventual dialysis
20
dependence. Patients with improved renal function experienced
a significant increase in dialysis-free survival [see Figure 7].2 For
patients whose renal function remained unchanged after oper-
10
ation, however, the risk of eventual dialysis dependence and
death was equivalent to that of patients whose renal function
0
worsened after surgery. Whereas renal function that is un-
0 20 40 60 80 100 120 140 160
changed after intervention is frequently described as “stabilized”
N=472 N=376 N=271 N=184 N=113 N=67 N=30 N=8
or “preserved,” our experience suggests that patients with ische-
Follow-up (months) mic nephropathy and atherosclerotic renovascular disease whose
renal function is unchanged postoperatively remain at increased
Cured Improved Failed
risk for eventual dialysis dependence and death.Whether similar
Figure 6 Illustrated are product-limit estimates of time to death associations exist for patients treated by means of catheter-based
or dialysis, stratified according to blood pressure response to oper- methods is unknown, but the question certainly merits future
ation for atherosclerotic renovascular disease.2 study.
References
1. Dean RH, Benjamin ME, Hansen KJ: Surgical man- tion. J Vasc Surg 29:140, 1999 8. Benjamin ME, Dean RH: Techniques in renal
agement of renovascular hypertension. Curr Probl artery reconstruction: part I. Ann Vasc Surg
5. Hansen KJ, Deitch JS, Oskin TC, et al: Renal artery
Surg 34:209, 1997 10:306, 1996
repair: consequence of operative failures. Ann Surg
2. Cherr GS, Hansen KJ, Craven TE, et al: Surgical 227:678, 1998 9. Benjamin ME, Dean RH: Techniques in renal
management of atherosclerotic renovascular disease.
J Vasc Surg 35:236, 2002 6. Hansen KJ, Reavis SW, Dean RH: Duplex scanning artery reconstruction: part II. Ann Vasc Surg
in renovascular disease. Geriatr Nephrol Urol 6:89, 10:409, 1996
3. Hansen KJ, Cherr GS, Craven TE, et al: Manage-
ment of ischemic nephropathy: dialysis-free survival 1996 10. Hansen KJ,Wong JM: Aortorenal bypass for renovas-
after surgical repair. J Vasc Surg 32:472, 2000 7. Dean RH,Tribble RW, Hansen KJ, et al: Evolution of cular hypertension in adults. Current Therapy in Vas-
4. Oskin TC, Hansen KJ, Deitch JS, et al: Chronic renal renal insufficiency in ischemic nephropathy. Ann cular Surgery, 4th ed. Ernst CB, Stanley JC, Eds.
artery occlusion: nephrectomy versus revasculariza- Surg 213:446, 1991 Harcourt Health Sciences, St Louis, 2000, p 735
Recommended Reading
Deitch JS, Hansen KJ, Craven TE, et al: Renal artery re- study. J Vasc Surg 36:443, 2002 sonography: main renal artery versus hilar analysis. J Vasc
pair in African-Americans. J Vasc Surg 26:465, 1997 Hansen KJ, Tribble RW, Reavis SW, et al: Renal duplex Surg 32:462, 2000
Edwards MS, Hansen KJ, Craven TE, et al: Relationships sonography: evaluation of clinical utility. J Vasc Surg
between renovascular disease, blood pressure, and renal 12:227, 1990
function in the elderly: a population-based study. Am J Hunt JC, Strong CG: Renovascular hypertension: mecha-
Kidney Dis 41:990, 2003 nisms, natural history and treatment. Am J Cardiol Acknowledgment
Hansen KJ, Edwards MS, Craven TE, et al: Prevalence of 32:562, 1973
renovascular disease in the elderly: a population-based Motew SJ, Cherr GS, Craven TE, et al: Renal duplex Figures 1 through 4 Alice Y. Chen.
6 VASCULAR SYSTEM 15 RENOVASCULAR DISEASE — 1
15 ENDOVASCULAR PROCEDURES
FOR RENOVASCULAR DISEASE
Juan Ayerdi, M.D.,Matthew S.Edwards, M.D., and Kimberley J.Hansen, M.D., F.A.C.S.
The treatment of renovascular disease is currently in a state of evolu- Contrast-Related Considerations

tion. Open surgical revascularization [see 6:14 Open Procedures for
Patients with known renovascular disease typically have a high
Renovascular Disease] remains the gold standard, having demonstrat-
prevalence of associated medical comorbidities (e.g., diabetes
ed its durability and efficacy in treating renovascular hypertension mellitus, congestive heart failure, chronic renal insufficiency, and
and ischemic nephropathy; however, it is associated with substantial diuretic-induced intravascular volume depletion). These condi-
morbidity and mortality, even when performed in centers with ex- tions may necessitate alterations in the usual routines for patient
tensive experience.1-4 As a result, endovascular techniques for renal preparation and use of iodinated contrast agents. Such agents are
revascularization, including percutaneous transluminal angioplasty known to be capable of impairing excretory renal function,20
with or without endoluminal stent placement (PTAS), have emerged sometimes permanently.The risk of this complication is highest in
as another option for the revascularization of occlusive renal artery persons with preexisting dehydration,21 renal insufficiency,22-24 or
lesions. Compared with conventional open surgical revasculariza- diabetes mellitus.25-27 Administration of higher volumes of iodi-
tion, these endovascular techniques offer a number of potential ben- nated contrast material28,29 and use of high-osmolarity agents25-27
efits (e.g., decreased morbidity, lower mortality, shorter recovery may also increase the risk of postprocedural renal function impair-
times, and reduced hospital resource utilization); however, they also ment. Several reports, however, have demonstrated that peripro-
possess certain potential drawbacks (e.g., reduced effectiveness and cedural administration of acetylcysteine30,31 and sodium bicar-
decreased durability). bonate hydration32 can lower the risk of renal function impair-
Predictably, controversy persists regarding the appropriate ment after angiography.
application of surgical and endovascular therapies to the treat- In accordance with the available evidence, our current policy is to
ment of renovascular disease, with proponents of each modality prepare all patients for aortorenal arteriography with saline hydra-
citing selected literature to support their position. In what follows, tion (limited in patients with significant heart failure) and periproce-
we review key technical aspects of endovascular renal revascular- dural administration of acetylcysteine, along with limited use of sodi-
ization and summarize the current data on technical results, clin- um bicarbonate in patients who have preexisting renal insufficiency.
ical outcomes, and associated complications. There is reason to Furthermore, we routinely select low-osmolarity iodinated contrast
believe that improvements in our ability to select patients most agents in these patients and pay special attention to limiting the vol-
likely to benefit from treatment,5-10 as well as the emergence of umes infused. In patients with moderate to severe preexisting renal
technical developments aimed at preventing procedure-related insufficiency, carbon dioxide33,34 or gadopentate dimeglumine35 may
embolization11-13 and long-term restenosis,14 may be on the hori- also be employed as an intra-arterial contrast agent to reduce or
zon. Such advances, if realized, may further narrow the gap eliminate the use of iodinated contrast material. Our practice with
between the clinical results of surgical renal revascularization and such patients is to use carbon dioxide or gadopentate dimeglumine
for initial localization [see Figure 1a] and selective cannulation [see
those of its endovascular counterpart and may improve the mar-
Figure 1b] of the renal artery, then to employ an iodinated contrast
ginal benefit and safety of renal artery PTAS.
agent in small volumes for definitive planning and performance of
the required intervention.
Preoperative Evaluation
Technical Considerations
The general principles of preoperative evaluation and patient
Choice of arterial access route Femoral artery access,
selection for persons being considered for renal revascularization, when feasible, is the most versatile and low-risk option. For non-
whether open or endovascular, will not be described in detail in selective renal arteriography, either femoral artery provides ade-
this chapter. As a rule, our group reserves renal artery PTAS for quate access. For selective renal cannulation, however, it is gener-
patients in whom open surgical repair is considered high risk or ally better to use the femoral artery contralateral to the renal
who refuse such repair. artery being addressed; this approach takes advantage of the ten-
CONTRAST ARTERIOGRAPHY
dency of the catheter to track preferentially toward the contralat-
eral aortic wall and facilitates cannulation of the renal ostia.
Despite advances in diagnostic imaging and functional testing If the patient has downsloping renal arteries or if femoral access
that allow noninvasive identification of patients with renovascular is not advisable, brachial artery access is a useful alternative. It is
disease,15-19 the formulation of an open surgical or endovascular preferable to access the left brachial artery so as not to cross the
therapeutic plan continues to depend on visualization of the renal origin of the right common carotid artery. Access may be estab-
artery anatomy by means of angiography. Accordingly, contrast lished by means of either percutaneous or open techniques. The
arteriography of the renal arteries should be considered an inte- risk of complications is higher with percutaneous brachial artery
gral component of the therapeutic armamentarium for clinically access, and the maximum permissible sheath and catheter sizes
significant renal artery lesions. are smaller.36 Accordingly, we generally use an open approach for
a b
Figure 1 (a) Shown is bilateral high-grade renal artery stenosis visualized by using carbon dioxide angiogra-
phy to localize the renal ostia. (b) Shown is selective right renal artery cannulation, with placement of a 6
French left internal mammary artery (LIMA) guide catheter and selective renal arteriography using hand-
injected half-strength iso-osmolar contrast material.
brachial artery access, with puncture, cannulation, and closure eter have been gently advanced into the renal artery ostia, contrast
carried out under direct vision. material is injected by hand to confirm intraluminal placement.
Selective images are then obtained with low-volume power injection
Choice of imaging views Aortography and selective renal or hand injection (our preference) of contrast material [see Figure 4].
arteriography with multiple projections are necessary for full radi- The proximal third of the left renal artery usually courses anterior-
ographic evaluation of the renal arteries and the juxtarenal aorta. ly, the middle third transversely, and the distal third posteriorly; the
Initial anteroposterior (AP) images of the visceral aorta are ob-
tained by delivering power contrast injections through a flush
catheter with multiple side holes positioned just beneath the
diaphragm at the level of the first lumbar vertebra.These initial AP
views provide an overview of the renal artery and the perivisceral
aortic anatomy [see Figure 2]. All further nonselective images of the
renal arteries should be obtained by moving the catheter to a loca-
tion below the origin of the superior mesenteric artery to prevent
contrast opacification of the visceral vessels, which could obscure
the anatomic details of the renal arteries.
The renal arteries usually arise from the anterolateral or the
posterolateral aspect of the aorta. As a result, lesions within the
renal ostia often are not seen or appear insignificant on AP aor-
tograms. Oblique aortography or oblique selective renal arteriog-
raphy projects these portions of the vessel in profile and thus are
often better at identifying any renal ostial lesions present. As a rule,
the most useful projection for visualizing the renal ostia is a 15º to
30º left anterior oblique view, though other oblique views may also
be necessary.37,38 Previously obtained axial images of the renal ori-
gins (i.e., computed tomographic scans) may allow better estima-
tion of the necessary degree of obliquity and permit the use of
smaller amounts of iodinated contrast material and lower doses of
ionizing radiation [see Figure 3].
For full delineation of lesions within the body of the renal artery,
selective arteriographic views may be required. Selective cannula-
tion is usually performed with an angled catheter (e.g., a cobra cath-
eter, a Sos catheter, or a renal double-curve catheter) in combina-
tion with a steerable guide wire; the varying configurations of the
available catheters offer specific advantages in particular anatomic Figure 2 Anteroposterior (AP) aortogram is obtained by delivering
situations. Before selective renal artery cannulation, we typically a power injection of iso-osmolar iodinated contrast material through
administer heparin intravenously. Once the guide wire and the cath- a 5 French pigtail catheter positioned at the L1-2 interspace.
Arteriographic Findings
As noted (see above), the primary role for contrast arteriogra-
phy in the treatment of renovascular disease is concerned with
therapy rather than diagnosis. Angiography is most frequently per-
formed to assess a renal artery lesion previously identified by
means of renal duplex ultrasonography, CT arteriography, or
magnetic resonance arteriography either before or as part of a
therapeutic intervention. Most clinically significant renal artery
lesions are caused by atherosclerotic disease or fibromuscular dys-
plasia (FMD), with a small minority occurring secondary to other
pathologic states. Each of these two major pathologic entities is
associated with specific imaging characteristics and specific treat-
ment considerations.
Atherosclerotic renovascular disease Atherosclerosis of

the renal artery accounts for roughly two thirds of all renovascular
lesions. Elderly persons with multiple comorbid medical condi-
tions and manifestations of atherosclerosis are most frequently
Figure 3 Axial CT scan image of the renal artery origins allows affected.41-44 Atherosclerotic renal lesions generally represent a
estimation of the degree of obliquity required for optimal imaging continuation of a process that begins in the aorta and spills over
of the renal ostia. into the origin of the renal vessels [see Figure 5]. These lesions are
characterized by an eccentric, irregular narrowing of the ostium
and the proximal portion of the renal artery [see Figure 6]. In the
majority of cases, the lesions are limited to the ostia and the prox-
imal renal artery, and the two sides are affected equally.45 The aor-
tic origin of the lesion has important implications for treatment.
Placement of an endovascular stent into the proximal renal artery,
without the aortic origin of the plaque being taken into account,
may result in residual or recurrent disease. Occlusions of the renal
artery are also common in patients with clinically significant
lesions [see Figure 7] and frequently occur in the setting of con-
tralateral renal artery stenosis.2,3
Fibromuscular dysplasia FMD is a term used to describe

a group of histologically distinct pathologic conditions of the arte-
rial wall that most commonly affect the main renal artery and its
branches. FMD of the renal artery, with resultant renal artery
stenosis, is responsible for approximately 25% to 30% of treated
cases of renovascular hypertension.45 The lesions are usually cate-
gorized according to the layer of the arterial wall predominantly
Figure 4 Shown is selective arteriography of the right renal
artery using hand-injected iso-osmolar contrast material through
a complexly curved Simmons catheter.
right renal artery generally pursues a more consistent posterior

course. For full delineation of lesions in the various segments,
oblique and cranial-caudad rotated images may be necessary.
Adjunctive measures The performance of arteriographic

imaging of the renal arteries also affords the surgeon the opportu-
nity to employ other measures to characterize a renal artery lesion.
For example, the hemodynamic effects of angiographically detect-
ed stenosis or the treatment thereof can be assessed by making
direct pressure measurements proximal and distal to the lesion. In
general, we consider any pressure gradient greater than 10 mm Hg
to be indicative of hemodynamically significant renovascular dis-
ease. Additional anatomic information can be obtained by means
of intravascular ultrasonography of the renal artery, which can
provide detailed information on plaque morphology, vessel size,
and potential dissection flaps to complement the data obtained Figure 5 Aortic endarterectomy specimen demonstrates the
through arteriography.39,40 pathologic basis of atherosclerotic renovascular disease.
beads [see Figure 8], an appearance created by weblike stenotic

areas with intervening areas of poststenotic dilatation. These
lesions are frequently unilateral, and they can also produce a renal
artery aneurysm or dissection.47 Stenotic medial fibroplasia of the
main renal artery is among the lesions most amenable to endovas-
cular treatment. In our view, however, the presence of branch ves-
sel disease or aneurysms precludes such treatment.
Perimedial dysplasia accounts for approximately 15% of cases
of FMD and is most commonly manifested by the appearance of
multiple irregular stenoses without microaneurysms.46 Intimal
fibroplasia is the least common variant of FMD, representing
fewer than 5% of recognized cases, and the typical lesions are
smooth concentric stenoses.45,46 In general, perimedial dysplasia
and intimal fibroplasia tend to respond less well to endovascular
treatment than medial fibroplasia does.
Operative Planning
PATIENT PREPARATION
Patient preparation for renal artery PTAS is similar to that rou-

tinely carried out for diagnostic arteriography. Oral intake of food
and liquid is stopped at midnight the evening before the procedure.
Figure 6 Magnified preintervention aortogram demonstrates Warfarin is discontinued at least 4 days beforehand; aspirin and
ostial right renal artery atherosclerotic stenosis. clopidogrel are continued. Intravenous fluids and acetylcysteine are
administered the evening before the procedure, with care taken to
involved—hence the terms medial fibroplasia, perimedial dyspla- avoid fluid overload in patients with impaired cardiac function. Rou-
sia, and intimal fibroplasia. Medial fibroplasia is the most com- tine medications, with the exception of angiotensin-converting en-
mon variant, representing 85% of recognized cases. It is encoun- zyme inhibitors and angiotensin receptor antagonists, are taken on
tered almost exclusively in women, most commonly in the third or the morning of the procedure with a sip of water. A first-generation
fourth decade of life.45,46 The arteriographic pattern most fre- cephalosporin is administered intravenously 30 minutes before the
quently associated with medial fibroplasia resembles a string of procedure unless the patient is allergic.
After the intervention, the patient is observed in the hospital
overnight to check for access-site problems and severe alterations
in blood pressure. Acetylcysteine is continued throughout the hos-
pital stay, and oral administration of clopidogrel is initiated the
evening after the procedure. The patient continues to take clopi-
dogrel for at least 30 days after revascularization and remains on
aspirin therapy indefinitely.
CORRELATION OF DIAGNOSTIC IMAGES WITH
CLINICAL FINDINGS
Once the diagnostic portion of the procedure is completed, the

images obtained are closely examined and correlated with the
patient’s clinical presentation. Intra-arterial pressure measure-
ments are occasionally misleading in renal vessels. Because most
renal arteries are approximately 5 to 6 mm in diameter, a stenotic
lesion that causes a greater than 60% reduction in the luminal
diameter leaves only 2.0 to 2.5 mm of patent lumen. A 4 or 5
French diagnostic catheter may completely occlude this narrowed
lumen, thus resulting in an inaccurately low pressure measure-
ment distal to the stenosis. Accordingly, it is our practice to assess
the anatomic arteriographic information in the light of the func-
tional significance of the lesion as determined by either renal vein
renin assays or duplex ultrasonography.
MATERIALS AND INSTRUMENTS
The materials commonly used for renal artery PTAS at our

center include various guide wires, catheters, sheaths, balloons,
and stents [see Table 1]. The basic principles underlying the use of
Figure 7 Aortogram demonstrates right renal artery stenosis and these devices are outlined more fully elsewhere [see 6:8 Fun-
left renal artery occlusion with distal renal artery reconstitution. damentals of Endovascular Surgery].
ter and the introducer sheath are exchanged over a 0.035 in. guide
wire so that an access platform can be established that will provide
secure renal artery access for the therapeutic intervention.
Most angioplasty and stenting devices in current use will pass
through a 6 French lumen. Access options include guide sheaths
and guide catheters. Common to both of these options is the pro-
vision of a long mechanical support segment for guide-wire place-
ment that affords direct access to the renal artery for easy passage
of therapeutic devices to the target lesion [see Figure 9]. Such sys-
tems vary in shape and diameter and come in multiple configura-
tions to facilitate renal artery access in different situations.
After the tip of the guide catheter is positioned at or within the
renal artery orifice, guide-wire access across the lesion is obtained.
For all subsequent manipulations, the sheath or the guide catheter
should not be advanced beyond the orifice, because the nonta-
pered tip may injure the vessel. Depending on the type, severity,
and location of the lesion, a 0.35, 0.18, or 0.14 in. guide wire with
a floppy radiopaque tip is chosen.The smaller guide-wire systems
appear to have inherent advantages, in terms of ability to cross
Figure 8 Selective right renal arteriogram demonstrates findings tighter stenoses, limitation of renal artery trauma, and liberation of
indicative of medial fibroplasia. emboli, but whether these apparent advantages are real remains to
be proved. Once the guide wire is in place, the access platform is
secured and remains in place until the intervention and any
Operative Technique postintervention imaging are complete.
STEP 1: SECURING OF ACCESS TO RENAL ARTERY FOR STEP 2: TRANSLUMINAL ANGIOPLASTY
THERAPEUTIC INTERVENTION
With the guide wire secured distal to the lesion, therapeutic
Once the decision for endovascular intervention is made, the pa- intervention may proceed. Both coaxial systems (in which the
tient is systemically heparinized, and the 5 French diagnostic cathe- entire catheter is exchanged over the wire, so that an assistant is
Table 1 Standard Equipment for Renal PTAS

Device Category Type Proprietary Name Length Diameter
Initial Starter 3 mm J 180 cm 0.035 in.
Magic Torque 180 cm 0.035 in.

Guide wires
Selective Platinum Plus, V-18 145–180 cm 0.018 in.
Transend, GuardWire 165–200 cm 0.014 in.
Flush angiography Pigtail 70 cm 5 Fr
Cobra C1 or C2 65 cm 5 Fr
Selective: diagnostic Contra 2 65 cm 5 Fr
VS–1 or Sos 65 cm 5 Fr
Simmons 65 cm 5 Fr
Catheters Renal Double Curve 55 cm 6 Fr

LIMA 55 cm 6 Fr
Selective: guide
JR 4 55 cm 6 Fr
Hockey Stick 55 cm 6 Fr
Pressure-measuring Straight Glide 90 cm 4 Fr
Initial access 10 cm 5 Fr
Sheaths Therapeutic access 10 cm 6 Fr
Pinnacle Destination 45 cm 6 Fr
Selective: guide
Flexor Check Flow ANL2 45 cm 6 Fr
1.5–2.0 cm balloon 3 mm balloon

Predilation Savoy, Gazelle, Aviator, Symmetry
75–90 cm shaft 5 Fr sheath
Angioplasty balloons
1.5–2.0 cm balloon 4–7 mm balloon
Therapeutic Savoy, Gazelle, Aviator, Symmetry
12–29 mm stent 5–7 mm stent

Stents* Balloon-expandable Genesis, Express, Racer
*None of these stents are FDA-approved for use in renal arteries.
Figure 9 Shown are (a) a guide catheter

inserted through a short 6 French arteri-
al sheath and (b) a diagnostic catheter
inserted through a guide sheath.
required to control the wire during intervention and catheter STEP 3: ENDOLUMINAL STENTING
exchange) and monorail or rapid-exchange systems (in which only Endovascular stent placement may be performed either as a pri-
the distal portion of the catheter is over the wire, so that a single mary procedure or as a secondary procedure in response to sub-
operator can control the wire during intervention and catheter optimal results from angioplasty. Most FMD lesions and nonos-
exchange) are available for renal artery intervention. tial atherosclerotic lesions respond well to angioplasty alone.
Regardless of the system chosen, the principles of intervention Secondary stent placement should, however, be considered for
remain the same. Transluminal angioplasty of the renal artery nonostial lesions that do not respond appropriately to angioplasty.
may be performed either as the sole therapy for a renal artery Secondary stent placement is typically performed to address elas-
lesion or as a means of predilating a lesion so that an endolumi- tic recoil, residual stenosis (> 30%), pressure gradients (> 10 mm
nal stent can be placed. Angioplasty may also be employed to Hg), and myointimal flaps or dissections. Either balloon-expand-
treat recurrent renal artery stenoses after surgical or endovascu- able or, less commonly, self-expanding stents may be employed in
lar therapy. Angioplasty is an effective stand-alone therapy in the renal artery. Typically, balloon-expandable stents have greater
most cases of main renal artery disease (FMD and nonostial ath- radial strength and can be placed more precisely, whereas self-
erosclerosis) but is frequently ineffective for atherosclerotic ostial expanding stents are more flexible and conform more readily to
and proximal renal artery disease. the shape of the lumen.We employ balloon-expandable stents pri-
The angioplasty balloon size is chosen on the basis of quantita- marily in the treatment of ostial atherosclerotic lesions, where their
tive angiographic images. Direct cut-film images with ball-bearing advantages are particularly useful.
or marker-catheter reference points may be used, as may the quan- In general, the technical aspects of stent placement parallel
titative software packages available on most contemporary digital those of transluminal angioplasty. Frequent hand injections of
angiographic systems. In general, the angioplasty balloon should small amounts of contrast material through the guide sheath or
be slightly larger than the adjacent normal artery for primary catheter are employed to guide the stent into position across the
treatment and somewhat smaller for predilation of a stenotic lesion before deployment [see Figure 10]. After the stent has been
lesion. For predilation before endoluminal stent placement, we deployed, a completion angiogram is performed while guide-wire
usually employ a 3 × 20 mm low-profile angioplasty balloon.This access to the renal artery is maintained. This is accomplished by
choice tends to make stent passage less traumatic and helps in esti- hand injection of contrast through the guide sheath or catheter.
mating the stent diameter and length required. For the treatment of ostial or proximal renal artery lesions, it is
During inflation of the angioplasty balloon, the aortic origin of preferable to position the stent with 1 to 2 mm extension into the
most ostial plaques is indicated by the appearance of a visible aorta. Frequent hand injection of contrast material through the
“waist,” and the image can be centered over a bony landmark to guide sheath allows precise placement of the stent and helps pre-
facilitate subsequent stent placement. It is not unusual for the vent misdeployment. If the stent is placed too far into the artery,
patient to experience some discomfort during balloon inflation. the true renal orifice is not supported, and there is a greater
This discomfort should resolve quickly when the balloon is deflat- chance of residual or recurrent disease.48-52 Such recurrent disease
ed; if it does not, renal artery trauma should be suspected. It is our often does not respond to further endovascular attempts; accord-
practice to inflate the balloon slowly to its fully inflated profile at the ingly, it is advisable to use the shortest possible stent that will ade-
rated nominal pressure, then maintain inflation for 30 to 45 sec- quately support the lesion. In addition, a stent that extends well
onds before deflation. out into the distal renal artery can make later surgical options
Once the balloon has been completely deflated, it is removed, more difficult53 and typically carries a higher failure rate.
and selective angiography is repeated to assess the response of the A balloon-expandable stent is deployed by inflating the angio-
lesion to angioplasty and check for complications. Guide-wire plasty balloon on which it is mounted. In the past, these stents had
access must be maintained until the end of the procedure so that to be crimped and hand-mounted on the angioplasty balloon,
complications or unsatisfactory results (e.g., dissection or residual which made their delivery somewhat insecure. Currently available
stenosis) can be addressed. stents, however, come securely premounted on low-profile deliv-
ery systems capable of passing across most lesions with minimal Postoperative Care
or no predilation. We deploy these stents with 1 to 2 mm exten- Longitudinal follow-up of all patients undergoing renal revas-
sion into the aorta, guided by anatomic information provided by cularization is mandatory to check for recurrent disease, con-
previous positioning over bony landmarks. Self-expanding stents,
tralateral disease, and deterioration of clinical benefit, as well as
though not commonly applied to the treatment of renovascular
other preventable cardiovascular and peripheral vascular condi-
disease, can also be employed in this setting. These devices are
tions. Our current approach to follow-up entails clinical visits at 1,
deployed by retracting an outer membrane of the delivery device
3, 6, 9, 12, 18, and 24 months after renal artery PTAS, with renal
to expose the stent. Care must be taken during deployment to
duplex ultrasonography, blood pressure measurement, and serum
ensure that foreshortening of the stent does not compromise cov-
erage of the lesion. creatinine measurement at each visit. After 24 months, this inten-
After a stent is deployed, there may be residual narrow areas sive early follow-up is relaxed to a yearly visit schedule if no con-
within the stent that necessitate balloon dilatation. These areas ditions necessitating shorter visit intervals have been identified.
may be visible on fluoroscopic evaluation of the stent, or they may Recurrent disease after renal stenting is a significant concern, and
be detected during postdeployment selective renal angiography. disease that recurs within the stent itself can be a particularly chal-
After all therapeutic measures have been completed, the tech- lenging problem [see Figure 11a]. Because most such recurrences are
nical result is assessed and undetected defects sought by means of related to intimal hyperplasia, repeat balloon angioplasty generally
repeat pressure-gradient measurements, intravascular ultrasonog- does little to improve the situation. Initial dilatation with a Cutting
raphy, or both. When a satisfactory result is obtained, the guide Balloon (Boston Scientific, Natick, Massachusetts) is extremely use-
wire and the sheath are removed and hemostasis is secured. ful for releasing the fibrous scar tissue of the restenotic lesion and al-
Although it is possible to perform bilateral renal interventions in a lowing subsequent dilatation to a larger diameter with a convention-
single procedure, we prefer, when possible, to stage these inter- al angioplasty balloon.The Cutting Balloon consists of a noncompliant
ventions so as to minimize contrast loads. balloon with three or four atherotomes (microsurgical blades) mount-
a b
c
Figure 10 (a) The orifice of a right renal artery
with high-grade ostial stenosis is catheterized
with a 6 French cobra catheter, and the lesion is
crossed with a 0.014 in. guide wire. (b) A balloon-
mounted stent is positioned across the renal
artery stenosis with the help of intermittent con-
trast injections and bony landmarks. (c) A fully
expanded stent is positioned in the renal artery.
a b
c
Figure 11 (a) Shown is high-grade recurrent in-
stent restenosis of the right renal artery. (b) The
Cutting Balloon is useful in dealing with such
lesions. (c) Dilation with a 4 × 15 mm Cutting
Balloon is followed by dilation with a standard 6 × 20
mm angioplasty balloon, and a completion
angiogram is obtained.
ed longitudinally on its outer surface [see Figure 11b].When the device fusion, surgical intervention, and deep vein thrombosis.There was
is inflated, the atherotomes score the intimal hyperplasia within the no apparent association between pretreatment patient characteris-
stent; the balloon is then rotated and reinflated to score the lesion in tics and the subsequent incidence of major complications. Two
multiple planes.To date, this technique has been used primarily in patients (1.1%) died within 30 days after the procedure.
coronary arteries, but it has also been applied to the treatment of renal
artery in-stent restenosis.54 After the lesion has been scored, a larger Outcome Evaluation
balloon is inserted and inflated to redilate the lesion [see Figure 11c].
To be considered successful, renal artery revascularization
should (1) improve quality of life, (2) reduce the incidence of
Complications adverse cardiovascular disease events, (3) slow or halt the pro-
gression of chronic renal insufficiency, (4) lower the incidence
Complications can arise at any point during renal artery PTAS or
of dialysis-dependent renal failure, and (5) improve overall sur-
during the early postoperative period. Potential complications in-
vival. Unfortunately, few studies addressing these clinical out-
clude access-site complications (e.g., hematoma, pseudoaneurysm,
come measures have been performed or reported. Thus, the
retroperitoneal hemorrhage, arteriovenous fistula, and closure-device
outcome of renal revascularization is currently assessed on the
infection), contrast-mediated allergic reactions or nephrotoxicity, basis of (1) the extent to which the procedure is anatomically or
atheroembolism, and direct renovascular trauma. In a meta-analysis technically successful and (2) the degree to which the proce-
published in 2000, the reported complication rate after renal PTAS dure alleviates or cures associated hypertension and ischemic
ranged from 0% to 40% (mean rate, 11%).55 The most frequently nephropathy. Technical success and the response of hyperten-
reported complications were hematomas at arterial access sites. sion or renal dysfunction to therapy are assumed to be the
Severe complications occurred in 9% of patients and included renal mechanisms by which the five important clinical outcomes list-
failure, segmental renal infarction, perinephric hematoma, and renal ed are achieved.
artery thrombosis.The mean mortality was 1%. Interpretation of the results of renal artery PTAS as reported in
A large single-center retrospective review of complications after the current literature is challenging. Despite the publication of
endovascular treatment with renal artery stenting reported similar hundreds of reports on this procedure, it remains unclear how
results.56 Major complications occurred after 15 of 179 procedures renal artery PTAS compares with surgical renal revascularization
(8.4%) and included renal infarction, permanently increased and whether renal artery PTAS conveys any meaningful benefit to
serum creatinine concentration, dialysis dependence, blood trans- patients beyond what can be achieved with medical therapy alone.
Table 2—Results after Primary Percutaneous Transluminal Angioplasty for

Atherosclerotic Renal Artery Stenosis
Patients with Renal Function Response (%) Hypertension Response (%) Major
Patients Technical Renal Restenosis Complication
Study (N) Success Dysfunction Rate (%)
Improved Unchanged Worsened Cured Improved Failed Rate (%)
Rate (%) (N)
Canzanello (1989)60 100 73 66 52 48 59 41 19 20
Klinge (1989)62 134 78 NR NR 11 78 10 16 11
Baert (1990)58 165 83 NR NR 32 36 32 10 11
Weibull (1993)67 29 83 NR 21 75 4 13 71 17 25 17
Losinno (1994)64 153 95 59 27 67 6 12 51 37 NR 8
Bonelli (1995)59 190 82 NR No change in mean SCr 8 62 30 10 23
Hoffman (1998)61 50 58 36 44 23 33 3 64 32 27 14
Klow (1998)63 295 92 NR No change in mean SCr 5 59 31 40 8
Zuccala* (1998)68 99 92 33 39 50 11 18 44 48 17 8
Paulsen (1999)69 135 90 79 23 56 21 6 41 53 45 9
Van de Ven (1999)65 41 57 22 18 55 27 5 44 51 48 29
Baumgartner (2000)70 163 95 107 33 42 25 43 57 35 3
Van Jaarsveld (2000)66 56 91 NR No change in mean SCr 7 61 32 48 5
Total 1,610 86 402 32 51 17 11 54 35 25 12
*All diabetic patients.

NR—not reported SCr—serum creatinine concentration
These shortcomings in our understanding of renal artery PTAS HYPERTENSION RESPONSE

(and of surgical renal revascularization, for that matter) stem Three randomized, controlled studies have compared endovas-
largely from the lack of well-designed clinical trials investigating cular surgery with medical treatment of renovascular hyperten-
these questions. Such trials will ultimately be necessary to estab- sion. These studies provide the best available data on the efficacy
lish the utility and safety of renal artery PTAS in the treatment of of endovascular therapy for managing hypertension, but they are
renovascular disease. Until such trials are performed, interpreta- limited in that they all investigated the use of renal artery angio-
tion of the existing literature is the only available guide to the pru- plasty without primary stent placement. The first study involved
dent application of renal artery PTAS. 49 patients with unilateral renal artery stenosis who were ran-
TECHNICAL SUCCESS domly assigned to either angioplasty or best medical hypertension
treatment.90 The angioplasty group demonstrated no statistically
Technical success is defined on the basis of angiographic find-
significant decrease in blood pressure; however, it did demonstrate
ings at the completion of renal artery PTAS. Criteria include com-
improvement in hypertension control, as evidenced by a signifi-
plete stent coverage of the targeted lesion (if a stent was used) and
cant reduction in the amount of antihypertensive medications
residual diameter-reducing stenosis of less than 30%.57 Angio-
plasty as stand-alone treatment of renovascular disease is of limit- required. The second study, reported by the Scottish and
ed applicability, especially in cases of atherosclerotic disease of the Newcastle Renal Artery Stenosis Collaborative Group, involved
renal ostia (the most commonly encountered lesion). The reason 55 patients who were randomly assigned to either angioplasty or
is that ostial renovascular disease usually represents the extension best medical antihypertensive therapy.91 Patients with both unilat-
of aortic-based plaque, which possesses substantial inherent recoil eral and bilateral renal artery stenosis were included in this study.
and thus is resistant to dilatation unless mechanical support is There was a modest improvement in blood pressure control in the
added to help maintain the enlarged lumen. angioplasty group, but this benefit was confined to those patients
A review of the literature on renal artery angioplasty for ath- who had bilateral disease. None of the patients were cured of their
erosclerotic renovascular disease determined that immediate tech- hypertension. The third study—the largest prospective, random-
nical success was reported in 86% of cases [see Table 2].58-70 The ized trial reported to date in this area—was performed by the
immediate technical success rate was higher when a stent was Dutch Renal Artery Stenosis Intervention Cooperative Study
employed, especially in cases of ostial disease. A review of the lit- Group.66 A total of 106 patients were randomly assigned to either
erature on primary stenting for atherosclerotic renovascular dis- renal artery angioplasty or best medical therapy for renovascular
ease determined that primary use of stents yielded an immediate hypertension. At 12 months, there was no significant reduction in
technical success rate of 98% [see Table 3].5,48,50,51,65,70-89 The supe- either systolic or diastolic blood pressure, though multiple treat-
riority of primary stenting for ostial lesions was confirmed in a ment crossovers occurred that might have skewed the results
prospective clinical trial.65 toward the best medical therapy arm.The authors concluded that
Table 3—Results after Primary Arterial Stent Placement for

Atherosclerotic Renal Artery Stenosis
Patients with Renal Function Response (%) Hypertension Response (%) Major
Study Patients Technical Renal Restenosis Complication
Success Dysfunction Rate (%) Rate (%)
(N) Improved Unchanged Worsened Cured Improved Failed
Rate (%) (N)
Rees (1991)84 28 96 14 36 36 29 11 5 36 39 18
Kuhn (1991)81 8 92 NR NR 22 34 44 17 13
Joffre (1992)80 11 91 4 50 50 0 27 64 9 18 13
Hennequin (1994)77 15 100 6 20 40 40 7 93 0 27 19
Macleod (1995)83 28 100 16 25 75 0 40 60 17 19
Van de Ven (1995)88 24 100 NR 33 58 8 0 73 27 13 13
Dorros (1995)72 76 100 29 28 28 45 6 46 48 25 11
Henry (1996)51 55 100 10 20 80 18 57 24 9 3
Iannone (1996)79 63 99 29 36 46 18 4 35 61 14 32
Harden (1997)76 32 100 32 35 35 29 NR 13 19
Blum (1997)48 68 100 20 0 100 0 16 62 22 17 0
Boisclair (1997)50 33 100 17 41 35 24 6 61 33 0 21
Rundback (1998)86 45 94 45 18 53 30 NR 26 9
Fiala (1998)5 21 95 9 0 100 0 53 47 65 19
Dorros (1998)73 163 99 63 No change in mean SCr 1 42 57 NR 14
Tuttle (1998)87 120 98 74 16 75 9 2 46 52 14 4
Gross (1998)75 30 100 12 55 27 18 0 69 31 13 NR
Henry (1999)78 200 99 48 29 67 2 19 61 20 11 2
Rodriguez-Lopez (1999)85 108 98 32 No change in mean SCr 13 55 32 26 12
Van de Ven (1999)65 40 88 29 17 55 28 15 43 42 14 30
Baumgartner (2000)70 64 95 NR 33 42 25 43 57 28 9
Giroux (2000)74 30 95 21 76 24 53 47 NR NR
Lederman (2001)82 300 100 111 8 78 14 70 30 21 2
Bush (2001)71 73 89 50 23 51 26 NR NR 9
Zeller (2004)89 456 98 239 34 39 27 46 54 NR NR
Total 2,091 98 910 22 56 22 10 51 39 19 9
NR—not reported SCr—serum creatinine concentration
angioplasty had little advantage over antihypertensive therapy in To date, only one prospective, randomized, controlled study has
the treatment of renovascular hypertension. compared endovascular treatment with surgical revascularization for
A 2000 meta-analysis examined data from retrospective reports the treatment of renovascular hypertension.67 In this report, 58
describing a total of 1,322 patients who were treated with renal patients with renovascular hypertension were randomly assigned to
artery angioplasty or stenting.55 The overall hypertension cure rate either surgical revascularization or angioplasty. In both groups, hyper-
was 20%, and 49% of the patients had improved blood pressure tension was cured or improved in approximately 90% of patients.
control. In a similar review of data from 36 reports on primary However, more than half of the patients in whom angioplasty failed
renal angioplasty or stent placement for the treatment of athero- were switched to the surgical arm for revascularization. On the basis
sclerotic renal artery stenosis [see Tables 2 and 3], the reported of these results, the authors recommended angioplasty as the treat-
treatment indications included hypertension, renal insufficiency, ment of choice for selected renovascular lesions contributing to reno-
and a combination of the two.The percentage of patients cured of vascular hypertension, with aggressive follow-up and repeat interven-
hypertension ranged from 0% to 32% (mean, 10%), and the per- tion (endovascular and surgical) carried out as needed.
centage of patients experiencing improved blood pressure control Another group of investigators, however, reported that the ben-
ranged from 5% to 93% (mean, 53%). eficial blood pressure response seen after open surgical repair for
failed angioplasty may be less than that seen in patients who 55%.2-4 Furthermore, patients with ischemic nephropathy whose
undergo primary surgical repair without previous endovascular renal function did not change after surgical revascularization had
treatment.53 Moreover, a previous endovascular procedure may increased rates of death and dialysis dependence during follow-up
make open surgical repair technically more demanding, especially that were similar to those noted in patients with poorer renal func-
if an endoluminal stent is present. tion after revascularization.2,3 These findings raise serious ques-
At present, there are no level I data demonstrating any associ- tions about the concept of stabilized renal function and suggest
ation between improved hypertension control after renal artery that improved postprocedural renal function may be the most per-
PTAS and either increased survival or reduced morbidity and tinent surrogate outcome marker for predicting improved survival
mortality from adverse cardiovascular events. In fact, very few and dialysis independence.
reports contain any data on these important clinical outcomes,
LONG-TERM COMPLICATIONS
and those that do have not documented any significant differ-
ences between medical management and renal artery Complications and suboptimal outcomes may also develop in a
PTAS.66,90,91 There is some evidence in the surgical literature of delayed manner. The principal long-term complications include
associations between hypertension response and a decrease in restenosis of the renal artery and inadequate durability of clinical
adverse cardiovascular events; notably, however, these associa- benefit. Restenosis is a common occurrence with all catheter-based
tions appear to exist only for persons whose renovascular hyper- methods of revascularization. According to the meta-analysis cited
tension is cured.2 earlier,55 restenosis complicates 11% to 42% (mean, 26%) of renal
artery angioplasties and 12% to 23% (mean, 17%) of renal artery
RENAL FUNCTION RESPONSE
stent procedures. Other studies have yielded very similar results [see
Several factors hinder accurate assessment of the effect of renal Tables 2 and 3]. Restenosis may or may not be clinically significant.
artery PTAS on renal function.To date, no prospective, controlled Accordingly, the decision whether to treat restenotic lesions should
studies have compared renal function responses after medical, be made on the basis of the specific physiologic or clinical findings,
surgical, and endovascular treatment of renal artery stenosis. not simply because restenosis is present.
Most observational series report results from a diverse group of The beneficial clinical responses noted after renal artery PTAS
patients whose baseline renal function and subsequent responses frequently are not durable. In two studies that reported on a to-
to treatment vary widely. Interpretation of the existing renal func- tal of 222 individuals undergoing renal artery PTAS, the investiga-
tion response data is further complicated by the insensitivity of se- tors found that the clinical response, especially the renal func-
rum creatinine measurement (the most commonly employed in- tion response, was transient.92,93 Overall, at 5 years, 50% to 70%
dicator of renal function in these studies) to changes in renal of patients exhibiting a positive hypertension response and
function, especially in patients with serum creatinine levels lower fewer than 50% of those exhibiting a positive renal function
than 1.2 mg/dl. response (defined as improvement or stabilization) retained any
These limitations notwithstanding, a number of reports pub- benefit. This deterioration of clinical benefit occurred even
lished between 1989 and 2004 provided useful data on renal func- though a patent renal artery was maintained in all cases. Such
tion response after renal artery PTAS, expressed in terms of results stand in stark contrast to the documented durability of the
change (or lack of change) in serum creatinine concentration [see clinical response after surgical revascularization and underscore the
Tables 2 and 3]. With improvement defined as a 20% or greater need for close lifelong follow-up of all patients undergoing renal
decrease in serum creatinine concentration, response rates ranging revascularization.1-4
from 0% to 55% were observed (mean, 22%). These results are
OUTCOMES AFTER RENAL ARTERY PTAS FOR FMD
very similar to those reported in the 2000 meta-analysis cited ear-
lier (range, 0% to 50%; mean response rate, 30%).55 A number of Patients with FMD respond to renal artery PTAS much dif-
authorities also make use of the concept of “stabilized” renal func- ferently from those with renal artery atherosclerosis. FMD is
tion, defined as a less than 20% change in serum creatinine con- most commonly manifested as medial fibroplasia in a young
centration. By this definition, renal function was stabilized in the woman. In general, balloon angioplasty appears to be an
majority of patients included in the studies published between acceptable treatment for adult patients with such lesions, and
1989 and 2004 (range, 23% to 100%; mean response rate, 53%) this approach yields excellent technical success rates, good
[see Tables 2 and 3]. Again, these results are very similar to those clinical benefit, and low morbidity. In a study addressing 85
reported in the meta-analysis (range, 0% to 64%; mean response renal artery stenoses in 66 FMD patients, hypertension was
rate, 38%).55 A significant percentage of treated patients (range, cured or improved in 98% of patients after renal angioplasty,
0% to 48%; mean, 21%) also experienced post-PTAS worsening and all patients with elevated creatinine levels exhibited
of renal function. improved or stabilized renal function.94 Another study, involv-
Although all investigators agree that worsened post-PTAS renal ing a series of older FMD patients (mean age, 59 years) with
function represents a treatment failure, it is less clear whether an longstanding hypertension (mean duration, 13 years), report-
unchanged serum creatinine concentration should be considered ed somewhat different blood pressure response results.95 At
beneficial to the patient. In one study, 88% of patients treated for follow-up more than 3 years later, hypertension was cured in
renal dysfunction exhibited improved or stabilized serum creati- 14% of patients and alleviated in 74%. Both studies support-
nine levels after angioplasty, stenting, or both.92 Only 25% of ed the general consensus that medial fibroplasia of the main
patients, however, showed sustained responses over a 5-year fol- renal artery can be adequately treated by means of primary
low-up period; the remainder demonstrated continuing deteriora- angioplasty, with stent placement reserved for technical fail-
tion of renal function.These results contrast sharply with those of ures. Furthermore, it appeared that a beneficial clinical
reports addressing open surgical treatment of renal dysfunction, response was seen after endovascular intervention and that
which documented durable improvement or stabilization rates of this response was more pronounced in younger patients with
85% to 93% and 5-year dialysis-free survival rates of 50% to a shorter duration of hypertension.
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71. Bush RL, Martin LG, Lin PH, et al: Endovascular Care System experience. J Vasc Surg 34:685,
2001
revascularization of renal artery stenosis in the soli- 2001
tary functioning kidney. Ann Vasc Surg 15:60, 2001 83. Macleod MJ, Connell JMC, Harden PN, et al:
Transluminal vascular stents for ostial atherosclerot- 93. Sivamurthy N, Surowiec SM, Culakova E, et al: Di-
72. Dorros G, Jaff M, Jain A, et al: Follow-up of primary
ic renal artery stenosis. Lancet 346:1109, 1995 vergent outcomes after percutaneous therapy for
Palmaz-Schatz stent placement for atherosclerotic
84. Rees CR, Palmaz JC, Becker GJ, et al: Palmaz stent symptomatic renal artery stenosis. J Vasc Surg
renal artery stenosis. Am J Cardiol 75:1051, 1995
in atherosclerotic stenoses involving the ostia of the 39:565, 2004
73. Dorros G, Jaff M, Mathiak L, et al: Four-year follow-
renal-arteries—preliminary report of a multicenter 94. Tegtmeyer CJ, Selby JB, Hartwell GD, et al: Results
up of Palmaz-Schatz stent revascularization as treat-
study. Radiology 181:507, 1991 and complications of angioplasty in fibromuscular
ment for atherosclerotic renal artery stenosis. Circu-
lation 98:642, 1998 85. Rodriguez-Lopez JA,Werner A, Ray LI, et al: Renal disease. Circulation 83:155, 1991
74. Giroux MF, Soulez G, Therasse E, et al: Percuta- artery stenosis treated with stent deployment: indica- 95. de Fraissinette B, Garcier JM, Dieu V, et al: Percuta-
neous revascularization of the renal arteries: predic- tions, technique, and outcome for 108 patients. J neous transluminal angioplasty of dysplastic stenoses
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2000 86. Rundback JH, Gray RJ, Rozenblit G, et al: Renal Intervent Radiol 26:46, 2003
6 VASCULAR SYSTEM 16 MESENTERIC REVASCULARIZATION PROCEDURES — 1
16 MESENTERIC REVASCULARIZATION
PROCEDURES
Scott E. Musicant, M.D., Gregory L. Moneta, M.D., F.A.C.S., and Lloyd M.Taylor, Jr., M.D., F.A.C.S.
Mesenteric ischemia is encountered infrequently. To date, there ceral stenosis or occlusion and the extent of collateral develop-
have been no randomized, controlled trials comparing treatment ment. In most cases, a transfemoral Seldinger technique is suit-
modalities for either acute or chronic mesenteric ischemia. able, though in the setting of iliofemoral occlusive disease, a
Consequently, decisions on how to treat this condition must be transaxillary approach is occasionally required. Between 60 and
based on a few large case series in which a variety of operations 100 ml of contrast material is required for appropriate lateral and
were used. anteroposterior views of the abdominal aorta. Visceral artery
Overall evaluation and management of acute mesenteric lesions are usually ostial but may extend beyond the orifice of the
ischemia are addressed more fully elsewhere [see 6:4 Acute vessel as a posterior plaque, especially in the superior mesenteric
Mesenteric Ischemia]. In what follows, we focus specifically on the artery (SMA). Selective catheterization of the main intestinal
operative techniques used to treat mesenteric ischemia (whether arteries is rarely necessary and may be dangerous. Appropriate
chronic or acute) and discuss the available literature supporting magnification views generally allow characterization of the proxi-
their use.The appropriate technique for a particular patient varies mal SMA beyond its origin, even without selective catheterization
according to the individual anatomy and the particular intraoper- of the SMA. Intra-arterial digital subtraction techniques are usu-
ative findings. ally adequate for lateral views, and they require less contrast mate-
The relevant surgical procedures may be conveniently divided rial than other techniques. Arteriography also demonstrates coex-
into those employed for chronic mesenteric ischemia and those isting lesions of the aorta and of the renal and iliac arteries that
employed for acute ischemia. may be important in planning revascularization.
OPERATIVE PLANNING
Procedures for Chronic Intestinal Ischemia Essentially all patients with peripheral artery disease have con-
comitant coronary artery disease (CAD). Although no symptoms
PREOPERATIVE EVALUATION of CAD may be evident, care must still be taken to provide peri-
J. E. Dunphy, in 1936, was the first to suggest that timely diag- operative cardiac protection. Perioperative beta blockade and anti-
nosis and intervention for mesenteric artery occlusive disease may platelet therapy should be routinely employed in all patients
prevent intestinal infarction.1 It is now clear that optimal treat- undergoing elective procedures.
ment of mesenteric ischemia depends on prompt diagnosis and If the patient is undergoing a bypass procedure, the choice of
that a high index of suspicion is vital. graft material should be addressed. In general, prosthetic grafts
Patients with chronic intestinal ischemia generally, but not
always, report experiencing colicky, dull, or aching abdominal
pain, primarily located in the epigastrium but occasionally radiat-
ing to the back. Symptoms typically begin 15 to 30 minutes after
eating and may last as long as 3 hours. Peritonitis is not a charac-
teristic of reversible intestinal ischemia; rather, it is indicative of
intestinal infarction. Chronic postprandial abdominal symptoms
result in markedly reduced food intake (so-called food fear),2
which generally leads to weight loss.
Physical examination often yields no significant abdominal
findings. Abdominal bruits may be audible, but they are a non-
specific sign. Patients often, but not always, show evidence of ath-
erosclerotic disease in other vascular territories. Bowel habits vary,
ranging from normal elimination to diarrhea or constipation.
Useful diagnostic tests include duplex ultrasonography, con-
trast angiography, and magnetic resonance angiography (MRA).
Duplex scanning is effective in detecting visceral artery stenosis
[see Figure 1] and may allow earlier detection of visceral artery
stenosis associated with chronic mesenteric ischemia.3,4 By itself,
however, it is not sufficient for planning a mesenteric revascular-
ization procedure.
Arteriography is the primary imaging procedure employed in
planning mesenteric revascularization for chronic intestinal
ischemia [see Figures 2 and 3]. Lateral and anteroposterior views Figure 1 Example of duplex spectral waveform with compara-
of the aorta are required for full evaluation of the severity of vis- tive arteriogram in patient with SMA stenosis.
A more versatile endarterectomy technique is transaortic

endarterectomy.7 This procedure involves a posterolateral
approach to the aorta, in which the aorta is exposed transperi-
toneally with medial visceral rotation. Alternatively, a completely
retroperitoneal approach may be taken.The main disadvantage of
the retroperitoneal approach is that it restricts the surgeon’s abil-
ity to assess the bowel at the completion of revascularization.
Transaortic endarterectomy Step 1: incision and initial

approach. A midline incision is recommended. A complete medi-
al visceral rotation is performed, with the left kidney left in its bed.
Step 2: exposure. The lateral aorta is exposed, and the celiac

artery and the SMA may be identified anteriorly; the left renal
artery lies posteriorly.
Step 3: endarterectomy. A trapdoor incision is made in the aor-

tic wall in such a way as to encompass the orifices of the SMA
and the celiac artery. Partial occlusion of the aorta with a clamp
is sometimes possible, but in most cases, complete aortic occlu-
sion is required. If necessary, the aortotomy can be extended dis-
tally and posteriorly to include the renal artery orifices as well.
Among the advantages of this operation are that it permits
simultaneous endarterectomy of the aorta and all visceral vessel
orifices and that it does not require the use of prosthetic materi-
al [see Figure 3]. The disadvantages include the potential risks
associated with suprarenal clamping (e.g., cardiac overload, renal
and lower-extremity embolization, and ischemia). Because of
Figure 2 Lateral aortogram clearly shows moderate

stenosis of proximal celiac artery and occlusion of SMA
(arrow) in patient with intestinal ischemia.
work well for mesenteric artery bypass. However, the entire

abdomen and both legs should still be included in the operative
field in case autologous vein proves necessary for the bypass con-
duit. Autologous vein is often required in cases involving bowel
resection and may also be preferable for bypasses to smaller vis-
ceral vessels. If an autologous vein bypass procedure is planned,
preoperative duplex scanning of the greater saphenous and
femoral veins is recommended to facilitate selection of the best
available vein for the conduit.
OPERATIVE TECHNIQUE
Visceral Endarterectomy
Visceral endarterectomy for treatment of mesenteric ischemia
was first described in 1958 by Shaw and Maynard,5 who per-
formed endarterectomy of the SMA in a blind retrograde fash-
ion through a distal arteriotomy. At present, retrograde endarte-
rectomy cannot be recommended.
The SMA can be approached directly once control of the
suprarenal aorta has been obtained.6 A longitudinal incision is
made across the origin of the SMA, and an endarterectomy is
performed. In most patients, the exposure is limited. This direct
approach may be considered when the SMA is widely separated
from the renal arteries and the visceral aorta is relatively free of Figure 3 Lateral aortogram showing so-called coral reef athero-
disease; however, this scenario is uncommon. ma involving visceral aorta with occlusion of origin of SMA.
these risks, the need for more extensive dissection, and the unfa- rograde if they originate from the infrarenal aorta or a common
miliarity of most surgeons with this procedure, arterial bypass iliac artery. Antegrade bypass from the supraceliac aorta, using
procedures are generally preferred for treatment of chronic either prosthetic material or autologous vein, has certain advan-
mesenteric ischemia. tages, including a straight graft configuration that minimizes tur-
bulence and graft kinking and, typically, reduced atherosclerotic
Mesenteric Arterial Bypass calcification in the supraceliac aorta.11 The disadvantages of ante-
Technical considerations Single-vessel versus multiple-vessel grade bypass are similar to those of visceral endarterectomy and
revascularization. There are two schools of thought on the extent derive from the need to clamp the supraceliac aorta for the prox-
of revascularization for chronic mesenteric ischemia. Proponents imal anastomosis. As with visceral endarterectomy, partial occlu-
of so-called complete revascularization advocate revascularization sion clamping is theoretically possible but not always practical.
of both the celiac artery and the SMA and suggest that this Clamping of the supraceliac aorta may increase the risk of cardiac
approach makes recurrent ischemia less likely should one graft or events, visceral or renal emboli, and ischemia. One prerequisite
graft limb undergo thrombosis.8 In a 1992 study, overall graft for use of the supraceliac aorta in an antegrade bypass is that the
patency and survival were better in patients who underwent mul- vessel must be angiographically normal to ensure that it can safe-
tiple-vessel bypass than in those who underwent single-vessel ly be clamped. It should also be kept in mind that reoperation on
bypass. The investigators concluded that multiple-vessel bypass the supraceliac aorta is difficult: once this site has been used, reex-
patients were likely to remain asymptomatic because of the pres- posure generally is not safe.
ence of additional grafts or graft limbs that remained patent.8
Others maintain that the critical vessel involved in chronic Antegrade bypass Step 1: incision and initial approach.
mesenteric ischemia is the SMA and argue that bypass to the SMA Supraceliac aorta–visceral artery bypass is performed through an
alone is a relatively simple procedure that relieves symptoms of upper midline incision. Self-retaining retractors are helpful.
mesenteric ischemia. In a 2000 study evaluating 49 patients who
underwent bypass to the SMA alone, the 9-year primary assisted Step 2:exposure. The dissection begins with division of the gas-
graft patency rate was 79% and the 5-year survival rate was 61%9— trohepatic ligament and retraction of the left lobe of the liver to the
results equivalent to those noted in contemporary studies of multi- right, followed by incision of the diaphragmatic crus and ex-
ple-vessel revascularization for chronic intestinal ischemia.10 posure of the anterior aspect of the aorta.
Antegrade versus retrograde bypass. Mesenteric bypass grafts Step 3: choice of graft. In clean cases with no intestinal necro-
may originate either above or below the renal arteries. Bypass sis or perforation, we use woven Dacron bifurcated grafts. If a sin-
grafts are considered antegrade if they originate on the anterior gle-vessel bypass is to be performed, a single limb is cut from the
surface of the abdominal aorta cephalad to the celiac artery, ret- bifurcated graft. Autologous vein grafts are usually reserved for
a b
Figure 4 Arterial bypass: antegrade. Shown is bypass from supraceliac aorta to SMA alone (a)
or to hepatic artery and SMA (b).28
contaminated cases. The femoral vein is an excellent autogenous

conduit for mesenteric arterial bypass.
Step 4: anastomosis of graft to supraceliac aorta and visceral artery.

If the celiac artery alone is to be revascularized, the usual procedure
is to perform an end-to-side proximal anastomosis to the aorta, fol-
lowed by an end-to-side distal anastomosis to the common hepat-
ic artery. If the SMA alone is to be revascularized, it is generally
necessary to tunnel the graft beneath the pancreas to the inferior
border of the pancreas, then perform an end-to-side anastomosis to
the SMA at that level [see Figure 4a]. Extreme care must be exer-
cised in developing the retropancreatic tunnel. If this area appears
too narrow or is scarred as a result of previous pancreatic inflam-
mation, the graft should be tunneled anterior to the pancreas to
ensure that it is not compressed and to avoid causing bleeding from
disrupted pancreatic veins.12 If a prepancreatic tunnel is required,
an autogenous conduit should be considered because the graft will
be lying adjacent to the posterior wall of the stomach. If both the
celiac artery and the SMA are to be revascularized from the
supraceliac aorta, a bifurcated prosthetic graft is attached to the
supraceliac aorta proximally, with one distal limb anastomosed to
the hepatic artery and the other to the SMA [see Figure 4b].
Retrograde bypass In a retrograde bypass, the infrarenal

aorta or a common iliac artery is used as the inflow vessel. One
clear advantage of this procedure is that the approach to the
infrarenal aorta is more familiar to most surgeons. Another is that
dissection and clamping of the infrarenal aorta are less risky than
dissection and clamping of the supraceliac aorta. Yet another is
that the surgeon can work within a single operative field. Once the
self-retaining retractor is placed, the operation on the infrarenal
aorta and the SMA can be performed without further adjustment
of the retractor. Figure 5 Arterial bypass: retrograde. Shown is bypass from
iliac artery to SMA.28
Step 1:incision and initial approach. Here too, a midline incision
and a transperitoneal approach are preferred.The transverse meso-
colon is retracted upward, and the ligament of Treitz is divided. to the SMA is passed cephalad, turned anteriorly and inferiorly
180°, and anastomosed to the anterior wall of the SMA just
Step 2: exposure. After division of the ligament of Treitz, the beyond the inferior border of the pancreas.12 In this manner, a
duodenum and the small bowel are retracted to the right. The gentle C loop is formed that, if placed correctly, keeps the graft
SMA may then be identified arising from beneath the inferior bor- from kinking when the viscera are restored to their anatomic posi-
der of the pancreas. The retroperitoneum is divided distally along tion after retractor removal [see Figure 5]. The ligament of Treitz
the aorta to a point just beyond the level of the aortic bifurcation. and the parietal and mesenteric peritoneum are closed over the
The distal aorta and both common iliac arteries are assessed graft to exclude it from the peritoneal cavity.
to allow determination of the proper location for the proximal
Endovascular Techniques
anastomosis.
Early reports describing the use of percutaneous transluminal
Step 3: choice of graft. As a rule, grafts made of Dacron or of angioplasty (PTA) to treat visceral atherosclerotic lesions indicat-
ringed, reinforced expanded polytetrafluoroethylene (ePTFE) ed that initial technical success rates were as high as 80% but that
are preferred. Problems may arise when retrograde bypasses are recurrence rates ranged from 20% to 40%.12,13 In a 1996 study of
performed with autologous vein grafts, in that such grafts are PTA in 19 patients who were considered high risk, the initial suc-
prone to kinking when the viscera are replaced. When a retro- cess rate was 95%, and the recurrence rate was 20% at 28
grade vein bypass is performed, the graft may be brought straight months.14 In a subsequent study of 25 patients who underwent
up from the right iliac artery so that it lies between the aorta and angioplasty and stenting of the celiac artery or the SMA for
the duodenum, then anastomosed to the posteromedial wall of chronic visceral ischemia, the initial technical success rate was
the SMA. 96%, and the initial clinical response rate was 88%.15 At 6
months, 92% of the stents remained patent.
Step 4: anastomosis to infrarenal aorta or common iliac artery and
COMPLICATIONS
SMA. Our preference is to use the area near the junction of the
aorta with the right common iliac artery for the proximal anasto-
mosis. (Short grafts originating from the midportion of the Technical
infrarenal aorta, though commonly used, are prone to kinking The main technical complication of mesenteric bypass is acute
when the viscera are returned to their normal position.) The graft graft thrombosis. This event is rare, but when it occurs, prompt
recognition is essential to prevent intestinal infarction. Kinking based contrast angiography is optimal for evaluating the bypass
and compression of the graft are the most common causes of this graft and the distal vasculature, allowing identification of anasto-
condition. If the retrograde graft is too long, the redundancy motic stenoses, kinking, or, in the case of autologous grafts, nar-
makes it more susceptible to kinking. Similarly, if the graft is not rowing caused by valves [see Figure 6a]. If a technical defect is dis-
positioned so as to form a gentle C loop, it is at risk for kinking covered, reoperation and correction are required to ensure pro-
when the viscera are returned to their normal position. An ante- longed patency. In the past few years, we have started evaluating
grade graft that is too long is equally at risk for kinking and occlu- selected patients perioperatively with CT angiography. This
sion.When an antegrade bypass is tunneled behind the pancreas, modality is less invasive than traditional contrast angiography, but
an adequate amount of space must be present to ensure that the it still requires administration of contrast material and exposure to
graft is not compressed. In general, prosthetic grafts are more radiation [see Figure 6b].
resistant to kinking and compression than vein grafts are. Duplex ultrasonography has been used for postoperative graft
Identification of perioperative graft occlusion is hindered by surveillance after mesenteric revascularization.18 At present, there
postoperative incisional pain, fluid shifts, fever, and leukocytosis, are no validated criteria for determining what constitute normal
all of which are common in the postoperative period and may velocities within a mesenteric bypass graft. Undoubtedly, duplex-
mask signs of intestinal ischemia. Patients with chronic mesen- derived peak systolic velocities and end-diastolic velocities depend
teric ischemia often have symptoms only when eating and thus on the caliber of the graft, whether the graft supplies both the celi-
may be asymptomatic in the postoperative period until they ac artery and the SMA, and the length of the graft.The lack of val-
resume oral feeding. For these reasons, we advocate evaluating the idating data notwithstanding, we routinely use postoperative
graft early in the postoperative period with either conventional duplex scanning to establish baseline values and to permit com-
contrast angiography or computed tomographic angiography [see parisons for follow-up evaluation of graft patency. If markedly ele-
Outcome Evaluation, below]. vated, focal peak systolic velocities are recorded—especially if they
Additional technical complications may occur as a result of increase on serial examinations—a contrast angiogram should be
clamp placement. Clamping of the supraceliac aorta can lead to obtained to confirm graft stenosis. Duplex scanning can be diffi-
renal atheroemboli or ischemia. These problems can be mini- cult in the early postoperative period because of incisional tender-
mized by using a supraceliac clamp only on an angiographically ness and the increased intra-abdominal gas associated with post-
normal aorta. operative ileus.
Systemic
Myocardial infarction is the most common cause of mortality Procedures for Acute Intestinal Ischemia
in patients treated for mesenteric ischemia. Pulmonary compro-
PREOPERATIVE EVALUATION
mise is also a common systemic complication of mesenteric revas-
cularization. Renal failure after mesenteric revascularization is As in the evaluation of patients with possible chronic mesen-
more common in patients with preoperative renal insufficiency.16 teric ischemia, a high index of suspicion is of primary importance
Mortality is markedly increased when renal failure occurs post- in the evaluation of patients with possible acute mesenteric
operatively.16 Postoperative renal insufficiency can be minimized ischemia [see 6:4 Acute Mesenteric Ischemia]. Most cases of acute
by administering mannitol, furosemide, and, possibly, vasodilators intestinal ischemia result either from thrombosis of a preexisting
intraoperatively. stenotic lesion or from embolization19 (most frequently to the
Patients who undergo mesenteric revascularization occasional- SMA). Cardiac emboli are the most common variety, though
ly experience a profound reperfusion syndrome manifested by aci- tumor emboli20 and atheroemboli are seen as well. Atheroemboli
dosis, pulmonary compromise, and coagulopathy.We recommend generally result from iatrogenically induced cholesterol emboliza-
administering sodium bicarbonate (to minimize the effects of tion caused by aortic catheterization. The prognosis for acute
metabolic acidosis) and mannitol (for its free radical–scavenging intestinal ischemia of embolic origin is more favorable than that
properties) before restoring intestinal perfusion. for ischemia of thrombotic origin. Emboli typically lodge distally
in the SMA distribution, and therefore, the proximal intestine is
OUTCOME EVALUATION
still partially perfused.19 In contrast, thrombotic occlusion occurs
Restoration of pulsatile flow to the small bowel usually results at the origin of the vessel, resulting in complete interruption of
in immediate active peristalsis and intestinal edema. The techni- midgut perfusion.
cal success of surgical revascularization is assessed intraoperative- Acute, severe abdominal pain that is out of proportion to the
ly through visual examination of the intestine and continuous- physical findings is the classic manifestation and is strongly sug-
wave Doppler examination of the distal mesenteric vasculature gestive of intestinal ischemia.The duration of symptoms does not
and the bowel wall. Doppler signals should be heard along the appear to correlate with the degree of intestinal infarction.21
antimesenteric border, and pulses should be palpable in the Peritonitis is initially absent, but vomiting and diarrhea may be
mesentery. Intraoperative duplex scanning may also be used to present, and occult gastric or rectal bleeding may be identified in
visualize anastomotic sites directly.17 as many as 25% of patients.21
Electromagnetic flow measurements can be helpful in evaluat- There are no reliable serum markers for acute intestinal
ing the adequacy of mesenteric revascularization. Such measure- ischemia. Leukocytosis, hyperamylasemia, or elevated lactate lev-
ments must be made after all packs and retractors have been els may be present, but these findings are insensitive and incon-
removed. In most cases, the flow rate through the graft should be sistent. Abdominal radiographs may reveal dilated bowel loops
between 500 and 800 ml/min, but flow rates as high as 1,000 and, occasionally, thickened bowel wall, but these findings are
ml/min may be recorded.12 similarly inconsistent. In theory, duplex ultrasonography may be
To confirm technical success after mesenteric revasculariza- helpful, but in practice, its applicability is often limited by the
tion, we advocate routine postoperative imaging of the graft. gaseous visceral distention frequently associated with acute
Ideally, this is done early in the postoperative period. Catheter- intestinal ischemia.
a b
Figure 6 Routine postoperative imaging is performed to confirm technical success after revascu-
larization. (a) Postoperative arteriogram shows iliac artery–SMA saphenous vein graft with kink
(arrow).This problem was asymptomatic and was corrected by reoperation on postoperative day
5. (b) Postoperative CT arteriogram shows retrograde iliac artery–SMA prosthetic graft. C (hook)
configuration of distal anastomosis provides antegrade flow into SMA.
The use of preoperative arteriography to diagnose acute ments of clearly viable bowel are often interspersed with segments
ischemia is controversial. Acute intestinal ischemia is a true surgi- of marginally viable bowel and segments of necrotic bowel.
cal emergency, and delaying treatment to perform arteriography Acutely ischemic bowel that is not yet necrotic may appear decep-
could result in further intestinal infarction. Angiography may be tively normal. Mildly to moderately ischemic bowel may exhibit
considered in patients who have abdominal pain without any other
signs or symptoms of systemic illness [see Figure 7]. In patients
who have rebound tenderness, rigidity, or evidence of toxicity or
shock, emergency exploration is indicated.
OPERATIVE PLANNING
Patients with acute intestinal ischemia who present with evi-

dence of toxicity must be resuscitated expeditiously to ensure that
surgical intervention is not delayed. Once it is determined that
surgery is indicated, no further delay is justified. The patient is
placed supine on the operating table, and the entire abdomen and
both legs are prepared. As in operative treatment of chronic intes-
tinal ischemia, the possibility that autologous vein will be needed
for bypass grafting must be anticipated.
OPERATIVE TECHNIQUE
Intraoperative Considerations
Mesenteric revascularization and bowel resection The
goals of surgical therapy are to restore normal pulsatile inflow, to
ensure that questionably viable bowel is adequately perfused, and
to resect any clearly nonviable bowel. During abdominal explo-
ration, the viability of the intestine and the status of the blood flow
to the SMA are assessed with an eye to determining the appro-
priate treatment. The surgeon should be prepared to perform Figure 7 Preoperative arteriogram shows embolic occlusion of
both intestinal revascularization and intestinal resection. Seg- SMA distal to its origin.
SMA
Divided
Ligament of Treitz
IMA
Figure 8 SMA embolectomy. Exposure of

infrarenal aorta, proximal right common
iliac artery, and proximal SMA is achieved
by intestinal retraction and division of pos-
terior peritoneum, ligament of Treitz, and
base of small bowel mesentery.29
loss of normal sheen, absence of peristalsis, and dull-gray discol- Restoration of normal flow to the SMA can produce remark-
oration. Other objective signs of ischemia are the absence of a pal- able changes in an ischemic bowel. Because these changes do not
pable pulse in the SMA or in its distal branches, the absence of always occur immediately, it is often necessary to preserve ques-
visible pulsations in the mesentery, and the absence of flow on tionably viable portions of the bowel initially and then perform a
continuous-wave Doppler examination of the vessels of the bowel second-look laparotomy within 12 to 36 hours. If the questionably
wall. The small bowel may be deeply cyanotic yet still viable. In viable bowel is not in significantly better condition at the time of
most cases, if there is any doubt, bowel resection should not be the second-look operation, it should be resected. Occasionally,
performed until after revascularization. however, even a third look is prudent. Revascularized intestine
The distribution of ischemic changes provides valuable informa- that was profoundly ischemic may swell dramatically. Temporary
tion about the cause of the ischemia. SMA thrombosis often results abdominal closure with mesh may permit tension-free abdominal
in ischemia to the entire small bowel, with the stomach, the duode- closure, prevent abdominal compartment syndrome, and perhaps
num, and the distal colon spared; in severe cases, the entire foregut even improve intestinal perfusion by reducing intra-abdominal
may be ischemic. In contrast, ischemia secondary to SMA embo- pressure.
lism generally spares the stomach, the duodenum, and the proximal
jejunum because the emboli tend to lodge at the level of the mid- Superior Mesenteric Artery Embolectomy
dle colic artery rather than at the origin of the SMA.The choice of Step 1: incision and initial approach Again, a midline inci-
operation for revascularizing the bowel depends on the underlying sion is made, and a transperitoneal approach is taken.
causative condition. Embolectomy is indicated for arterial embo-
lism, whereas bypass is indicated for thrombotic occlusion. Step 2: exposure of SMA at root of mesentery The SMA
is exposed after division of the ligament of Treitz at the base of the
Revascularization of the acutely ischemic intestine In transverse colon mesentery. The duodenum and the small bowel
patients with very advanced intestinal ischemia, widespread bowel are retracted to the right [see Figure 8].The visceral peritoneum is
necrosis may be obvious.This situation invariably proves fatal, and incised above the ligament of Treitz, just cephalad to the third
thus, revascularization is not indicated. In many patients, howev- portion of the duodenum. The SMA should be readily palpable
er, substantial portions of the bowel are ischemic but not frankly in this location as it crosses over the third portion of the duode-
necrotic. Whether such bowel segments can be restored to viabil- num. The dissection is continued to obtain sufficient proximal
ity cannot be accurately predicted. In most instances, therefore, and distal control of the vessel. Heparin is administered, and the
revascularization should precede resection. vessel is clamped proximally and distally.
b c
Figure 9 SMA embolectomy. (a) Location of embolus

within SMA is identified. (b) Transverse (as shown) or lon-
gitudinal arteriotomy is performed, and embolus is
extracted with balloon catheter. (c) Arteriotomy is closed.
Primary closure (as shown) suffices for transverse arteri-
otomy, but vein patch is usually required for closure of lon-
gitudinal arteriotomy.29
Step 3: arteriotomy An arteriotomy is then made in the patients have fluid within the peritoneal cavity.This finding is not,
SMA. The incision may be either transverse or longitudinal. We in itself, a contraindication to the use of a prosthetic graft.
prefer to perform a longitudinal arteriotomy if there is any possi- However, if the patient has necrotic bowel that must be resected
bility that a bypass graft may be needed. The arteriotomy should or if perforation has occurred, a prosthetic graft should not be
be made approximately 2 to 3 cm distal to the origin of the SMA, used. In these situations, an autologous vein graft is preferred. A
though alternative placements may be appropriate on occasion, good-quality vein is mandatory; if the saphenous vein is inade-
depending on the anatomy and the estimated location of the quate, the femoral vein may be used instead.
occlusion [see Figures 9a, b]. The techniques of mesenteric bypass for acute intestinal isch-
emia are identical to those for chronic intestinal ischemia. Because
Step 4: embolectomy Proximal embolectomy should be these patients are often acutely ill, it is vital to perform the opera-
performed first to ensure adequate inflow. A 3 or 4 French balloon tion rapidly and efficiently. In the acute setting, bypass to the SMA
catheter is sufficient in most cases. If very good pulsatile inflow is alone is strongly preferred [see Figure 10]. As a rule, a retrograde
not achieved after embolectomy, then thrombosis of a stenotic approach, using the infrarenal aorta or a common iliac artery for
lesion is likely to be the underlying cause of the acute intestinal inflow, is best; the supraceliac aorta is used for inflow only if the
ischemia, and a bypass graft should be placed. Even when inflow infrarenal vessels are unsuitable for this purpose. Even highly cal-
is apparently adequate, a bypass should be strongly considered if cified iliac arteries can be used for inflow, provided that there is no
the proximal SMA is palpably abnormal. significant pressure gradient and that the surgeon is familiar with
The narrowness and fragility of the distal SMA and its branch- intraluminal balloon occlusion techniques for proximal and distal
es can make distal embolectomy particularly challenging. It is control.
best to use a 2 French embolectomy catheter for this procedure.
The catheter must be passed gently, without undue force. Endovascular Techniques
It would seem reasonable that endovascular therapies might
Step 5: closure Once all possible thrombus has been re- come to play a role in the treatment of acute intestinal ischemia,
moved, the arteriotomy is closed. A transverse arteriotomy may be given that a preoperative angiogram is usually feasible in stable pa-
closed primarily with interrupted monofilament sutures [see Figure tients. Several groups have reported treating acute arterial embol-
9c]; however, a longitudinal arteriotomy frequently must be closed ism with intra-arterial thrombolysis22,23; others have reported
with an autologous vein patch. If adequate flow is not restored treating acute embolism, as well as thrombotic occlusion, with
after the clamps are removed, the arteriotomy is used as the distal PTA.24,25 Although a degree of anecdotal success with these tech-
anastomotic site of a bypass graft. niques has been achieved in selected cases, it should be kept in
mind that reliance on endovascular therapy alone for presumed
Superior Mesenteric Artery Bypass acute intestinal ischemia runs the risk of missing bowel necrosis.
Patients with SMA thrombosis who are seen early enough and After endovascular therapy, frequent clinical reevaluation is neces-
who have no intestinal necrosis may undergo SMA bypass graft- sary to identify patients with persistent intestinal ischemia.
ing with a prosthetic conduit. At exploration, many of these Abdominal exploration should be very strongly considered in
a b
Figure 10 SMA bypass. (a) Iliac artery–SMA bypass with prosthetic graft is suitable for cases
in which SMA thrombosis produces ischemic but salvageable bowel. (b) Iliac artery–SMA
bypass with saphenous vein is suitable for cases in which some segments of necrotic or
perforated bowel must be resected.29
most cases, even if the angiographic result of endovascular treat- pulsatile flow in the mesenteric arcades, peristalsis, bleeding from
ment is good. cut surfaces, and, of course, color. In one study, clinical parame-
ters were found to be 82% sensitive and 91% specific for bowel
TROUBLESHOOTING
viability.26
Occasionally, patients present with emboli that have lodged in We routinely use a sterile continuous-wave Doppler ultrasound
the small arterial branches of the SMA.These vessels are often too flow detector to evaluate pulsatile flow on the bowel surface.
small to allow the passage of embolectomy catheters, and bypass Grossly discolored bowel with no Doppler signal after a period of
beyond the point of obstruction frequently is not possible. In these observation should be resected; marginal bowel with no Doppler
situations, resection of marginally viable bowel is the best option. signal is an indication for second-look laparotomy.
As noted (see above), avoidance of graft kinking is crucial for With the fluorescein fluorescence method, 10 to 15 mg/kg of
preventing early graft failure. Graft failure can have an even fluorescein is injected intravenously, and the intestine is inspected
greater adverse effect on bowel viability in the setting of acute with a Wood lamp. A complete absence of fluorescence is diagnos-
ischemia than in the setting of chronic intestinal ischemia. tic of nonviability; rapid, confluent, bright fluorescence is diagnos-
Recovery after revascularization is often prolonged. Early and tic of viability. There is, however, a large gray area between these
prolonged parenteral nutrition may be necessary in patients with two extremes in which interpretation is subjective. In one study,
extensive bowel infarction. Only rarely, however, is lifelong par- the I.V. fluorescein method was found to be 100% sensitive and
enteral nutrition required. specific for detecting nonviable bowel.27 The disadvantages of this
technique are that it requires special equipment and that it expos-
OUTCOME EVALUATION
es the critically ill patient to the risk of an adverse reaction to the
The techniques employed to evaluate the success of mesenteric dye. Other assessment methods (e.g., surface oximetry, infrared
revascularization for acute ischemia include clinical inspection, photoplethysmography, and laser Doppler velocimetry) are avail-
continuous-wave Doppler ultrasonography, and I.V. administra- able, but at present, they are mostly experimental and are not in
tion of fluorescein. Clinical inspection entails visual assessment of general use for evaluation of bowel viability.
References
1. Dunphy JE: Abdominal pain of vascular origin. 12. Taylor LM, Moneta GL, Porter JM: Treatment of 22. Calin GA, Calin S, Ionescu R, et al: Successful local
Am J Med Sci 192:109, 1936 chronic visceral ischemia.Vascular Surgery. Ruther- fibrinolytic treatment and balloon angioplasty in
2. Moneta GL: Diagnosis of intestinal ischemia. Vas- ford RB, Ed.WB Saunders Co, Philadelphia, 2000, superior mesenteric arterial embolism: a case re-
cular Surgery. Rutherford RB, Ed. WB Saunders p 1532 port and literature review. Hepatogastroenterol-
Co, Philadelphia, 2000, p 1501 13. Odurny A, Sniderman KW, Colapinto RF: Intesti- ogy 50:732, 2003
3. Moneta GL, Yeager RA, Dalman R, et al: Duplex nal angina: percutaneous transluminal angioplasty 23. Michel C, Laffy P, Leblanc G, et al: Intra-arterial
ultrasound criteria for diagnosis of splanchnic ar- of the celiac and superior mesenteric arteries. fibrinolytic therapy for acute mesenteric ischemia.
tery stenosis or occlusion. J Vasc Surg 14:511, 1991 Radiology 167:59, 1988
J Radiol 82:55, 2001
4. Nicholls SC, Kohler TR, Martin RL, et al: Use of 14. Allen RC, Martin GH, Rees CR, et al: Mesenteric
24. Yilmaz S, Gurkan A, Erdogan O, et al: Endovascu-
hemodynamic parameters in the diagnosis of mes- angioplasty in the treatment of chronic intestinal
ischemia. J Vasc Surg 24:415, 1996 lar treatment of an acute superior mesenteric
enteric insufficiency. J Vasc Surg 3:507, 1986 artery occlusion following failed surgical embolec-
5. Shaw RS, Maynard EP III: Acute and chronic 15. Sharafuddin MJ, Olson CH, Sun S, et al: Endo- tomy. J Endovasc Ther 10:386, 2003
thrombosis of the mesenteric arteries associated vascular treatment of celiac and mesenteric artery
with malabsorption: a report of two cases success- stenoses: applications and results. J Vasc Surg 38: 25. Brountzos EN, Critselis A, Magoulas D, et al:
fully treated by thromboendarterectomy. N Engl J 692, 2003 Emergency endovascular treatment of a superior
Med 258:874, 1958 16. Mateo RB, O’Hara PJ, Hertzer NR, et al: Elective mesenteric artery occlusion. Cardiovasc Intervent
surgical treatment of symptomatic chronic mesen- Radiol 24:57, 2001
6. Hansen HJB: Abdominal angina: results of arterial
reconstruction in 12 patients. Acta Chir Scand 142: teric occlusive disease: early results and late out- 26. Bulkley GB, Zuidema GD, Hamilton SR, et al:
319, 1976 comes. J Vasc Surg 29:821, 1999 Intraoperative determination of small bowel viabil-
7. Stoney RJ, Ehrenfeld WK,Wylie EJ: Revasculariza- 17. Leke MA, Hood DB, Rowe VL, et al: Technical ity following ischemic injury: a prospective, con-
tion methods in chronic visceral ischemia. Ann Surg consideration in the management of chronic trolled trial of two adjuvant methods (Doppler and
186:468, 1977 mesenteric ischemia. Am Surg 68:1088, 2002 fluorescein) compared with standard clinical judg-
18. Nicoloff AD, Williamson WK, Moneta GL, et al: ment. Ann Surg 193:628, 1981
8. McAfee MK, Cherry KJ, Naessens JM, et al: Influ-
ence of complete revascularization on chronic mes- Duplex ultrasonography in evaluation of splanch- 27. Carter MS, Fantini GA, Sammartano RJ, et al:
enteric ischemia. Am J Surg 164:220, 1992 nic artery stenosis. Surg Clin North Am 77:339, Qualitative and quantitative fluorescein fluores-
1997 cence in determining intestinal viability. Am J Surg
9. Foley MI, Moneta GL, Abou-Zamzam AM, et al:
Revascularization of the superior mesenteric artery 19. Taylor LM, Moneta GL, Porter JM: Treatment of 147:117, 1984
alone for treatment of intestinal ischemia. J Vasc acute intestinal ischemia caused by arterial occlu- 28. Taylor LM Jr, Porter JM: Treatment of chronic
Surg 32:37, 2000 sions. Vascular Surgery. Rutherford RB, Ed. WB
intestinal ischemia. Semin Vasc Surg 3:186, 1990
Saunders Co, Philadelphia, 2000, p 1512
10. Park WM, Cherry KJ, Chua HK, et al: Current
29. Kazmers A: Operative management of acute mesen-
results of open revascularization for chronic 20. Low DE, Frenkel VJ, Manley PN, et al: Embolic
mesenteric infarction: a unique initial manifesta- teric ischemia. Ann Vasc Surg 12:187, 1998
mesenteric ischemia: a standard for comparison. J
Vasc Surg 35:853, 2002 tion of renal cell carcinoma. Surgery 106:925,
11. Murray SP, Ramos TK, Stoney RJ: Surgery of the 1989
celiac and mesenteric arteries. Haimovici’s Vas- 21. Ottinger LW: The surgical management of acute Acknowledgment
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Malden, Massachusetts, 2004, p 861 Surg 188:72L, 1978 Figures 4, 5, 8, 9, and 10 Alice Y. Chen.
6 VASCULAR SYSTEM 17 REPAIR OF FEMORAL AND POPLITEAL ARTERY ANEURYSMS — 1
17 REPAIR OF FEMORAL AND

POPLITEAL ARTERY ANEURYSMS
Amir Kaviani, M.D., and Patrick J. O’Hara, M.D., F.A.C.S.
Femoral and popliteal artery aneurysms constitute the majority of ponents of the management of femoral and popliteal artery aneu-
peripheral aneurysms. Recognition of these aneurysms is increas- rysms, with specific attention to preoperative planning and intra-
ing, perhaps because of better surveillance of the aging popula- operative exposure and technique.
tion, as well as improvements in and more widespread use of vas-
cular imaging modalities.1 Femoral and popliteal aneurysms
rarely rupture, but they have a significant potential for limb- Repair of Femoral Artery Aneurysms
threatening complications such as embolization and thrombosis. True (degenerative) aneurysms of the femoral artery are rela-
Large aneurysms can also exert a mass effect and thereby cause tively unusual.They are generally confined to the common femoral
compression of veins or nerves. artery, but in approximately 50% of cases, they extend to the
In general, with both femoral and popliteal aneurysms, elective femoral artery bifurcation. According to a classification scheme
repair and reconstruction tend to be associated with significantly proposed by Cutler and Darling in 1973, femoral artery aneu-
better postoperative outcomes than is emergency repair undertak- rysms are classified as type I if they are confined to the common
en after a limb-threatening complication. Specific treatment deci- femoral artery and as type II if they involve the orifice of the pro-
sions may be influenced by the presence or absence of symptoms funda femoris artery.5 This classification scheme is convenient for
of aneurysmal disease.There is little disagreement regarding opti- the discussion of operative repair, in that type II aneurysms fre-
mal management of symptomatic femoral or popliteal aneurysms, quently necessitate more extensive surgical reconstruction than
but there is some controversy regarding optimal management of type I aneurysms do.
aneurysms that are asymptomatic when detected, especially if they Like peripheral aneurysms elsewhere, true femoral artery aneu-
are small. The extent of aneurysmal disease may also influence rysms are frequently associated with abdominal aortic aneurysms,
management choices. For example, a more extensive and complex as well as with aneurysms in other locations. In a large series of
reconstruction is required for treatment of diffuse arteriomegaly patients with multiple aneurysms, 95% of patients with a femoral
than is necessary for treatment of a focal femoral or popliteal artery aneurysm had a second aneurysm, 92% had an aortoiliac
aneurysm. aneurysm, and 62% had an aneurysm in the contralateral femoral
Lower extremity aneurysms may be either true aneurysms, in artery.6 The natural history of these lesions is not fully under-
which the degenerative process involves all three layers of the arte- stood; it may be relatively benign unless they are symptomatic or
rial wall, or pseudoaneurysms, which result from trauma, anasto- large at presentation.
motic disruption, or infection. The pathogenesis of true (i.e., de- Femoral pseudoaneurysms, on the other hand, are increasing-
generative) lower extremity aneurysmal disease has not been defin- ly encountered after trauma (e.g., iatrogenic catheter injury) or
itively established, but it is known that the disease is much more after arterial reconstruction.These lesions, especially those arising
common in men than in women; in fact, men with true femoral or from disrupted anastomoses, are thought to have a more ominous
popliteal aneurysms may outnumber women with such lesions by course if untreated. Aneurysms confined to the superficial femoral
more than 30 to 1.2,3 One of the factors proposed as a possible artery or the profunda femoris artery alone are distinctly unusual
contributor to aneurysm formation is turbulent flow beyond a rel- and are often of mycotic or traumatic origin.
ative stenosis. At the groin, the inguinal ligament may act as a con-
stricting band, and at the popliteal level, the tendinous hiatus, the
heads of the gastrocnemius, and the popliteal ligament may com- Asymptomatic patients may present with a smooth, fusiform,
press the artery in certain susceptible individuals. In addition, there nontender, pulsatile mass discovered either during physical exam-
is evidence for the existence of a genetic predisposition to true ination or incidentally on imaging studies done for other reasons.
aneurysm formation in the femoral and popliteal arteries, in view Symptoms may result from local compression of the femoral
of the demonstrated association of femoral and popliteal aneu- nerve, which causes pain in the groin or the anterior thigh, or
rysms with abdominal aortic aneurysms.4 Accordingly, all patients compression of the femoral vein, which may be associated with
presenting with femoral or popliteal aneurysms should be careful- lower extremity edema and skin changes suggestive of venous sta-
ly evaluated for other aneurysms, especially in the aortoiliac seg- sis. Arterial symptoms (e.g., claudication or lower extremity isch-
ment and in the contralateral limb. emia) may be present in as many as 40% of patients with femoral
Regardless of the underlying cause of disease, repair of periph- artery aneurysms. Atheroemboli originating from the aneurysm
eral artery aneurysms follows the same basic principles applicable can cause painful ischemic lesions; however, such lesions may also
to repair of aneurysms in other locations. Specifically, the objec- be partly a result of concomitant atherosclerotic occlusive disease
tives of treatment are (1) to eliminate the embolic source, (2) to rather than a direct result of the aneurysm itself.6
minimize the risk of rupture, (3) to eliminate the mass effect pro- Complications of femoral artery aneurysms include thrombosis,
duced by the aneurysm (if present), (4) to restore adequate distal embolization, and rupture. In one series of 45 patients with 63
limb perfusion, and (5) to accomplish all of the preceding objec- aneurysms, nearly one half (47%) of the patients had experienced
tives in a durable fashion. In what follows, we describe key com- a complication by the time of initial presentation.4 Acute thrombo-
the outflow bed may compromise blood flow to the entire limb,
resulting in limb-threatening ischemia. Rupture of a femoral
pseudoaneurysm is not unusual, especially if the lesion is enlarg-
ing. Rupture of a true femoral artery aneurysm, however, is a rel-
atively uncommon event, with reported rupture rates ranging
from 1% to 12%, and is accompanied by severe groin pain, ec-
chymosis, and swelling.3,6
Femoral artery aneurysms can usually be diagnosed by means
of physical examination alone. Ultrasonography is a useful ad-
junctive measure for delineating the aneurysm, as well as for
screening patients for associated popliteal or aortoiliac aneurysms
[see Figure 2a]. CT and MRI scans can be helpful in delineating
the extent and morphology of the aneurysm, as well as the status
of the adjacent arteries, especially in obese patients [see Figure 2b].
Once the diagnosis has been made, angiography should be per-
formed to establish the extent of aneurysmal and associated
occlusive or embolic disease by providing detailed information
about the inflow and outflow vessels [see Figure 3]. In selected cir-
cumstances (e.g., the presence of recent thrombosis of the out-
flow bed), arteriography may provide the opportunity for a trial
of thrombolytic therapy to improve outflow. Good judgment
Figure 1 Shown is an example of extensive atheroembolization must be exercised, however, in that there may not be enough time
to the foot. The source of the atheromatous debris may be a prox- for adequate thrombolysis if the limb is severely ischemic.
imal aneurysm or an ulcerating atherosclerotic lesion. Finally, preoperative evaluation should include careful assess-
ment and optimization of comorbid medical conditions often pre-
sent in patients with femoral artery aneurysms. Because cardiac
sis, because it involves compromise of both the profunda femoris complications are a major source of early postoperative and late
artery and the superficial femoral artery, may result in a critically morbidity in this population, special emphasis should be placed
threatened limb that initially exhibits sensory or motor deficits and on evaluating patients for associated coronary artery disease by
eventually manifests frank gangrene. Acute thrombosis secondary means of cardiac stress testing or coronary angiography and on
to a femoral artery aneurysm is associated with substantial mor- following evaluation with appropriate treatment when indicated.
bidity: limb loss is reported to occur in more than 28% of cases.6 Similarly, imaging of the contralateral limb and the aortoiliac ves-
Patients with gradual or chronic thrombosis, who have had time to sels is prudent to detect associated aneurysms and establish treat-
develop collateral circulation, may present with claudication. ment priorities.
Embolization from a femoral artery aneurysm may be clinical-
OPERATIVE PLANNING
ly silent or, if extensive, may present as the so-called blue toe syn-
drome [see 6:5 Pulseless Extremity and Atheroembolism]. Embolic Repair is clearly indicated for all symptomatic femoral aneu-
debris originating in the aneurysm may lodge in the digital arter- rysms, irrespective of cause. Patients who present with limb-threat-
ies or obstruct the microcirculation, leading to characteristic ening complications require expeditious intervention. Asympto-
painful distal ischemic lesions, despite the presence of palpable matic femoral pseudoaneurysms should also be repaired once the
distal pulses [see Figure 1]. In more severe cases, obstruction of diagnosis is established because they are often associated with
a b
Figure 2 (a) Shown is a duplex ultrasonogram of a left common femoral artery aneurysm (sagittal view).
(b) Shown is a CT scan of a left common femoral aneurysm (arrow). In practice, multiple slices are used to
delineate the proximal and distal extent of the aneurysm.
appears that symptomatic lesions tend to be larger than asympto-

matic ones. Most surgeons, however, would probably agree that
true femoral artery aneurysms larger than 2.5 cm in diameter
should be repaired in good-risk patients, especially if the aneurysm
is known to have enlarged. Smaller asymptomatic true femoral
artery aneurysms, particularly in high-risk patients, should be fol-
lowed, with intervention reserved for cases in which symptoms
develop or the lesion enlarges significantly. On occasion, it may also
be necessary to repair a small asymptomatic true femoral aneurysm
in conjunction with an aortofemoral or femoropopliteal bypass
graft procedure in order to avoid performing an anastomosis to a
diseased artery.
OPERATIVE TECHNIQUE
At present, endovascular approaches to definitive treatment of

femoral artery aneurysms are limited because the femoral artery
crosses the groin crease and is subject to repeated flexion and
extension stresses in this location. Current endoprostheses are
likely to fail at this site because of kinking, migration, or metal
fatigue. Furthermore, the femoral incision required for standard
surgical repair is not extensive and is usually well tolerated by most
patients. Consequently, the potential advantages of an endo-
vascular approach are less apparent with respect to the repair of
femoral artery aneurysms than they are with respect to repair of
abdominal or thoracic aneurysms.
Small femoral pseudoaneurysms arising after catheter diagnos-
Figure 3 Anteroposterior arteriogram demonstrates a localized
tic or interventional procedures may resolve over time or, some-
common femoral artery aneurysm (arrow).
times, may be managed with ultrasound-guided compression or
thrombin injection at the time of diagnostic imaging. Surgical
repair is usually reserved for pseudoaneurysms that enlarge,
complications. Currently, however, there is no firm consensus on become symptomatic, or do not resolve spontaneously [see Figure
the indications for treatment of asymptomatic true femoral 4]. A potential advantage of open repair of large pseudo-
aneurysms, because the natural history of these lesions is not aneurysms is the capacity for decompression of large hematomas,
known with certainty and is thought to be relatively benign. Fur- which may be especially important if continued anticoagulation is
thermore, no specific aneurysm size has been identified at which likely to be required.
the incidence of complications increases dramatically, though it The common femoral artery may be approached through
a Pseudoaneurysm b c d e
New Femoral
Aneurysm
Diffuse
Pseudoaneurysm Disease
Figure 4 Repair of femoral artery aneurysms (pseudoaneurysms) (a). Depicted are commonly employed options for repair
of femoral artery pseudoaneurysms: (b) primary closure and (c) patch angioplasty with either autogenous or synthetic patch
material. Also depicted is repair of anastomotic femoral pseudoaneurysms (d). An interposition graft is placed to the profun-
da femoris (e), and a jump graft is placed to the superficial femoral artery.
e
a
Figure 5 Repair of femoral artery aneurysms (type II true aneurysms) (a). Depicted are commonly employed options for
repair of true femoral artery aneurysms involving the origins of the profunda femoris and superficial femoral arteries
(type II femoral aneurysms). (b) The profunda femoris artery may be implanted into an interposition graft placed to the
superficial femoral artery. (c) The superficial femoral artery may be implanted into an interposition graft placed to the
profunda femoris artery. (d) An interposition graft may be placed to the profunda femoris artery, with a jump graft to the
superficial femoral artery. Alternatively, the superficial femoral artery may be reimplanted into the interposition graft if
there is sufficient length to allow the reconstruction to be performed without tension. (e) Syndactylization of the profunda
femoris and superficial femoral arteries may be done to form a common outflow channel for a synthetic interposition
graft originating from the common femoral artery or the distal external iliac artery.
either a longitudinal or an oblique incision over the femoral artery. or as the origin of a femorodistal bypass graft [see 6:18
The usual preference, however, is a longitudinal incision angled Infrainguinal Arterial Procedures].
approximately 20° medially, which permits exposure of the distal If the femoral aneurysm is more extensive, a bypass from the
profunda femoris artery without the creation of a skin flap. Both common femoral artery to the profunda femoris artery with a
the distal extent of the femoral aneurysm and the degree of asso- jump graft to the superficial femoral artery is usually preferred [see
ciated occlusive disease may influence the configuration of open Figures 5d and 7]. This approach allows the surgeon to work
surgical repair [see Figure 5]. Type I aneurysms, which spare the sequentially from the deep tissue planes to the more superficial
origins of the profunda femoris and superficial femoral arteries, ones.
are usually managed by constructing a short interposition graft Alternatively, some surgeons favor implantation of the distal
with the proximal anastomosis at the level of the distal external profunda femoris artery into an interposition graft placed be-
iliac artery or the proximal common femoral artery [see Figure 6]. tween the common femoral artery and the superficial femoral
Occasionally, if proximal control of the retroperitoneal iliac artery artery [see Figure 5b]. Others have described joining the superficial
is required, a flank incision may be needed. When it is necessary and deep femoral arteries at their bifurcation to form a common
to repair additional proximal or distal aneurysms, the short outflow tract that serves as the distal anastomotic end point for
femoral interposition graft may also act as the recipient of an the interposition graft, a technique sometimes referred to as syn-
aortofemoral or iliofemoral graft [see 6:12 Aortoiliac Reconstruction] dactylization [see Figure 5e]. Application of these two methods
a b
Figure 6 Repair of femoral artery aneurysms (type I true aneurysms). Shown is a type I true aneurysm
of the common femoral artery (a) before and (b) after reconstruction with a Dacron interposition graft.
may be hampered by the presence of associated occlusive disease, ty ranges from 0 (for isolated asymptomatic femoral aneurysm
which is frequently present. Nevertheless, the surgeon should be repair) to approximately 4% (if aneurysm repair is combined with
familiar with all of the available options for reconstruction and more extensive aortic procedures).5-7 The reported 5-year paten-
should be prepared to adapt his or her choice of reconstruction cy rate for saphenous vein and Dacron interposition grafts used
method to the details of the local anatomy. for repair of isolated femoral artery aneurysms is 80% to 83%.5,7
For treatment of noninfected femoral aneurysms, especially In general, patients who are operated on before they show evi-
anastomotic pseudoaneurysms, synthetic grafts have been used dence of impaired limb perfusion fare better than those present-
with good results; they usually offer a better size match with the ing with lower extremity complications.6
native femoral arteries [see Figure 4d]. If local infection is present
or the potential for wound complications is high, autogenous
grafts are preferred. Repair of Popliteal Artery Aneurysms
OUTCOME EVALUATION
Aneurysms of the popliteal artery are the most commonly en-
countered peripheral aneurysms. Unlike femoral aneurysms,
The results of operative repair of femoral artery aneurysms are popliteal aneurysms are more likely to be true (i.e., degenerative)
generally excellent. In published series, the perioperative mortali- aneurysms than pseudoaneurysms.True popliteal aneurysms typ-
ically occur in men in their fifth and sixth decades. Their clinical
importance lies in their propensity to cause limb-threatening
complications. When true popliteal aneurysms are left untreated,
the future incidence of thromboembolic events in initially asymp-
tomatic patients is high. In one series of patients who were man-
aged conservatively, only 32% had no complications at 5 years’
follow-up.8 Multiple aneurysms are common in this population,
and it has been reported that nearly 50% of patients presenting
with a popliteal aneurysm have associated abdominal aortic
aneurysms and that 40% may also have coexisting femoral artery
aneurysms.4,8,9 In the largest reported series, 70% of these
patients had a popliteal artery aneurysm in the contralateral
extremity.10 The clear link between the presence of popliteal
aneurysms and the presence of other associated aneurysms
underscores the importance of careful investigation of all patients
who present with a newly diagnosed popliteal artery aneurysm. In
Figure 7 Repair of femoral artery aneurysms (type II true
approximately 50% of cases, popliteal artery aneurysms are con-
aneurysms). Shown is the repair of a type II femoral artery fined to the popliteal artery itself; in the remaining cases, aneurys-
aneurysm with a Dacron interposition graft to the profunda mal degeneration may extend proximally to involve the superficial
femoris artery and a polytetrafluoroethylene (PTFE) jump graft femoral artery or distally down to the level of the tibioperoneal
to the superficial femoral artery. trunk.9
Popliteal artery aneurysms may be asymptomatic on initial pre-

sentation. The diagnosis is usually suspected on the basis of the
detection of a prominent pulsatile mass behind the knee during
physical examination. The mass is often best felt with the knee in
a slightly flexed position. Small aneurysms may be more difficult
to detect during physical examination, especially if thrombosis has
already occurred. A high index of suspicion, usually based on
recognition of an aneurysm in another location, is helpful in iden-
tifying these lesions.
The most frequent initial presentation of a symptomatic pop-
liteal aneurysm is the development of acute limb-threatening is-
chemia as a consequence of arterial occlusion from thrombosis of
the aneurysm or distal embolization.9,11 Early manifestations (i.e.,
those occurring before complete occlusion of the popliteal artery
itself) may be limited to painful petechial hemorrhages or localized
gangrenous changes in the digital arteries that result from Figure 8 Repair of popliteal artery aneurysms. Ultrasonographic
microembolization [see Figure 1]. In some series, claudication has examination of the right popliteal artery demonstrates a 2.6 cm
been a presenting symptom in 40% to 75% of patients with right popliteal artery aneurysm, shown in both sagittal (left) and
popliteal aneurysms.9 Rupture is a distinctly unusual event: fewer transverse (right) views.
than 5% of patients present with this complication.9 In rare
instances, patients with very large popliteal aneurysms may pre- it can delineate the extent of aneurysmal involvement of the
sent with symptoms resulting from compression of adjacent struc- popliteal and adjacent arteries and detect the presence of associ-
tures, such as paresthesias or neuropraxia involving the lower leg ated occlusive disease [see Figure 9]. In addition, as noted (see
(from direct popliteal nerve compression) or deep vein thrombo- above), it may facilitate the use of adjunctive thrombolytic thera-
sis, superficial varicosity formation, and phlebitis (from popliteal py, which may be particularly beneficial if the outflow bed has
vein compression). been severely compromised by distal thrombosis or embolization.
Plain radiographs of the knee may demonstrate calcium in the The goal of thrombolysis of occluded outflow vessels is to uncov-
aneurysm wall; however, once the diagnosis is suspected, it is best er a suitable target vessel that can be used to provide outflow for a
confirmed by means of ultrasonography [see Figure 8], computed surgical bypass; this modality is particularly useful in this setting,
tomography, or magnetic resonance imaging. These imaging mo- in that intraoperative balloon thromboembolectomy sometimes
dalities are particularly helpful in distinguishing popliteal aneur- cannot clear sufficient thrombus from small vessels to maintain
ysms from other space-occupying lesions of the popliteal fossa long-term graft patency. In one study of selected patients with
(e.g., Baker’s cyst). poor outflow, thrombolytic therapy followed by surgical repair
Angiography is less useful for the diagnosis of popliteal artery yielded results that compared favorably with those of isolated sur-
aneurysms: it demonstrates only the flow channel of the vessel, gical repair, and the combined approach was associated with lower
and any intramural thrombus that is present may obscure the pres- amputation rates.12 It should be kept in mind, however, that
ence of the popliteal aneurysm. Nevertheless, angiography plays a thrombolytic therapy is more rapid and effective if thrombosis is
valuable role in the planning of operative reconstruction because recent and the volume of thrombus is not large. If limb ischemia
a b
Figure 9 Repair of popliteal

artery aneurysms. Preoperative
arteriograms illustrate two
common varieties of popliteal
artery aneurysm. Extent of dis-
ease influences choice of recon-
struction. (a) The aneurysm is
localized to the popliteal artery.
(b) Arteriomegaly extends
proximally to involve the super-
ficial femoral artery.
Vastus Medialis
Popliteal Artery
Medial Approach
Popliteal Vein
Tibial Nerve
Sartorius
Medial Head of
Gastrocnemius
Popliteal Artery
Popliteal Vein
Figure 10 Repair of popliteal artery

aneurysms. Depicted is the medial
Sartorius
approach to the popliteal artery, which
can afford complete exposure of the Tibial Nerve
vessel.
Popliteal Veins
Cut Heads of
Gastrocnemius
is severe, the length of time required to establish reperfusion may greater than 2 cm, the presence of mural thrombus, and poor dis-
be prohibitive, and it may be best to proceed with direct surgical tal lower extremity runoff were significant predictors of the devel-
intervention before irreversible tissue loss occurs. opment of symptoms. In a meta-analysis of the published literature
In patients with popliteal artery aneurysms, as in those with that encompassed nearly 2,500 popliteal artery aneurysms, nearly
femoral artery aneurysms, there is a high incidence of associated 35% of the patients who were treated conservatively eventually
atherosclerotic disorders: nearly 50% have some degree of myo- experienced ischemic complications, and 25% of the patients who
cardial dysfunction, and nearly two thirds are hypertensive.13 required surgical treatment for an ischemic complication eventual-
Consequently, preoperative evaluation of patients under consider- ly required amputation.15 Given these results, most surgeons
ation for popliteal aneurysm repair should include careful opti- would agree that surgical repair of asymptomatic popliteal artery
mization of associated coexisting medical conditions, especially aneurysms is indicated for all but extremely high risk patients.
associated coronary artery disease. Although the likelihood that popliteal aneurysms will give rise
to complications does not appear to be related to the size of the
OPERATIVE PLANNING
aneurysms, optimal management of small asymptomatic popliteal
There is a consensus that all patients with symptomatic popli- aneurysms remains controversial—in part because of problems
teal aneurysms should undergo expeditious operative repair; con- with their definition, especially in the presence of generalized arte-
servative management in these cases is associated with a substan- riomegaly. Factors believed to be associated with the eventual
tial risk of limb loss, especially in the presence of limb-threatening development of ischemic complications include size greater than 2
ischemia. There is also general agreement that asymptomatic cm, deformation of the artery itself, and the existence of intralu-
popliteal aneurysms should be repaired upon diagnosis; such minal thrombus. The presence of these factors, especially if the
lesions are associated with the development of limb-threatening popliteal aneurysm is localized, makes a case for operative repair.
complications in a substantial number of patients. In a series of 94
OPERATIVE TECHNIQUE
patients with asymptomatic popliteal artery aneurysms who were
followed for nearly 7 years, 18% of the limbs with aneurysms even- The primary therapeutic objectives of popliteal artery aneu-
tually became symptomatic (25% acutely and 75% chronically), rysm repair are (1) to eliminate the aneurysm as a source of em-
and 4% had to be amputated.14 In this cohort, aneurysm size boli or thrombosis and (2) to maintain distal perfusion in a dur-
Popliteal Vein
Popliteal Artery
Sciatic Nerve
Common
Peroneal Nerve
Tibial Nerve
Figure 11 Repair of Popliteus

popliteal artery aneurysms.
Depicted is the posterior
approach to the popliteal
fossa.
Popliteal
Veins
a b c d
Figure 12 Repair of popliteal artery aneurysms (a). Depicted are various bypass configurations that can be employed
for repair of popliteal aneurysms. (b) An interposition graft may be placed within a large aneurysm. (c) If the graft and
the artery are sufficiently well matched in terms of size, ligation and bypass of the aneurysm with end-to-end proximal
and distal anastomoses may be employed. (d) If there is a significant size mismatch between the graft and the artery,
ligation and bypass of the aneurysm with an end-to-side proximal anastomosis may be employed.
a b
Figure 13 Repair of popliteal artery aneurysms. (a) Operative photograph shows a large popliteal
aneurysm (arrow) exposed via the medial approach. (b) A PTFE interposition graft (arrow) is placed within
the aneurysm sac, which has been decompressed. Saphenous vein is the preferred graft material, but a syn-
thetic conduit may be required if the autogenous conduit is unavailable or inadequate. Collateral inflow into
the sac has been interrupted.
able fashion. Other objectives are to prevent hemorrhage result-

ing from rupture, to eliminate the mass effect exerted by large
aneurysms, and to prevent recurrence. Several reports have eval-
uated endovascular treatment of popliteal aneurysms with cov-
ered stents delivered under fluoroscopic guidance16,17; however,
to date, the results have been inferior to those of open surgical
treatment. At present, endovascular treatment of popliteal
aneurysms remains investigational and should be confined to
those patients who are considered to be at unacceptable risk with
standard surgical therapy. If endovascular therapy is employed,
close late follow-up is necessary to detect fracture or migration of
the stent, as well as expansion or thrombosis of the aneurysm.
The two most important factors influencing the surgical
approach to popliteal aneurysm repair and the configuration of
the reconstruction used are (1) the extent of the aneurysmal dis-
ease and (2) the size of the aneurysm. In most settings, the medi-
al approach with the patient in the supine position is preferred.
This approach allows exposure of the entire popliteal artery, if
necessary, through division of the semimembranosus, semitendi-
nosus, and gastrocnemius tendons, which can be repaired at the
time of closure. In addition, it offers the most flexibility for
expanding the reconstruction if the aneurysm is large, extensive,
or multilobed [see Figure 10]. The posterior approach to the
popliteal artery, which is favored by some surgeons, can also pro-
vide adequate exposure of localized popliteal aneurysms, but it
requires that the patient be prone [see Figure 11]. Although it is
well tolerated, the posterior approach precludes exposure of the Figure 14 Repair of
common and superficial femoral arteries or the greater saphenous popliteal artery aneurysms.
vein and offers less flexibility for proximal or distal extension. When femoral and popliteal
Familiarity with both approaches permits the vascular surgeon to aneurysms are accompanied
choose the one that best suits the given clinical situation. by diffuse arteriomegaly or
A small, localized popliteal artery aneurysm with few side associated arterial occlusive
disease, more extensive
branches may be treated with simple proximal and distal ligation
reconstructions are
of the aneurysm sac, accompanied by construction of a bypass required. For example, as
graft with a short segment of autologous saphenous vein. The shown, a femoral interposi-
venous graft may be tunneled in the anatomic position, deep to tion graft may provide the
the medial head of the gastrocnemius muscle. The proximal and inflow for an infrapopliteal
distal anastomoses are fashioned in either an end-to-end or an bypass.
end-to-side configuration, depending on the compatibility of the
graft’s diameter with that of the artery [see Figure 12].
As a rule, grafts constructed from autogenous vein are pre-

ferred, but synthetic grafts may be required if the autogenous vein
is unavailable or inadequate. An effort should be made to keep
graft length to the minimum necessary to treat the aneurysmal
disease. Intraoperative completion angiography is recommended
to allow detection and correction of technical problems with the
reconstruction before closure [see Figure 15].
OUTCOME EVALUATION
In a study from the Cleveland Clinic that described the surgi-

cal management of 110 popliteal aneurysms, there were eight
(7.3%) early postoperative deaths.9 Six (75%) of the eight early
postoperative deaths were attributable to cardiac complications—
an observation that highlights the need for careful cardiac evalua-
tion, when feasible, before the treatment of popliteal artery
aneurysms.
The presence of symptoms, the adequacy of the outflow bed on
presentation, and the choice of autogenous graft material for
reconstruction are the main factors that influence limb salvage
and graft patency rates after repair of popliteal artery aneurysms.
In one study, the 5-year patency rate for saphenous vein grafts was
92% for patients who had asymptomatic popliteal aneurysms and
in whom good outflow vessels were identified, compared with
66% for a matched cohort with known occlusive disease.18 In
other studies that included similar patients, the 10-year patency
rate was in excess of 80%, and the limb salvage rate was approxi-
mately 95%.9,19
Patients who undergo urgent surgical treatment of popliteal
aneurysms that were symptomatic on presentation have less favor-
able outcomes. In one study, when thrombosis of the popliteal
aneurysm was apparent on presentation or distal outflow was
Figure 15 Repair of popliteal artery aneurysms. Preoperative poor, the 5-year patency rate was approximately 50%, and the
and postoperative arteriograms show a localized popliteal artery
limb salvage rate was only 60%.20 Several studies documented the
aneurysm (arrow, left) and its subsequent repair with a saphe-
nous vein interposition graft (arrow, right).
influence of the choice of conduit graft material on bypass dura-
bility; each demonstrated that patency rates were nearly four times
higher with saphenous vein grafts than with nonvenous alternative
In the case of a large aneurysm for which evacuation of mural grafts.8,14,21 Limb salvage rates were also higher with autogenous
thrombus is required to relieve mass effect symptoms, it may be saphenous vein grafts. For example, in one report, 23% (7/31) of
feasible to construct a short interposition graft [see Figure 13]. the popliteal artery bypasses performed with a prosthetic conduit
Opening the sac also allows ligation of the feeding geniculate resulted in limb loss, whereas only 2% (1/42) performed with a
branches, which may help minimize the risk of late enlargement saphenous vein graft resulted in amputation.14
of the aneurysm sac associated with recurrence of mass effect In the past few years, instances of continued expansion of the
symptoms. popliteal aneurysm sac despite ligation and bypass have been
If the superficial femoral artery is severely involved with occlu- reported.22 This phenomenon may result from inadequate ligation
sive or aneurysmal disease, it may be necessary to construct a long of the aneurysm sac, but it may also result from retrograde perfu-
saphenous vein bypass graft originating from the common fem- sion of the sac via patent geniculate collateral vessels. Conse-
oral artery, in either an in situ or a reversed configuration [see quently, it seems advisable to ligate all large collateral vessels feed-
Figure 14]. The distal anastomotic site is determined on the basis ing the aneurysm sac at the time of the initial aneurysm repair. If
of the preoperative angiographic findings, in conjunction with the aneurysm is large, it may be necessary to perform the ligation
intraoperative assessment. from within the evacuated sac.
References
1. Lawrence PF, Lorenzo-Rivero S, Lyon JL: The Surgical management of popliteal aneurysms: 17. Henry M, Amor M, Beyar R, et al: Clinical expe-
incidence of iliac, femoral, and popliteal artery trends in presentation, treatment, and results rience with a new nitinol self-expanding stent in
aneurysms in hospitalized patients. J Vasc Surg from 1952 to 1984. J Vasc Surg 3:125, 1986 peripheral arteries. J Endovasc Surg 3:369, 1996
22:409, 1995 10. Szilagyi DE, Schwartz RL, Reddy DJ: Popliteal 18. Upchurch GR Jr, Gerhard-Herman MD,
2. Dawson I, Sie R, van Baalen JM, et al: Asympto- arterial aneurysms: their natural history and Sebastian MW, et al: Improved graft patency and
matic popliteal aneurysm: elective operation ver- management. Arch Surg 116:724, 1981 altered remodeling in infrainguinal vein graft
sus conservative follow-up. Br J Surg 81:1504, reconstruction for aneurysmal versus occlusive
11. Whitehouse WM Jr,Wakefield TW, Graham LM,
1994 disease. J Vasc Surg 29:1022, 1999
et al: Limb-threatening potential of arterioscle-
3. Dawson I, Sie RB, van Bockel JH: Atherosclerotic rotic popliteal artery aneurysms. Surgery 19. Roggo A, Brunner U, Ottinger LW, et al: The
popliteal aneurysm. Br J Surg 84:293, 1997 93:694, 1983 continuing challenge of aneurysms of the
4. Dent TL, Lindenauer SM, Ernst CB, et al: Multi- 12. Wyffels PL, DeBord JR, Marshall JS, et al: popliteal artery. Surg Gynecol Obstet 177:56,
ple arteriosclerotic arterial aneurysms. Arch Surg Increased limb salvage with intraoperative and 1993
105:338, 1972 postoperative ankle level urokinase infusion in 20. Lilly MP, Flinn WR, McCarthy WJ 3rd, et al:The
5. Cutler BS, Darling RC: Surgical management of acute lower extremity ischemia. J Vasc Surg 15:
effect of distal arterial anatomy on the success of
arteriosclerotic femoral aneurysms. Surgery 74: 771, 1992
popliteal aneurysm repair. J Vasc Surg 7:653,
764, 1973 13. Bouhoutsos J, Martin P: Popliteal aneurysm: a 1988
6. Graham LM, Zelenock GB, Whitehouse WM Jr, review of 116 cases. Br J Surg 61:469, 1974
21. Hagino RT, Fujitani RM, Dawson DL, et al:
et al: Clinical significance of arteriosclerotic fem- 14. Lowell RC, Gloviczki P, Hallett JW Jr, et al: Does infrapopliteal arterial runoff predict suc-
oral artery aneurysms. Arch Surg 115:502, 1980 Popliteal artery aneurysms: the risk of nonoper- cess for popliteal artery aneurysmorrhaphy? Am
7. Sapienza P, Mingoli A, Feldhaus RJ, et al: Fem- ative management. Ann Vasc Surg 8:14, 1994 J Surg 168:652, 1994
oral artery aneurysms: long-term follow-up and 15. Dawson I, van Bockel JH, Brand R, et al: Popli-
results of surgical treatment. Cardiovasc Surg 22. Ebaugh JL, Morasch MD, Matsumura JS, et al:
teal artery aneurysms: long-term follow-up of Fate of excluded popliteal artery aneurysms. J
4:181, 1996 aneurysmal disease and results of surgical treat- Vasc Surg 37:954, 2003
8. Vermilion BD, Kimmins SA, Pace WG, et al: A ment. J Vasc Surg 13:398, 1991
review of one hundred forty-seven popliteal an- 16. Henry M, Amor M, Ethevenot G, et al: Initial
eurysms with long-term follow-up. Surgery 90:
1009, 1981
experience with the Cragg Endopro System 1 for Acknowledgment
intraluminal treatment of peripheral vascular
9. Anton GE, Hertzer NR, Beven EG, et al: disease. J Endovasc Surg 1:31, 1994 Figures 4, 5, 10, 11, 12, and 14 Alice Y. Chen.
6 VASCULAR SYSTEM 18 INFRAINGUINAL ARTERIAL PROCEDURES — 1
18 INFRAINGUINAL ARTERIAL
PROCEDURES
William D. Suggs, M.D., F.A.C.S., and Frank J.Veith, M.D., F.A.C.S.
Since the early 1980s, there have been enormous advances in ments provide a basis for comparison if the disease subsequent-
the treatment of lower-extremity ischemia secondary to ly progresses and may help determine the approach to be used
infrainguinal arteriosclerosis. Effective interventional manage- to salvage the threatened limb.
ment strategies have been developed for virtually all patterns of
NONINVASIVE TESTING
arteriosclerosis underlying limb-threatening ischemia.1,2
Bypasses to the infrainguinal arteries using segments of autol- Noninvasive tests are helpful in that they provide semiquanti-
ogous vein have become routine for limb salvage. As this tech- tative assessment of the circulation and help confirm the diag-
nique has evolved, the distal limits of revascularization have nosis made on the basis of the history and the physical examina-
been extended. Bypasses to arteries near the ankle or in the tion. Such test measurements include the ankle-brachial index
foot can now be offered to patients who have no patent arter- (ABI) and pulse volume recordings (PVRs).
ies suitable for more proximal bypasses. In addition, bypasses The ABI is determined by dividing the ankle pressure in each
to distal tibial or tarsal vessels may be performed in some lower limb by the higher of the two brachial pressures. Normal
patients whose popliteal arteries are patent but who have three- circulation typically yields an ABI of 1.0 to 1.2; claudication, an
vessel distal occlusive disease and forefoot gangrene.3,4 ABI of 0.40 to 0.95; and limb-threatening ischemia, an ABI of 0
Frequently, patients who require very distal bypasses have to 0.5. It is vital to remember, however, that lower-extremity
already undergone vascular reconstruction; these patients may pressure measurements are less reliable in patients with heavily
be candidates for alternative approaches, such as a popliteal- calcified vessels (e.g., diabetics and patients with end-stage renal
distal bypass or a tibiotibial bypass.5-7 disease). In these patients, ABIs are falsely elevated as a result of
Patients with limbs threatened by distal tibial occlusive disease the higher cuff pressures required to occlude calcified vessels,
present an ongoing challenge to the vascular surgeon. Provided which in some cases are not occluded even with pressures high-
that careful attention is paid to obtaining high-quality preopera- er than 300 mm Hg.
tive angiograms and that the surgeon is willing to consider alter- PVRs are obtained by means of calibrated air-cuff plethysmog-
native approaches, it is generally possible to achieve good results raphy. Standard blood pressure cuffs are placed at different levels
from limb salvage procedures. of the lower extremity, and the increases in pressure within the
It should be kept in mind that only patients with threatened cuffs resulting from the volume increase during systole are
limbs—manifested by rest pain, frank gangrene, or nonhealing recorded as pulse waves. Tracings exhibiting a brisk rise during
ulcers—should be considered candidates for infrainguinal bypass. systole and a dicrotic notch are characterized as normal, those
Patients who have gangrene that extends into the deeper tarsal exhibiting loss of the notch and a more prolonged downslope are
region of the foot, who have a severe organic mental syndrome, characterized as moderately abnormal, and those exhibiting a
or who are nonambulatory are not candidates for limb salvage flattened wave are characterized as severely abnormal. Absolute
surgery and should be treated with primary amputation instead.1,2 amplitudes on PVRs are not directly comparable between
patients; however, serial PVRs from a single patient are highly
reproducible and thus are quite useful for following the course of
Preoperative Evaluation severe peripheral vascular disease in individual cases.4 One disad-
vantage of PVRs is that they cannot differentiate proximal
femoral disease from iliac occlusive disease.8
A careful history and a thorough physical examination are
IMAGING
crucial for accurate assessment of the extent of the patient’s ath-
erosclerotic disease. In the course of the history, the examiner
should pay particular attention to distinguishing true rest pain Duplex Scanning
from other causes of pain (e.g., arthritis and neuritis). Significant Duplex scanning is a useful noninvasive method of assessing
ischemic pain is usually associated not only with decreased puls- the aortoiliac and infrainguinal arterial systems. Several studies
es but also with other manifestations of ischemia (e.g., atrophy, have evaluated the ability of duplex scanning to predict iliac
decreased skin temperature, marked rubor, and pain that is artery stenosis. A 1987 trial found that duplex scanning was
relieved when the foot is dangled). In the course of the physical highly sensitive (89%) and specific (90%) in predicting iliac
examination, the examiner should look for and assess the extent stenosis of 50% or greater.9 Three subsequent trials corroborat-
of any underlying infection and should closely examine any sured these findings, reporting sensitivities ranging from 81% to
gical scars for clues to the nature and extent of any previous vas- 89% and specificities ranging from 88% to 99%.10-12 This non-
cular operations involving the use of the saphenous vein. In addi- invasive modality may be especially useful for improving evalua-
tion, a careful pulse examination should be performed to assess tion of diabetic patients before invasive procedures (e.g., angiog-
the patient’s baseline arterial status; these baseline measure- raphy and angioplasty).10
Duplex scanning has also been used to allow infrapopliteal ishing the risk of contrast nephropathy. Administration of man-
bypasses to be performed without preoperative angiography. In nitol, which has an osmotic diuretic effect, helps prevent contrast
one study, a limb salvage rate of 86% was achieved with this toxicity as well. These measures, coupled with judicious use of
approach, and completion arteriography matched the runoff sta- contrast agents, should minimize renal impairment associated
tus predicted by duplex scanning in 96% of cases.13 In a study with arteriography.
from our own institution, we were able to perform femoro-
popliteal bypasses without preoperative arteriography and were
Femoropopliteal Bypass
able to perform distal bypasses with confirmatory arteriograms
at the time of operation.14 Patients whose limbs are clearly threatened and who have
undergone arteriographic examination should undergo femoro-
Magnetic Resonance Angiography popliteal bypass when the superficial femoral artery or the
Magnetic resonance angiography (MRA), a noninvasive popliteal artery is occluded and when arteriography indicates
modality that does not require contrast agents, often yields good that a patent popliteal artery segment distal to the occlusion has
arterial images and may, in fact, be more sensitive than angiog- luminal continuity with any of its three terminal branches (even
raphy in imaging distal lower-extremity runoff vessels.15,16 More if one or more of these branches ends in an occlusion anywhere
recently, developments such as gadolinium enhancement, mul- in the leg). Even if the popliteal artery segment into which the
tistation examination, and the floating table technique have fur- graft is to be inserted is occluded distally, femoropopliteal bypass
ther improved the resolution of MRA,17-19 to the point where to this segment can be considered.27,28 If the isolated popliteal
many institutions that use current forms of MRA no longer rou- segment is shorter than 7 cm or if there is extensive gangrene or
tinely obtain preoperative angiograms. MRA, in combination infection in the foot, a femorodistal artery bypass or a sequential
with arterial duplex scanning, has the potential to replace con- bypass is sometimes performed in one or two stages.
trast arteriography in the assessment of patients with distal arte- OPERATIVE TECHNIQUE
rial occlusive disease.
Femoropopliteal bypass may be carried out either above or
Arteriography below the knee.
Until MRA and duplex scanning become more widely avail- Above-the-Knee Bypass
able, contrast angiography will remain the gold standard for the
evaluation of patients with distal arterial occlusive disease. A For above-the-knee bypass, the patient is placed in the supine
complete evaluation of the existing arterial disease from the position with the thigh externally rotated and the knee flexed
aorta to the pedal vessels is necessary for diabetic patients, who approximately 30°. This position affords easy exposure of the
frequently have multilevel occlusive disease. Obtaining intra- femoral and popliteal arteries as well as of the saphenous vein.
arterial pressure measurements at the time of angiography sig-
nificantly improves detection of clinically significant stenosis. Harvesting of saphenous vein The greater saphenous
The systolic pressure gradient across the lesion should also be vein is harvested through intermittent skip incisions starting in
measured: gradients greater than 15 mm Hg are considered the groin and proceeding distally toward the knee [see Figure 1].
hemodynamically significant.20 Multiple short skin incisions heal better than a single long one
and are less likely to result in skin necrosis.
In the general population, arteriography has a complication
Dissection of the saphenous vein begins at the groin. This
rate of only 1.7% to 3.3%.21 Elderly patients with severe aor-
proximal incision is also used for exposure of the femoral artery.
toiliac or infrainguinal disease must be carefully evaluated
The saphenofemoral junction is carefully mobilized, and the
before the procedure because they are more likely to experience
tributaries are ligated with fine silk close to where they enter the
local and systemic complications than patients in the general
main trunk, with care taken not to impinge on the wall of the
population are. For the majority of patients, the transfemoral
trunk. As dissection continues distally, the main trunk of the
approach is the safest; however, for patients with weak or non-
saphenous vein is progressively elevated, and all tributaries are
palpable femoral pulses, other approaches (e.g., translumbar,
identified and ligated.The vein is then removed from its bed and
transbrachial, or transaxillary) may be preferable.These alterna-
tive approaches are associated with higher rates of local compli-
cations, including hematomas, pseudoaneurysms, dissections,
thrombosis, and embolization.
Renal insufficiency is an important complication of angiogra-
phy: 6.5% to 8.2% of patients who undergo arteriography expe-
rience some degree of impairment associated with contrast
agents.22,23 Patients who have preexisting azotemia and whose
baseline creatinine concentrations exceed 2.0 mg/dl are at high-
est risk for renal complications after angiography. Elderly patients
typically have lower creatinine clearances for a given serum cre-
atinine level and thus should always be considered at higher risk
for nephrotoxicity. All possible precautions should be taken to
limit the renal insult. There is some evidence to suggest that the
use of low-osmolar contrast agents can decrease the incidence Figure 1 Femoropopliteal bypass: above knee. Shown is the
of renal impairment,24,25 but the data are not unanimous on appropriate position of the leg. Interrupted skin incisions are
this point.26 Adequate hydration and administration of oral made in the thigh and upper leg to permit harvesting of the
acetylcysteine before arteriography are highly effective in dimin- saphenous vein.
Figure 2 Femoropopliteal bypass: above knee. Depicted is exposure of the femoral artery. (a) A curved 4 to
5 in. skin incision is made slightly lateral to the pulsation of the femoral artery. (b) Lymphoadipose tissue is
retracted to expose the deep fascia overlying the course of the femoral artery. (c) The deep fascia is incised,
exposing the femoral arterial sheath, which is then opened along its axis (d). (e) The common and superficial
femoral arteries are mobilized and encircled with Silastic vessel loops.
immediately placed into a basin containing heparinized saline divided lymphatic vessels should be controlled with electrocoag-
(or heparinized whole blood) at a temperature of 4° C or cold ulation or fine ligatures. Self-retaining retractors are placed both
Hanks solution. A small cannula is passed through the distal end proximally and distally in the wound, and the lymphoadipose tis-
of the divided vein, and the vessel is irrigated with cold Hanks sue is gently retracted medially [see Figure 2b].
solution to expel any liquid blood or clot and to locate any leaks. The deep fascia is opened along the femoral artery [see Figure
If a leak is found, it is repaired with 6-0 Prolene. 2c], and the sheath of the artery is opened along its axis [see
Figure 2d]. The common and superficial femoral arteries are
Step 1: exposure of femoral artery A slightly curved skin mobilized, and Silastic loops are placed around them [see Figure
incision, with the concavity facing the medial aspect, is made 2e]. These vessels are then elevated slightly, and the origin of the
starting at a point slightly above the inguinal crease and extend- deep femoral artery comes into view lateral and posterior to the
ing distally for 10 to 12.5 cm [see Figure 2a].The incision should common femoral artery and just proximal to the superficial
be slightly lateral to the pulsation of the femoral artery so as to femoral artery. Dissection of the origin of the deep femoral
avoid the lymphatics as much as possible. Any minor bleeding or artery must be done carefully so as not to injure the collateral
Figure 3 Femoropopliteal bypass: above knee. Depicted is medial exposure of the proximal popliteal artery. (a) An
incision is made in the lower third of the thigh, anterior to the sartorius muscle. (b) The deep fascia is incised, and
the sartorius muscle is retracted posteriorly, allowing the popliteal artery to be readily palpated. (c) The popliteal
arterial sheath is opened, exposing the vessel and its surrounding venules. The adductor magnus tendon may be seen
covering the proximal end of the artery (d), and it may have to be divided (e) to provide better exposure of the
artery. (f) The popliteal artery, freed of the venous plexus, is mobilized between two vessel loops.
vessels coming off the artery at that level and the one or two muscle is detached from the vastus medialis muscle and retract-
branches of the satellite veins that cross the anterior portion of its ed posteriorly.The popliteal artery is identified by palpation; it is
initial segment. If mobilization of the deep femoral artery proves the most superficial structure palpable through this exposure [see
difficult, the satellite vein branches can be divided and ligated. Figure 3b]. The overlying fascia is incised, and the adipose tissue
usually present at this level is dissected until the vascular bundle
Step 2: exposure of proximal popliteal artery For the is reached.
approach to the popliteal artery, the surgeon moves to the oppo- The sheath of the artery is opened [see Figure 3c]. At this level,
site side of the table. An incision is made in the lower third of the there is almost always a network of venules surrounding the
thigh anterior to the sartorius muscle and is extended close to artery, which must be carefully dissected away from the arterial
the medial aspect of the knee [see Figure 3a]. The deep fascia wall. Division of the adductor magnus tendon may be required
anterior to the sartorius muscle is opened, and the sartorius to yield adequate exposure of the proximal portion of the
popliteal artery [see Figures 3d and 3e]. The venous network is

separated from the arterial adventitia, and the various branches
are divided and ligated.The popliteal vein is then separated from
the artery—a process that, because of the intimate connection
between the two vessels, is sometimes quite difficult. In separat-
ing the vein from the artery, care must be taken not to injure any
of the genicular branches of the artery. The popliteal artery is
freed for a length of approximately 1.5 to 2 in., and vessel loops
are placed around it [see Figure 3f].
If the proximal popliteal artery appears markedly sclerotic and
unsuitable for anastomosis to the graft, the exposure must be
extended to the middle portion of the artery. To achieve this
extended exposure, the hamstring muscles and their tendons are
mobilized and retracted posteriorly, and the medial head of the
gastrocnemius muscle is divided close to the medial condyle of
the femur.
Next, the sheath of the popliteal artery is opened farther dis-
tally, and the tributaries of the veins surrounding the artery are
further dissected away from it. Dissection of the middle portion
of the popliteal artery may be facilitated by flexing the knee; this
measure relaxes the artery, thereby allowing it to be readily
drawn closer to the superficial level of the exposure.
Step 3: creation of tunnel Implantation of the graft may

be started in either the popliteal artery or the femoral artery; the
former is our usual preference. Before the anastomoses are con-
structed, a tunnel is created under the sartorius muscle by means
of either a tunneler or an aortic clamp with a red rubber catheter
attached to it to mark the tunnel.
Figure 4 Femoropopliteal bypass: above knee. Shown are
Step 4: construction of distal anastomosis to popliteal details of the anastomotic suturing, which is begun at the distal
artery Heparin is routinely administered before the vascular end and continued to the middle portion of each side of the
anastomosis of the artery and the saphenous vein graft. Equal
clamps are applied. A longitudinal arteriotomy is made in the
bites of all layers of each vessel are included in each stitch, all of
anterior wall of the artery with a sharp No. 15 knife blade. This which are placed under direct vision.
arteriotomy is then enlarged with a scalpel or a Potts angled scis-
sors.The length of the opening in the artery should be approximate-
ly twice the diameter of the vessel. If the edges of the arteriotomy Step 5: placement of graft in tunnel The graft is dis-
are calcified and the atheromatous intima overlaps the cut edge, tended by injecting heparinized saline solution into it to test for
the diseased intima should be excised with arteriotomy scissors. leaks either from the vein segment itself or from the anastomot-
The saphenous vein segment is then brought into the field. ic site. The graft is then marked to ensure that it does not
It is reversed so that its proximal end becomes the distal end become twisted when brought through the tunnel. The graft is
for the anastomosis.This distal end is then enlarged with a lon- brought through the tunnel either by using an aortic clamp or by
attaching it to the previously placed red rubber catheter.
gitudinal incision in its posterior wall, and the right-angle tips
of the two sides of the divided posterior wall are cut away.
Step 6: construction of proximal anastomosis to
Double-armed sutures are placed through the proximal angle
femoral artery Before the proximal anastomosis is begun, the
(or heel) of the graft, with the needles going from the outside
proper length of the graft should be determined to ensure that
of the arteriotomy to the inside and then from the inside to the there is no redundancy.The proximal end of the graft is split and
outside. Next, a similar double-armed suture is passed through enlarged in the same fashion as the distal end, and the resulting
the distal angle (or toe) of the graft from the outside to the right-angle corners are similarly trimmed.The graft is then anas-
inside and then from the inside to the outside through the end tomosed to the arteriotomy made in the femoral artery (which,
of the arteriotomy. like the popliteal arteriotomy, should be at least twice as long as
The edge of the vein is then approximated to that of the arteri- the vessel is wide). The graft is attached by double-armed nee-
otomy with a continuous suture starting at the toe of the graft and dles at its proximal angle and then in a similar fashion at its dis-
proceeding toward the heel [see Figure 4]. When half of the anas- tal angle. The anastomosis is then completed from each end
tomosis has been completed, the edge of the vein graft is separat- toward the center, just as the popliteal anastomosis was.
ed from the edge of the opposite side of the arteriotomy to permit
inspection of the arterial lumen and the completed suture. The Below-the-Knee Bypass
other half of the anastomosis is then completed by placing a sec- When occlusion or marked stenosis renders the proximal and
ond continuous suture, starting at the heel and proceeding toward middle portions of the popliteal artery unsuitable for graft implan-
the toe. Finally, the two sutures are tied together midway between tation, the lower portion of the vessel, which is often relatively free
the heel and the toe to complete the popliteal anastomosis. of atherosclerosis, may be used for the distal anastomosis instead.
Figure 5 Femoropopliteal bypass: below knee. Depicted is medial exposure of the distal popliteal artery.
(a) An incision is made just behind the posteromedial surface of the tibia. (b) The crural fascia is exposed.
(c) The fascia is incised, exposing the vascular bundle. (d) The medial head of the gastrocnemius muscle is
retracted posteriorly, exposing the distal popliteal vessels and the arcade of the soleus muscle. (e) The distal
popliteal artery is freed and mobilized between vessel loops.
Step 1: exposure of popliteal artery With the knee mod- through the upper popliteal space, and finally through the region
erately flexed and supported by a rolled sheet placed under it, a behind the popliteus muscle.
vertical skin incision is made just behind the posteromedial sur-
face of the tibia [see Figure 5a], exposing the crural fascia [see Steps 4 through 6 Steps 4, 5, and 6 of a below-the-knee
Figure 5b]. Care must be taken to avoid injury to the greater femoropopliteal bypass—the distal anastomosis of the vein
saphenous vein during the skin incision. When a saphenous vein graft to the distal popliteal artery, the placement of the graft in
graft is to be used, the same incision can serve both for harvest- the tunnel, and the proximal anastomosis to the femoral
ing of the vein and for exposure of the artery. artery—are carried out in much the same way as the corre-
The crural fascia is opened along its fibers [see Figure 5c], its sponding steps in an above-the-knee bypass. A completion
distal attachments are separated from the semitendinosus and angiogram should be obtained to confirm the adequacy of the
gracilis tendons, and the two tendons are mobilized proximally distal anastomosis and verify the position of the graft in the
and, if necessary, divided.The medial head of the gastrocnemius tunnel [see Figure 6].
muscle is retracted posteriorly [see Figure 5d] to expose the
OUTCOME EVALUATION
popliteal artery and vein and the posterior tibial nerve as these
structures cross the popliteus muscle posteriorly [see Figure 5e]. Femoropopliteal bypasses performed with segments of the
It should be noted that (1) the distal popliteal artery has few greater saphenous vein are associated with 4-year primary paten-
branches below the inferior geniculate arteries, (2) atheromatous cy rates ranging from 68% to 80% and limb salvage rates rang-
plaques are rarely present at this level, and (3) the arterial wall is ing from 75% to 80%.29 Femoropopliteal bypasses performed
often more suitable for graft implantation in this portion of the with polytetrafluoroethylene (PTFE) grafts yield comparable
popliteal wall than it is above the knee. patency and limb salvage rates above the knee but are signifi-
cantly less successful below the knee.30
Step 2: exposure of femoral artery This exposure is Newer vein harvesting techniques may help improve out-
accomplished in essentially the same way as it would be in an come further. The use of endoscopic vein harvesting methods
above-the-knee bypass. has been shown to reduce the incidence of wound complica-
tions associated with femoropopliteal bypass.31 This approach
Step 3: creation of tunnel Tunneling for a below-the-knee allows above-the-knee bypasses to be performed through two
femoropopliteal bypass is carried out through Hunter’s canal, incisions.
Infrapopliteal Bypass
Bypasses to the small arteries beyond the popliteal artery are
performed only when femoropopliteal bypass is contraindicated
according to accepted criteria [see Femoropopliteal Bypass, above].
Infrapopliteal bypasses are performed to the posterior tibial
artery, the anterior tibial artery, or the peroneal artery, in that order
of preference. As a rule, a tibial artery is used only if its lumen
runs without obstruction into the foot, though bypasses to isolat-
ed tibial artery segments and other disadvantaged outflow tracts
have been performed and have remained patent for more than 4
years.2,3 Generally, the peroneal artery is used only if it is contin-
uous with one or two of its terminal branches, which communi-
cate with foot arteries [see Figure 7]. Neither the absence of a plan-
tar arch nor vascular calcification is considered a contraindication
to a reconstruction.2,7 With both femoropopliteal and infrapopliteal
bypasses, stenosis of less than 50% of the diameter of the vessel is
acceptable at or distal to the site chosen for the distal anastomosis.
OPERATIVE TECHNIQUE
Bypasses to tibial arteries should be performed with autoge-
nous vein grafts, and either the reversed technique (as previous-
ly described [see Femoropopliteal Bypass, above]) or the in situ
technique [see In Situ Bypass, below] may be used. Placement of
a tourniquet above the knee allows the distal anastomosis to be
performed without extensive dissection of the tibial vessels or the
application of clamps.32 Exposure of the inflow vessel (i.e., the
femoral artery or the popliteal artery) is achieved in the same way
as in femoropopliteal bypass. Accordingly, bypasses to tibial and
Figure 7 Infrapopliteal bypass. An arteriogram from a 65-year-

old female with rest pain in the right foot who underwent in situ
bypass to the middle portion of the peroneal artery shows com-
munication of the peroneal artery with foot arteries and reconsti-
tution of the dorsalis pedis artery.
peroneal arteries are best described in terms of the approaches

required for exposure of these vessels and the tunnels required
for routing the bypass conduits.
Exposure of Posterior Tibial Artery
The very proximal portion of the posterior tibial artery is
aproached via a below-the-knee popliteal incision. The deep
fascia is incised, and the popliteal space is entered. The gas-
trocnemius muscle is retracted posteriorly, and the soleus mus-
cle is separated from the posterior surface of the tibia. The dis-
tal portion of the posterior tibial artery is approached via a
medial incision along the posterior edge of the tibia [see Figure
8]; deepening this incision along the posterior tibialis muscle
and the posterior surface of the tibia allows exposure of the
posterior tibial artery.The tunnel from the popliteal fossa to the
distal posterior tibial artery is made just below the muscle fas-
cia, ideally with a long, gently curved clamp.
Exposure of Anterior Tibial Artery
Figure 6 Femoropopliteal bypass: below knee. A completion
arteriogram from a patient who underwent below-the-knee To expose the proximal portion of the anterior tibial artery, an
femoropopliteal bypass for a nonhealing toe amputation site anterolateral incision is made in the leg midway between the tibia
shows runoff through all three tibial vessels. and the fibula over the appropriate segment of patent artery [see
Figure 9c]. Alternatively, the tunnel for the bypass may be placed
lateral to the knee in a subcutaneous plane.
The distal anterior tibial artery is approached via an anterior
incision placed midway between the tibia and the fibula [see
Figure 8]. A tunnel is made from the distal popliteal fossa across
the interosseous membrane (like the tunnel to the peroneal
artery) and beneath the deep fascia to a point 5 to 7 cm above
the lateral malleolus. Once the distal anastomosis is complete
and the graft has been drawn through the tunnel, any tendons
that may be distorting or compressing the graft in its course
around the tibia are divided; this measure proves necessary in
most low anterior tibial bypasses.
Figure 8 Infrapopliteal bypass: posterior tibial artery. Shown
are incisions for bypasses to the distal regions of the leg. Exposure of Peroneal Artery
The peroneal artery is usually approached via the same inci-
Figure 9a]. Additional small medial incisions are also required for sion as the posterior tibial artery [see Exposure of the Posterior
tunneling.The anterior incision is carried through the deep fascia, Tibial Artery, above].The artery is located and isolated just medi-
and the fibers of the anterior tibial muscle and the extensor digi- al to the medial edge of the fibula. In its distal third, however, and
torum longus muscle are separated to reveal the neurovascular in patients with stout calves and ankles, the peroneal artery
bundle. The accompanying veins are mobilized and their branch- should be approached via a lateral incision [see Figure 8], followed
es divided to allow visualization of the anterior tibial artery, which by excision of the fibula.
can then be carefully mobilized [see Figure 9b]. With the artery For lateral exposure of the peroneal artery, a long segment of
mobilized, further posterior dissection can be performed, and the fibula is freed from its muscle attachments with a combination of
interosseous membrane can then be visualized and incised in a blunt and sharp dissection; particular care should be taken in dis-
cruciate fashion. secting along the medial edge of the bone because the peroneal
Careful blunt finger dissection via the anterior incision and vessels run just below this edge and are easily injured by instru-
from the popliteal fossa via the medial incision facilitates creation ments. Next, a finger is passed around the fibula [see Figure 10a];
of a tunnel without injury to the numerous veins in the area [see once this is done, the free edge of bone is further developed by
b c
Figure 9 Infrapopliteal bypass: anterior tibial artery. (a) An anterolateral incision is made midway between the tibia
and the fibula over the artery; small medial incisions are also made for tunneling. (b) The anterior incision is carried
through the deep fascia, the anterior tibial and extensor digitorum longus muscles are separated, the accompanying
veins are mobilized and divided, and the anterior tibial artery is mobilized. (c) A tunnel is created with careful blunt
finger dissection.
approached down to a point several centimeters below the medi-

a al malleolus.
In Situ Bypass
In situ bypass is an acceptable alternative to reversed vein
bypass. Minimally invasive techniques have been developed to
reduce the wound complications encountered when in situ
bypass is performed with long incisions.
With the help of a side-branch coil occlusion system, in situ
bypass can be performed through the two arterial access inci-
sions. The angioscopic coil device is passed through the proxi-
mal greater saphenous vein, and the coils are placed into the side
branches under angioscopic guidance [see Figure 13]. As the
device is advanced more distally through the vein, the valves are
lysed with a flexible valvulotome.
Another approach to side-branch occlusion involves the use of
an endoscopic vein harvesting system. Three skin incisions are
made: two incisions for arterial access and one 2 cm incision
above the knee for insertion of an endoscopic device to locate
b and clip the side branches of the saphenous vein. Once the prox-
imal anastomosis is complete, the valves are lysed with a flexible
valvulotome passed through the distal end of the vein.
Completion cineangiography is then performed to confirm side-
branch occlusion and to assess the entire reconstruction.33
OUTCOME EVALUATION
Infrapopliteal bypasses should have 5-year primary patency

rates ranging from 60% to 67% and limb salvage rates ranging
from 70% to 75% whether they are done with the reversed-vein
technique or with the in situ technique.34,35 For all such grafts,
close patient follow-up and graft surveillance improve secondary
Figure 10 Infrapopliteal bypass: lateral exposure of peroneal
artery. Lateral exposure of the peroneal artery typically requires
excision of part of the fibula; this is done by (a) passing a finger
behind the fibula, developing the free bone edge further with a
right-angle clamp, (b) passing a right-angle retractor behind the
fibula, and dividing the bone with a power saw.
forcefully pushing a right-angle clamp inferiorly and superiorly

[see Figure 10b]. A right-angle retractor is passed behind the
bone, and the fibula is divided with a power saw. The peroneal
artery can then be dissected free from surrounding veins and
used in the construction of the distal anastomosis.
Gentle blunt finger dissection is required to develop a tun-
nel from this lateral wound to the distal popliteal fossa, and
great care should be taken to avoid injury to the numerous
veins in the area. Because the peroneal artery is the least acces-
sible of the three leg arteries used for infrapopliteal bypasses
and normally has the poorest connections with the arteries
of the foot, we recommend that it be used as a distal implan-
tation site only when the anterior and posterior tibial arteries
are not suitable.
Exposure of Dorsalis Pedis Artery
When no more proximal procedure is possible, a bypass to the
ankle region or the foot may be performed. The dorsalis pedis
artery is easily approached via a lateral incision on the dorsum of
the foot [see Figure 11a].The incision is curved slightly and a flap
raised so that the incision will not be directly over the anastomo-
sis [see Figure 11b]. If the artery must be approached at the ankle, Figure 11 Infrapopliteal bypass: dorsalis pedis artery. (a) The
the extensor retinaculum must be divided. Otherwise, the opera- dorsalis pedis artery is approached via an incision on the dorsum
tion is performed in much the same fashion as a distal anterior of the foot. (b) The incision is curved and a flap raised so that the
tibial bypass [see Figure 12]. The posterior tibial artery can be incision is not directly over the anastomosis.
patency rates. Reduced complications and decreased length of

stay have been reported for patients undergoing distal in situ
bypasses using either the endoscopic or the coil occulsion
approach.36,37
Plantar Bypass
Extension of the standard approaches to limb salvage has led
to the performance of bypasses to vessels below the ankle joint
[see Figures 14 and 15]. Such bypasses are indicated when the
more proximal tibial vessels are occluded, which frequently
occurs secondary to failure of a more proximal bypass.The tech-
nique required for performing bypasses to secondary branches in
the foot is essentially the same as that required for performing
bypasses to major infrapopliteal vessels.
Optimal illumination by means of head lamps is important for
achieving technical success with plantar bypass, and loupe mag-
nification is helpful when the vessel is less than 1.5 mm in diam-
eter. In addition, visualization of perimalleolar and inframalleo-
lar arteries requires excellent preoperative imaging studies.
Figure 13 Infrapopliteal bypass: in situ technique. A completion

arteriogram from a patient who underwent an in situ bypass with
coil occlusion of the side branches shows the two coils (arrows),
which have successfully occluded the side-branch veins.
Figure 12 Infrapopliteal bypass: dorsalis pedis artery. Shown is an Figure 14 Plantar bypass. Shown are the major arteries of the
arteriogram from a 72-year-old diabetic patient who underwent a foot, including the two major branches of the posterior tibial
popliteal artery–dorsalis pedis artery bypass with a reversed saphe- artery.3 The lateral plantar artery is usually the larger and ends in
nous vein graft for a nonhealing great toe amputation. the deep plantar arch.
eral plantar artery forms the deep plantar arch and is larger than
the medial plantar artery. If the lateral branch is occluded, the
medial branch may enlarge and feed the plantar arch through
collateral vessels.
The initial incision is made over the termination of the poste-
rior tibial artery below the malleolus. The artery is isolated, and
the incision is extended inferiorly and laterally onto the sole. A
direct approach to the individual branches is difficult, for sever-
al reasons. First, because the skin of the sole is not easily retract-
ed, adequate exposure of the lateral and medial plantar arteries
is hard to obtain if the incision does not follow their course
exactly. Second, because these arteries are small in diameter and
lie deep within the foot, they can be quite difficult to locate.
Third, it is sometimes hard to distinguish the lateral plantar
artery from the medial plantar artery. Dissection of the termina-
tion of the posterior tibial artery can help the surgeon make this
distinction. The lateral branch is usually located inferiorly when
the foot is externally rotated on the operating table.
Exposure of the proximal 2 to 3 cm of the plantar branches is
accomplished by incising the flexor retinaculum and the adduc-
tor muscle of the great toe. More distal exposure of these
Figure 15 Plantar bypass. A completion arteriogram from a 62- branches can be obtained by dividing the medial border of the
year-old diabetic with nonhealing toe ulcers who underwent a plantar aponeurosis and the extensor digitorum brevis muscle.
popliteal artery–medial plantar artery bypass with a reversed
saphenous vein graft shows the distal anastomosis, with flow visi- Exposure of Deep Plantar Artery and Lateral Tarsal Artery
ble through a small but patent medial plantar artery.
The deep plantar artery and the lateral tarsal artery are
branches of the dorsalis pedis artery. The deep plantar artery
These very distal bypasses offer a viable alternative to a major originates at the metatarsal level, where it descends into a fora-
amputation. Like infrapopliteal bypasses, they are best described men bounded proximally by the dorsal metatarsal ligament,
in terms of the anatomic approaches to the distal branch vessels. distally by the dorsal interosseous muscle ring, and medially
In what follows, we outline exposure of the plantar and tarsal and laterally by the bases of the first and second metatarsal
arteries; exposure of the dorsalis pedis artery is outlined else- bones. As the deep plantar artery exits from this tunnel, it con-
where [see Infrapopliteal Bypass, above]. nects with the lateral plantar artery to form the deep plantar
arch [see Figure 17].
OPERATIVE TECHNIQUE
A slightly curved longitudinal 3 to 4 cm incision is made over
the dorsum of the middle portion of the foot, and the dorsalis
Exposure of Lateral and Medial Plantar Arteries pedis artery is dissected distally down to its bifurcation into the
The lateral and medial plantar branches are the continuation deep plantar and first dorsal metatarsal branches. The extensor
of the posterior tibial artery in the foot [see Figure 16]. The lat- hallucis brevis muscle is retracted laterally—or, if necessary,
Figure 16 Plantar bypass.

Depicted is exposure of the distal
portion of the posterior tibial
artery. The lateral and medial
plantar arteries branch from this
vessel and lie beneath the flexor
retinaculum and the abductor
hallucis muscle, which can be
incised.
Figure 17 Plantar bypass. Shown is a dorsal

view of the arteries of the foot. Exposure of the
distal dorsalis pedis artery (insert) highlights
the origin of the deep plantar artery and its
downward course between the first and second
metatarsal bones. This exposure is facilitated by
lateral retraction of the extensor hallucis brevis
muscle.
transected—and the dorsal interosseous muscle ring is split to ited. Currently, the superficial femoral artery and the popliteal
allow better exposure of the proximal portion of the deep plan- artery are preferentially used for primary bypasses when they are
tar artery. The periosteum of the proximal portion of the second free of disease.
metatarsal bone is then incised and elevated. A fine-tipped The strategy of utilizing more distal inflow sources is particu-
rongeur is used to excise enough of the metatarsal shaft to per- larly applicable to inframalleolar bypasses, in which very long vein
mit ample exposure of the deep plantar artery. segments would be required to reach the dorsalis pedis or other
pedal arteries from the usual more proximal inflow sites. Two
OUTCOME EVALUATION
studies from the latter half of the 1980s reported that the paten-
Bypasses to the dorsalis pedis artery and its branches have cy rates in bypasses originating from the superficial femoral and
yielded results comparable to those of bypasses to more proxi- popliteal arteries were comparable to those in bypasses originat-
mal tibial vessels, with 3-year primary patency rates ranging ing from the common femoral artery.43,44 In a review of our own
from 58% to 60% and limb salvage rates ranging from 75% to experience with popliteal-distal vein graft bypasses,5 we reported
95%.38-40 In one review, patency rates were higher in patients a patency rate of 65% at 4 years—a figure comparable to rates
who had an intact plantar arch than in those who did not; how- reported for femorodistal bypasses with reversed or in situ vein
ever, failure to visualize the plantar arch on preoperative arteri- grafts (67% and 69%, respectively).34 Given these results, sur-
ograms does not preclude the performance of these bypasses for geons should not hesitate to employ either the popliteal artery or
limb salvage. With careful follow-up, the assisted primary paten- the superficial femoral artery as an inflow source. Use of these
cy rates for these grafts have been substantially improved.41 The more distal inflow sites results in shorter grafts and allows por-
available reports emphasize the need to repair failing grafts tions of saphenous vein to be preserved for other purposes.
because their secondary patency was much better than that of An increasing number of limb salvage procedures are sec-
failed grafts. In one study, patients who required shorter bypass- ondary interventions. These secondary procedures are generally
es or had lower preoperative C-reactive protein levels experi- more difficult to perform because the access routes to the arter-
enced significantly better outcomes.42 In some patients, occlu- ies have been previously dissected and because there frequently
sion of the distal tibial vessel necessitates performance of a tibi- is little good autologous vein left. In some cases, patients present
otibial bypass to achieve wound healing.7 with gangrene developing below a functioning bypass or after a
Bypasses to plantar or tarsal vessels performed with vein grafts previous failed bypass. Some of these patients need nothing
yield 2-year patency rates ranging from 65% to 75% and limb more than a short distal extension of their functioning bypass;
salvage rates higher than 80%.4,5 In one report, the primary others have only enough vein left to make up a short graft. For
patency rate for these grafts was 74% at 1 year and 67% at 2 such patients, a tibiotibial bypass may be an effective alternative
years, and the limb salvage rate was 78% at 2 years.3 revascularization approach.
In 1994, our group reported our 11-year experience with tibi-
otibial bypasses, comprising 42 procedures in 41 patients.7 Ten
Alternative Bypasses Using More Distal Inflow Vessels of these bypasses were performed because previous bypasses
Traditionally, the femoral artery has been the inflow site of failed; the remainder were performed because the amount of
choice for infrainguinal bypasses. Since the early 1980s, the super- autologous vein available was limited. Approximately 50% of the
ficial femoral, deep femoral, popliteal, and tibial arteries have all bypasses were to pedal or tarsal vessels. At 5 years, the patency
been used as inflow sources when these vessels were relatively dis- rate for these grafts was 65%, and the limb salvage rate was
ease free or when the amount of autologous vein available was lim- 73%.7 A subsequent study reported comparable results.45
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mapping. J Vasc Surg 15:275, 1992 bypasses to isolated popliteal artery segments. J bypasses. Eur J Vasc Endovasc Surg 18:138,
12. Legemate DA, Teeuwen C, Hoenveld H, et al: Vasc Surg 14:386, 1991 1999
Value of duplex scanning compared with angiog- 28. Veith FJ, Gupta SK, Daly V: Femoropopliteal 43. Cantelmo NL, Snow JR, Menzoian JO, et al:
raphy and pressure measurement in the assess- bypass to the isolated popliteal segment: is poly- Successful vein bypass in patients with an
ment of aortoiliac lesions. Br J Surg 78:1003, tetrafluoroethylene graft acceptable? Surgery ischemic limb and a palpable popliteal pulse.
1991 89:296, 1981 Arch Surg 121:217, 1986
13. Ascer E, Mazzariol F, Hingorani A, et al:The use 29. Taylor LM, Edwards JM, Porter JM: Present sta- 44. Rosenbloom JS, Walsh JJ, Schuler JJ, et al: Long-
of duplex ultrasound arterial mapping as an tus of reversed vein bypass grafting: five-year term results of infragenicular bypasses with
alternative to conventional arteriography for pri- results of a modern series. J Vasc Surg 11:193, autogenous vein originating from the distal
mary and secondary infrapopliteal bypasses. Am 1990 superficial femoral and popliteal arteries. J Vasc
J Surg 178:162, 1999 30. Veith FJ, Gupta SK, Ascer E, et al: Six year Surg 7:691, 1988
14. Wain RA, Berdejo GL, Delvalle WN, et al: Can prospective multicenter randomized comparison 45. Plecha EJ, Lee C, Hye RJ: Factors influencing
duplex scan arterial mapping replace contrast of autologous saphenous vein and expanded
the outcome of paramalleolar bypass grafts. Ann
arteriography as the test of choice before infrain- polytetrafluoroethylene grafts in infrainguinal
Vasc Surg 10:356, 1996
guinal revascularization? J Vasc Surg 29:100, arterial reconstructions. J Vasc Surg 3:104, 1986
1999 31. Jordan WD, Voellinger DC, Schroeder PT, et al:
15. Owens RS, Carpenter JP, Baum RA, et al: Video-assisted saphenous vein harvest: the eval-
Magnetic resonance imaging of angiographically uation of a new technique. J Vasc Surg 26:405,
occult runoff vessels in peripheral arterial occlu- 1997 Acknowledgment
sive disease. N Engl J Med 326:1577, 1992 32. Wagner WH, Treiman RL, Cossman DV, et al:
16. Carpenter JP, Owen RS, Baum RA, et al: Tourniquet occlusion technique for tibial artery Figures 1 through 17 Tom Moore.
6 VASCULAR SYSTEM 19 Lower-Extremity Amputation For Ischemia — 1
19 LOWER-EXTR EMITY AMPUTATION

FOR ISCHEMIA
William C. Pevec, M.D., F.A.C.S.
Patients with infected, painful, or necrotic lower extremities can extremity amputation for ischemia is associated with a mortality
be restored to a better functional level by means of a properly of 4.5% to 16%,1-6 owing to the poor overall condition of the pa-
selected and performed amputation. This procedure should be tient population. Accordingly, optimization of cardiac and pulmo-
considered reconstructive and restorative. In what follows, I nary function and control of systemic infection are mandatory.
address amputations across the toe, the forefoot, the leg, and the Finally, the timing of elective amputation is crucial. Because
thigh. Because Symes’ amputations and hip disarticulations are the loss of a limb is a difficult and frightening thing for a patient
seldom appropriate on ischemic limbs, I omit discussion of these to accept, there is a natural tendency to delay amputation for as
procedures. long as possible. This tendency is understandable but must be
weighed against the potential problems associated with delay,
such as poor preoperative pain control, which leads to an in-
General Preoperative Planning creased incidence of postamputation phantom limb pain, and
Selecting the appropriate level of amputation is of primary extended preoperative immobility, which leads to physical decon-
importance for healing and preservation of function. For an ditioning and makes prosthetic limb rehabilitation more difficult.
ambulatory patient who has either a palpable pulse over the dor- A preoperative consultation with a physiatrist can allay some of
sal pedal or posterior tibial arteries or a functioning infrainguinal the patient’s anxiety by addressing the expected postoperative
arterial bypass graft, amputation on the foot (either toe amputa- course of rehabilitation and thereby removing some of the fear of
tion or transmetatarsal amputation) is appropriate. For an ambu- the unknown.
latory patient who has a palpable femoral pulse and a patent pro-
funda femoris artery, whose skin is warm at least to the level of
the ankle, and who has no skin lesions on the proposed amputa- Toe Amputation
tion flaps, amputation below the knee is appropriate. For a non- Amputation of the toe can be done either across a phalanx or
ambulatory patient who has ischemic rest pain, ulceration, or across a metatarsal bone; the latter procedure is commonly
gangrene, amputation above the knee is appropriate. Arterial referred to as a ray amputation. Many of the perioperative issues
reconstruction is not indicated if the extremity is nonfunctional. are essentially similar for the two approaches; however, indica-
Below-the-knee amputation does not offer nonambulatory pa- tions and operative details differ somewhat and thus will be
tients any functional advantage; moreover, it is less likely to heal described separately.
and often results in a flexion contracture at the knee that leads to
OPERATIVE PLANNING
pressure ulceration of the stump. Above-the-knee amputation
depends on pulsatile flow into the ipsilateral internal iliac artery As noted (see above), for a toe amputation to heal properly,
for successful healing. Above-the-knee amputation is also neces- there must be either a palpable pulse over the dorsal pedal or
sary for a patient whose skin is cool at or above the midcalf or posterior tibial artery or a functioning bypass graft to an
who has skin lesions at or proximal to the midcalf. infrapopliteal artery. If tissue necrosis or infection is confined to
Several adjunctive measurements (e.g., transcutaneous oxy- the distal or middle phalanx, transphalangeal amputation is
gen tension and segmental arterial pressure) have been used to appropriate; if tissue loss or necrosis involves the proximal pha-
select the level of amputation but have not proved particularly lanx, ray amputation is indicated. If tissue necrosis or infection
helpful. Generally, these adjuncts can reliably determine a level extends over the metatarsophalangeal joint, either transmeta-
of amputation at which healing is virtually ensured, but they can- tarsal amputation of the entire forefoot or below-the-knee ampu-
not reliably determine the level at which an amputation will not tation is usually necessary (see below).
heal. Consequently, reliance on such measures to select the level Multiple transphalangeal amputations are functionally well
of amputation will result in an unnecessarily high percentage of tolerated. If, however, ray amputation of the great toe or of more
more proximal amputations. than one smaller toe is called for, it is preferable to perform a
In most cases, definitive amputation can be accomplished in a transmetatarsal amputation of the forefoot. Adequate skin cov-
single stage. Local cellulitis can usually be controlled beforehand erage is usually difficult to achieve with a great-toe or multiple-
with bed rest and systemic administration of antibiotics. Un- toe ray amputation. In addition, ray amputation of more than
drained pus or recalcitrant cellulitis, however, must be treated one of the middle toes often causes central deviation of the
with debridement and drainage in advance of definitive amputa- remaining outside toes, which can lead to ulcerations secondary
tion. This can be accomplished with local soft tissue debride- to abnormal pressure points. Finally, loss of the first metatarsal
ment, single-toe amputation, or guillotine amputation across the head or of several of the other metatarsal heads results in abnor-
ankle. mal weight bearing on the remaining metatarsal heads, which
Careful preoperative medical assessment is essential. Lower- may give rise to late ulceration.
OPERATIVE TECHNIQUE
a
Transphalangeal Amputation
Digital block anesthesia is ideal for transphalangeal amputa-
tion. A 25-gauge needle is inserted into the skin over the medi-
al aspect of the dorsum of the proximal phalanx and advanced
until the bone is encountered. The needle is then withdrawn
slightly, and a small amount of fluid is aspirated to confirm that
the tip of the needle is not in a blood vessel. Next, 0.5 to 1.0 ml
of lidocaine, 0.5% or 1.0% without epinephrine, is slowly
injected. The needle is then carefully advanced medial to the
bone until the tip can be felt pressing against (but not punctur-
ing) the plantar skin. Again, the needle is withdrawn slightly,
b
fluid is aspirated, and 0.5 to 1.0 ml of lidocaine is injected. The
same technique is repeated on the lateral aspect of the proximal
phalanx. In this way, all four digital nerve branches are blocked.
If multiple toe amputations are required, an ankle block,
epidural anesthesia, spinal anesthesia, or general anesthesia can
be used.
An incision is made to create dorsal and plantar skin flaps.
Typically, these flaps are equal in length; however, depending on
the location of the skin lesion, either the dorsal flap or the plan-
tar flap can be left longer [see Figure 1]. Care must be taken not Figure 1 Toe amputation: transphalangeal amputation.
to create excessively long flaps, which may lack sufficient perfu- Transphalangeal amputation can be performed either with dorsal
sion for healing, or to create undermined bevels with the scalpel and plantar flaps of equal length (a) or with a plantar flap that is
[see Figure 2], which will lead to epidermolysis of the suture line. longer than the dorsal flap (b). The phalanx is transected at the
The incision is extended down to the phalanx, and the soft level of the apex of the skin flaps (dashed line). The bone is tran-
sected through the shaft of the phalanx, never across the joint.
tissues are gently separated from the bone with a small
periosteal elevator. All tendons and tendon sheaths are debrid-
ed because the poor vascularity of these tissues may compromise tinized skin of the foot is easily lacerated. The final step is the
the healing of the toe. The phalanx is transected at the level of application of a soft dressing.
the apices of the skin incisions [see Figure 1]. Care must be taken
not to leave the remaining bone segment too long: this places Ray Amputation
undue tension on the skin flaps and is a primary cause of poor For ray amputation [see Figure 3], spinal, epidural, or gener-
healing. The best way of transecting the phalanx is to use a al anesthesia can be employed. A so-called tennis-racket inci-
pneumatic oscillating saw. Manual bone cutters can splinter the sion is made—that is, a straight incision along the dorsal sur-
bone, and manual saws can cause extensive damage to the soft face of the affected metatarsal bone coupled with a circumfer-
tissues. The bone is always transected across the shaft: because ential incision around the base of the toe. The goal is to save all
of the poor vascularity of the articular cartilage, disarticulation available viable skin on the toe; this skin is used to ensure a ten-
across a joint typically leads to poor healing. sion-free closure, and any excess skin can be debrided later, at
Hemostasis is achieved with absorbable sutures and limited the time of closure. Again, undermined bevels are avoided. The
use of the electrocautery. Excessive tissue manipulation and incision is taken down to the bone, and the soft tissues are sep-
electrocauterization should be avoided. The skin edges are care- arated from the distal metatarsal bone with a periosteal eleva-
fully approximated with simple interrupted nonabsorbable tor. Dissection must be kept close to the affected metatarsal
monofilament sutures; perfect apposition is necessary to maxi- head to prevent injury to the adjacent metatarsophalangeal
mize the potential for primary healing. The sutures must not be joint, which can lead to necrosis of the adjacent toe. The
placed too close to the skin edges, because the heavily kera- metatarsal bone is transected across the shaft with a pneumat-
a Distal Proximal b Distal Proximal
Figure 2 In a lower-extremity amputation, the skin is always incised perpendicular to its surface (a). Given the vary-
ing contours encountered during extremity amputation, it can be difficult to maintain the perpendicular orientation of
the scalpel; however, an incision that undermines the proximal skin flap (b) will devascularize the epidermis and lead
to necrosis of the suture line.
a b
Figure 3 Toe amputation: ray amputation. (a) A longitudinal incision is made along the dorsum of the
shaft of the metatarsal bone of the affected toe. A circumferential incision is then made around the pha-
lanx. The circumferential incision should be placed as distal on the toe as there is viable skin so that as
much skin as possible is retained for closure of the wound. (b) The metatarsal bone is transected across its
shaft, proximal to the metatarsal head; the joint is never disarticulated.
ic oscillating saw. The tendons and the tendon sheaths are Transmetatarsal Amputation
debrided.
OPERATIVE PLANNING
Meticulous hemostasis is achieved with absorbable sutures
and limited use of the electrocautery. The skin is approximated As noted (see above), transmetatarsal amputation is indicated
with simple interrupted nonabsorbable monofilament sutures if there is tissue loss in the forefoot involving the first metatarsal
[see Figure 4]. If sufficient viable skin was preserved, a flap of head, two or more of the other metatarsal heads, or the dorsal
plantar skin is rotated dorsally, and the incision is closed in the forefoot. It is contraindicated if there is extensive skin loss on the
shape of a Y. Alternatively, the medial and lateral edges are shift- plantar surface of the foot or on the dorsum proximal to the mid-
ed (one proximally and the other distally), the corners are shaft of the metatarsal bones. The peroneus longus and the per-
trimmed, and the incision is closed in a linear fashion. A soft oneus brevis insert on the proximal portions of the fourth and
supportive dressing is applied. fifth metatarsal bones; if these insertions are sacrificed, inversion
of the foot results, eventually leading to chronic skin breakdown
COMPLICATIONS from the side of the foot repeatedly striking the ground during
Complications of toe amputation include bleeding, infection, ambulation.Transmetatarsal amputation is also contraindicated if
and failure to heal. Because even a small amount of bleeding there is a preexisting footdrop (peroneal palsy).
under the skin flaps can prevent proper healing, meticulous
OPERATIVE TECHNIQUE
hemostasis is mandatory. In most cases, infection and failure to
heal are attributable to poor patient selection and poor surgical Spinal, epidural, or general anesthesia may be employed for
technique; the usual result is a more proximal amputation. transmetatarsal amputation. Placement of a tourniquet on the
calf is a useful adjunctive measure. This step greatly reduces
OUTCOME intraoperative blood loss. More important, the bloodless opera-
For optimal healing, there must be an extended period (2 to 3 tive field that results allows more accurate assessment of tissue
weeks) during which no weight is borne by the foot that under- viability and hence more precise selection of the level of ampu-
went toe amputation. Once healing is complete, the patient tation; in a field stained with extravasated blood, it is easy to
should be able to walk normally, with no need for orthotic or leave behind nonviable tissue that will doom the amputation.
assist devices. Beginning ambulation too early can disrupt healing Use of a tourniquet is, however, contraindicated in patients who
flaps and necessitate more proximal amputation, which lengthens have a functioning infrapopliteal artery bypass graft.
the hospital stay and increases long-term disability. For these rea- After sterile preparation and draping, the leg is elevated to help
sons, toe amputation in patients with arterial occlusive disease is drain the venous blood, and a sterile pneumatic tourniquet is
not an outpatient procedure. Patients are kept on bed rest and placed around the calf, with care taken to pad the skin under the
instructed in techniques (e.g., use of a wheelchair, a walker, or tourniquet and to position the tourniquet over the calf muscles,
crutches) that allow them to function without stepping on the where it will not apply pressure over the fibular head (and the
foot that was operated on. Hospital discharge is delayed until common peroneal nerve) or other osseous prominences. The
such techniques are mastered. tourniquet is then inflated to a pressure higher than the systolic
A B
A B
C
C
A
A B
D B
E
D E
Figure 4 Toe amputation: ray amputation. (a) If adequate skin is available, a plantar flap can be rotated
dorsally and the skin closed in a Y configuration. This closure is technically easy to perform; however, there
is a risk of skin necrosis at corners A and B. (b) Alternatively, the skin can be closed in a linear fashion.
Corners A and B are gently trimmed. Corner B is shifted distally toward point D as corner A is shifted
proximally. A slight dog-ear will result at point E; however, it will diminish with time.
blood pressure. In patients who do not have diabetes mellitus, a Care is taken not to bevel the skin incisions.
tourniquet inflation pressure of 250 mm Hg is typically employed; A plantar flap is created by making an incision with the scalpel
in patients who have diabetes mellitus and calcified arteries, a adjacent to the metatarsophalangeal joints; the incision is then
pressure of 350 to 400 mm Hg is preferred. carried more deeply to the level of the midshafts of the metatarsal
An incision is made across the dorsum of the foot at the level bones on their plantar surfaces. The periosteum of the first
of the middle of the shafts of the metatarsal bones, extending metatarsal bone is scored circumferentially with the scalpel, and
medially and laterally to the level of the center of the first and the soft tissue is dissected away from the first metatarsal bone
fifth metatarsal bones, respectively [see Figure 5].The dorsal inci- with a periosteal elevator to a point about 1 cm proximal to the
sion is curved proximally at the medial and lateral edges to dorsal skin incision. The first metatarsal bone is then transected
ensure that no dog-ears remain at the time of closure. The dor- perpendicular to its shaft at the level of the dorsal skin incision
sal incision is continued perpendicularly through the soft tissues with a pneumatic oscillating saw.This process is repeated for each
on the dorsum down to the metatarsal bones. The plantar inci- individual metatarsal bone, with care taken to follow the normal
sion is extended distally to a point just proximal to the toe crease. contour of the forefoot by cutting the lateral metatarsal bones at
Figure 5 Transmetatarsal amputation. The skin incisions are shown from various angles. The metatarsal shafts
are divided in their midportions (dashed line). The metatarsal bone transection is at the level of the apices of
the skin incision, and the lateral metatarsal bones are cut slightly more proximally than the medial metatarsal
bones, in a pattern reflecting the normal contour of the forefoot.
a level slightly proximal to the level at which the more medial the first 3 to 5 days. This step is particularly important if the
bones are transected. All visible digital arteries are clamped and transmetatarsal amputation was performed simultaneously with
tied with absorbable ligatures. If a tourniquet was used, it is arterial reconstruction, which carries a high risk of reperfusion
deflated at this time. All tendons and tendon sheaths are debrid- edema of the foot. After 3 to 5 days, the patient is instructed in
ed from the wound. techniques for moving in and out of the wheelchair without step-
Meticulous hemostasis is achieved with absorbable sutures ping on the foot. The foot that was operated on should not bear
and limited use of the electrocautery. Any sharp edges on the any weight at all for at least 3 weeks; early weight-bearing may
metatarsal bones are smoothed with a rongeur or a rasp. The disrupt the healing of the plantar flap and necessitate more prox-
wound is irrigated to flush out devitalized tissue and thrombus. imal amputation.
The plantar flap is trimmed as needed. The dermis is approxi- Once healed, patients should be able to walk independently
mated with simple interrupted absorbable sutures, and the knots with standard shoes. There is, however, a risk that they may trip
are buried. Because the edge of the plantar flap is generally over the unsupported toe of the shoe. In addition, the pushoff
longer than the edge of the dorsal flap, the sutures must be normally provided by the toes is lost after transmetatarsal ampu-
placed slightly farther apart on the plantar flap than on the dor- tation, and this change results in a halting, flat-footed gait. These
sal flap if perfect alignment is to be obtained. It is imperative to problems can be obviated by using an orthotic shoe with a steel
achieve the correct skin alignment with the dermal suture layer. shank (to keep the toe of the shoe from bending and causing trip-
Once this is accomplished, the skin edges are gently and per- ping) and a rocker bottom (to provide a smooth heel-to-toe
fectly apposed with interrupted vertical mattress sutures of non- motion).
absorbable monofilament material. Finally, a soft supportive
dressing with good padding of the heel is applied; casts and
splints are avoided because of the risk of ulceration of the heel or Guillotine Ankle Amputation
over the malleoli.
OPERATIVE PLANNING
COMPLICATIONS
Guillotine amputation across the ankle is indicated when a
If a tourniquet is not used, intraoperative blood loss can be sub- patient presents with extensive wet gangrene that precludes sal-
stantial; the blood pools in the sponges and drapes, often out of vage of a functional foot (e.g., wet gangrene that destroys the
the anesthesiologist’s field of view. Consequently, good communi- heel, the plantar skin of the forefoot, or the dorsal skin of the
cation between the surgeon and the anesthesiologist is crucial for proximal foot). In such patients, initial guillotine amputation
preventing ischemic complications secondary to hemorrhage. through the ankle is safer than extensive debridement: the oper-
Postoperative complications include bleeding, infection, and fail- ation is shorter, less blood is lost, the risk of bacteremia is
ure to heal, all of which are likely to result in more proximal ampu- reduced, and better control of infection is possible. Guillotine
tation. They can best be prevented by means of careful patient amputation is also indicated in patients with foot infections who
selection and meticulous surgical technique. have cellulitis extending into the leg. Transection at the ankle,
perpendicular to the muscle compartments, tendon sheaths, and
OUTCOME
lymphatic vessels, allows effective drainage and usually brings
For proper healing, postoperative edema must be avoided and about rapid resolution of the cellulitis of the leg, thus permitting
the plantar flap protected against shear forces. To prevent salvage of the knee in many cases in which the knee might oth-
swelling, the patient is kept on bed rest with the foot elevated for erwise be unsalvageable.
OPERATIVE TECHNIQUE
General anesthesia is preferred for guillotine ankle amputa-

tion; regional anesthesia is relatively contraindicated for critical-
ly ill patients who are in a septic state. Anesthesia is required for
no more than 15 to 20 minutes.
A circumferential incision is made at the narrowest part of the
ankle (i.e., at the proximal malleoli) regardless of the level of the
cellulitis [see Figure 6]. This placement takes the line of incision 10 cm
across the tendons, thereby preventing bleeding from transected
muscle bellies. The incision is then carried through the skin and
soft tissues to the bone. If the arteries are patent, the assistant
applies circumferential pressure to the distal calf.The distal tibia A
and fibula are then divided with a Gigli saw. Hemostasis is
achieved with suture ligation and electrocauterization. A moist B
dressing is applied. Figure 7 Below-the-knee amputa-
tion. The transverse incision (A) is
OUTCOME made 10 cm distal to the tibial
After the procedure, the patient is kept on bed rest and given tuberosity. Its length is equal to two
systemic antibiotics. Formal below-the-knee amputation can be thirds of the circumference of the leg
at that level. The posterior incision (B)
performed when the cellulitis resolves, usually within 3 to 5 days.
is made parallel with the gastrocne-
Routine dressing changes are unnecessary—first, because they
mius-soleus muscle complex. The
are painful, and second, because the decision to proceed with for- length of the posterior flap is equal to
mal below-the-knee amputation is based on the extent of the cel- one third of the measured circumfer-
lulitis in the calf, not on the appearance of the transected ankle. ence of the leg. The corners of the
incisions are curved to avoid dog-ears.
Below-the-Knee Amputation
OPERATIVE PLANNING
Below-the-knee amputation is indicated when the lower

extremity is functional but the foot cannot be salvaged by arte-
rial reconstruction or by amputation of one or more of the toes
or the forefoot. Healing can be expected if there is a palpable
femoral pulse with at least a patent deep femoral artery, provid-
ed that the skin is warm and free of lesions at the distal calf. As with any amputation, the surgeon’s preoperative interac-
Before formal below-the-knee amputation, infection should be tion with the patient should be as positive as possible. A con-
controlled with antibiotic therapy, debridement, and, if indicat- structive perspective to convey is that the amputation, though
ed, guillotine amputation. It is advisable to obtain consent to regrettably necessary, is in fact the first step toward rehabilita-
possible above-the-knee amputation beforehand in case unex- tion. A well-motivated patient whose cardiopulmonary status is
pected muscle necrosis is encountered below the knee. not too greatly compromised can generally be expected to walk
again, albeit at an increased energy cost. In this regard, a preop-
erative discussion with a physiatrist can be very helpful, as can a
meeting with an amputee who is doing well with a prosthesis. By
inculcating a positive attitude in the patient before the proce-
dure, the surgeon can greatly improve the patient’s chances of
achieving full rehabilitation, as well as decrease the time needed
for rehabilitation.
Figure 6 Guillotine ankle
amputation. The skin incision OPERATIVE TECHNIQUE
is made circumferentially at
Epidural, spinal, or general anesthesia is appropriate for
the narrowest portion of the
below-the-knee amputation. The lines of incision should be
ankle. The bones are then
transected at the same level marked on the skin. The primary level of amputation is deter-
(dashed line). mined by measuring a distance of 10 cm from the tibial tuberos-
ity [see Figure 7].The circumference of the leg at this level is then
measured by passing a heavy ligature around the leg and cutting
the ligature to a length equal to the circumference. The ligature
is folded into thirds and cut once more at one of the folds, so that
two segments of unequal length remain. The longer segment of
the ligature, which is equal in length to two thirds of the leg’s cir-
cumference 10 cm below the tibial tuberosity, is used to measure
the anterior transverse incision; this incision is centered not on
the tibial crest but on the gastrocnemius-soleus muscle complex.
The shorter segment, which is one third of the leg’s circumfer-
ence at this level, is used to measure the posterior flap; the line tion. The tibia is transected perpendicularly, with a cephalad
of the posterior incision runs parallel with the gastrocnemius- bevel of the anterior 1 cm to keep from creating a sharp point at
soleus complex.To prevent dog-ears, the medial and lateral ends the tibial crest [see Figure 8]. The tibia can be transected with
of the anterior transverse incision are curved cephalad before either a Gigli saw or an oscillating saw; because of the unpleas-
meeting the posterior incision, and the distal corners of the pos- ant sound of the power saw, the Gigli saw is preferred if the
terior incision are curved as well. patient is under regional anesthesia. Sedation should be aug-
Blood loss can be reduced by using a sterile pneumatic tourni- mented in awake patients before division of the tibia. Benzo-
quet. A gauze roll is passed around the distal thigh.The leg is ele- diazepines provide good sedation and amnesia.
vated to drain the venous blood, and the tourniquet is applied The lateral muscles are divided, and the fibula is scored cir-
over the gauze roll. The tourniquet is inflated to a pressure of cumferentially. A periosteal elevator is used to dissect the soft tis-
250 mm Hg (350 to 400 mm Hg if the patient has heavily calci- sues away from the fibula to a point 2 to 3 cm cephalad to the
fied arteries). The assistant elevates the leg, and the incision on level at which the tibia was transected. The fibula is then tran-
the posterior flap is made first, followed by the anterior trans- sected with a bone cutter at least 1 cm cephalad to the tibial tran-
verse incision; this sequence helps prevent blood from obscuring section level.The distal end of the tibia is lifted with a bone hook,
the field while the incisions are being made. The incisions are and division of the posterior muscles is completed with an ampu-
carried fully through the dermis, and the skin edges are allowed tation knife. The specimen is then handed off the field.
to separate and expose the subcutaneous fat. Care is taken to The anterior tibial, posterior tibial, and peroneal arteries and
keep the scalpel perpendicular to the skin so as not to bevel the veins are clamped, and the tourniquet is released. Clamps are
incision, which can lead to necrosis of the epidermal edges [see placed on all other bleeding vessels.The posterior tibial and sural
Figure 2]. nerves are placed on gentle traction and clamped proximally.
The anterior muscles are transected with the scalpel in a The distal nerves are transected, and the proximal nerves are
direction parallel to the transverse skin incision. The tibia is allowed to retract into the soft tissues so as to prevent painful
scored circumferentially, and a periosteal elevator is used to dis- neuromas at the end of the stump. All clamped structures are
sect the soft tissues away from the tibia for a distance of approx- then ligated with absorbable ligatures. The nerves are ligated
imately 3 to 4 cm. The tibia is then transected just proximal to because their nutrient vessels can bleed significantly. The distal
the transverse skin incision. Dividing the tibia more than 1 cm anterior tip of the tibia is smoothed with a rasp to decrease the
proximal to the anterior skin incision will cause the thin skin of risk of skin ulceration over this osseous prominence. The stump
the anterior leg to be pulled taut over the cut end of the tibia by is gently irrigated to remove all thrombus and devitalized tissue
the weight of the posterior flap, thereby leading to skin ulcera- and to reveal any bleeding sites that may have been missed.
Electrocauterization is rarely necessary.
The deep muscle fascia—not the Achilles tendon—is approxi-
mated with simple interrupted absorbable sutures, with care taken
to align the posterior flap with the anterior incision.The dermis is
approximated as a separate layer with simple interrupted
absorbable sutures; if correctly placed, the dermal sutures should
take all tension off the skin. The skin edges are then accurately
apposed with interrupted vertical mattress sutures composed of
monofilament nonabsorbable material. A carefully padded poste-
rior splint or cast is applied to prevent flexion contracture.
COMPLICATIONS
The most common complications after below-the-knee ampu-

tation are bleeding, infection, and failure to heal, all of which are
likely to result in a more proximal amputation, frequently accom-
panied by loss of the knee. Prevention of these complications
depends on careful patient selection, preoperative control of
infection, and meticulous surgical technique.
To walk with a prosthetic leg, the patient must be able to fully
extend and lock the knee; thus, flexion contracture at the knee is
a major complication. Such contractures are usually attributable
either to poor pain control or to noncompliance with knee exten-
sion exercises. Good perioperative analgesia is of vital impor-
tance because knee flexion is the position of comfort and the
patient will be unwilling to extend the knee if doing so proves too
painful.To maintain knee extension, the patient should be placed
Posterior Anterior in either a cast or a splint in the early postoperative period. Once
postoperative pain has abated, the splint or cast can be removed.
At this point, the patient must be taught extension exercises, in
Figure 8 Below-the-knee amputation. In this lateral
which the quadriceps muscles are contracted to maintain the
view of the right leg, the tibia is beveled anteriorly, and length of the hamstring muscles. If a patient spends all of his or
the anterior portion is smoothed with a rasp. The fibula her time in a sitting position with the knee flexed, a flexion con-
is transected at least 1 cm proximal to the level of tran- tracture will quickly develop. Once this happens, the patient may
section of the tibia. find it very difficult to regain full knee extension, and without full
on the femoral condyles, the patella, and the tibial tuberosity.

Breakdown of the stump can occur if weight is borne on the dis-
tal portion of the stump. Several decades ago, Jan Ertl described
a tibiofibular synostosis designed to allow distal weight-bearing;
however, this technique has not been widely adopted.7
OUTCOME
Shortly after the amputation, the patient should be encour-

aged to start working on strengthening the upper body; upper-
body strength is critical for making transfers and for using paral-
lel bars, crutches, or a walker. In patients who have preoperative
intractable ischemic rest pain, postoperative administration of
epidural analgesia can break the cycle of pain. Once postopera-
tive pain is adequately controlled, patients are taught to transfer
in and out of a wheelchair. A compression garment is used on
the stump once the sutures have been removed and the stump is
fully healed.
Prosthetic rehabilitation begins when the stump achieves a
conical shape. Unfortunately, a number of patients who have
Figure 9 Above-the-knee undergone amputation for ischemia are unable to walk with a
amputation. Broadly based prosthetic limb because of comorbid medical conditions and
anterior and posterior flaps general debility. In many cases, however, even if full ambulation
are created. The femur is is impossible, patients can maintain relative independence if the
transected along the dashed knee is salvaged by using a combination of a prosthetic leg and
line, at the apices of the skin a walker for transfers and movement around the house.6
flaps. The skin flaps and the
level of transection of the
femur can be placed more Above-the-Knee Amputation
proximally if clinically indi-
cated.
OPERATIVE PLANNING
Above-the-knee amputation is indicated if the lower extremi-

ty is unsalvageable and there is no femoral pulse. The presence
knee extension, prosthetic limb rehabilitation is impossible. of pulsatile flow into a well-developed ipsilateral internal iliac
Phantom sensation is a common complication after below- artery usually ensures healing, but even when there is more
the-knee amputation but is rarely of any consequence. Phantom severe arterial occlusive disease in the pelvis, healing can some-
pain, on the other hand, can be devastating. Sometimes, phan- times be achieved. Above-the-knee amputation is also indicated
tom pain develops as a consequence of unintentional suggestions if there is tissue necrosis or uncontrollable infection extending
made to the patient by medical personnel who fail to distinguish cephalad to the midleg. Above-the-knee amputation is the pro-
between the two entities. For example, a patient remarks to a cedure of choice in the case of gangrene or ulceration of a com-
medical attendant that he or she can still feel the amputated foot pletely nonfunctional lower extremity.
and toes, and the attendant suggests in response that the patient
has phantom pain; the patient then focuses on the sensation and OPERATIVE TECHNIQUE
exaggerates the severity of the foot and toe discomfort, setting up Epidural, spinal, or general anesthesia may be used for above-
a cycle of ever-worsening pain. This scenario is even more likely the-knee amputation. For the best functional results, it is desir-
if the patient has had prolonged ischemic rest pain before the able to keep the femur as long as possible. A longer stump im-
amputation. Phantom pain can be prevented by (1) encouraging proves the prognosis for prosthetic limb rehabilitation and pro-
early amputation in a patient with a hopelessly ischemic foot vides better balance for sitting and transfers. Healing potential,
(while taking into account the patient’s need to come to grips however, is lower with a longer stump; therefore, if the pelvic cir-
with the prospect of amputation), (2) providing good pain con- culation is severely compromised, a shorter stump should be
trol in the early postoperative period, and (3) assuring the pa- fashioned.
tient that phantom sensation after a below-the-knee amputation Anterior and posterior flaps of equal length are marked on the
is common and that any discomfort in the foot immediately after skin. The flaps should be wide and long [see Figure 9], and their
the operation period will vanish once he or she begins walking apices should be centered on the line dividing the anterior and
again with a prosthetic leg. posterior muscle compartments. The posterior incision is made
Ulceration of the skin over the transected anterior portion of first to minimize the presence of blood in the operative field.The
the tibia is another serious complication that may preclude suc- anterior incision is made second and carried through the anteri-
cessful prosthetic limb fitting. This complication is also best or muscles in a plane parallel to the skin incision. The skin inci-
managed through prevention, which depends on meticulous sur- sions are carried through the dermis, and the skin edges are
gical technique. As noted (see above), the anterior tibial crest allowed to separate and expose the subcutaneous fat; as in other
must be carefully beveled and smoothed at the level of transec- amputations, they should be perpendicular to the skin surface so
tion, and the tibia must not be transected more than 1 cm prox- as not to undermine the skin.
imal to the anterior skin incision. If the superficial femoral artery is patent, the artery and vein
With a standard below-the-knee prosthetic leg, weight is borne are isolated and clamped after the sartorius is divided but before
a b
c Figure 10 Above-the-knee amputation. (a) After an

aerosol tincture of benzoin is applied to the thigh, the hip,
and the lower abdomen, a 4 in. wide stockinette is rolled
over the amputation stump.The cuff of the stockinette is
cut medially at the groin. (b) The remainder of the stock-
inette is then rolled laterally up over the hip, and the cuff
is cut on the lateral midline. (c) The two resulting strips of
cloth are passed around the waist, one anteriorly and one
posteriorly, and these strips are tied on the anterior mid-
line to complete the dressing.
the remainder of the anterior muscles are divided. The femur is rior and one posterior, which are passed around the patient’s
scored circumferentially.The soft tissues are dissected away from waist and tied on the anterior midline.
the femur to the level of the apices of the flaps, and the femur is If the patient is a candidate for prosthetic limb rehabilitation,
divided with an oscillating saw at this level. If the end of the re- a traction rope is passed through a hole cut in the distal end of
sected femur extends beyond the apices of the flaps, the wound the stockinette and tied.The rope is hung over the end of the bed
cannot be closed without tension. The posterior flap is complet- and tied to a 5 lb weight; this step helps prevent flexion contrac-
ed with an amputation knife, and the specimen is handed off the ture at the hip.
field. The stockinette need not be removed for the wound to be
All bleeding points are clamped and tied with absorbable inspected. A window is cut in the distal end of the stockinette,
sutures. The sciatic nerve is placed on gentle traction, clamped, and the gauze is removed. Once the incision has been inspected,
divided, and ligated, and the transected nerve is allowed to fresh gauze is applied, and the window in the stockinette is closed
retract into the muscles. The deep fascia is approximated with with safety pins.
interrupted absorbable sutures, with adjustments made for any
COMPLICATIONS
discrepancy in length between the two flaps. The dermis is
approximated with interrupted absorbable sutures; the dermal Postoperative complications include bleeding, infection, and
sutures should take all tension off the skin. The skin edges are failure to heal, all of which are likely to result in the need for sur-
then carefully apposed with interrupted vertical mattress sutures. gical revision of the amputation stump. Control of preoperative
A nonadherent dressing is placed on the suture line and cov- infection and meticulous surgical technique and hemostasis are
ered with dry, fluffed gauze bandages. An aerosol tincture of ben- necessary to prevent these complications.
zoin is sprayed on the thigh, the hip, and the lower abdomen. Flexion contracture of the hip is a major complication of
When the benzoin is dry, a cloth stockinette with a diameter of 4 above-the-knee amputation. Such contractures preclude suc-
in. is stretched over the stump [see Figure 10]. The cuff of the cessful prosthetic limb rehabilitation. In dealing with this com-
stockinette is cut medially at the groin, and the stockinette is plication, prevention is far more effective than treatment: once
rolled laterally above the hip, where the cuff is then cut on the a flexion contracture at the hip becomes fixed, it is very difficult
midaxillary line.This process yields two strips of cloth, one ante- to reverse. If a patient is a candidate for prosthetic limb reha-
bilitation, the traction weight mentioned earlier (see above) can abnormal abduction of the femur. Accordingly, he proposed
be very helpful. As soon as postoperative pain is controlled, the preservation of the adductor magnus and myodesis of the tran-
patient should be taught to spend three periods daily in a prone sected muscles to the femur to improve the biomechanics after
position to help extend the hip. He or she should then be taught above-the-knee amputation.8,9
exercises for maintaining range of motion in the hip before
OUTCOME
prosthetic limb rehabilitation is initiated. Flexion contracture
of the hip is less of a problem in nonambulatory patients; how- Once postoperative pain has abated, patients are mobilized to
ever, it can still lead to wound breakdown and chronic skin wheelchair transfers.The prognosis for successful prosthetic limb
ulceration. ambulation in patients undergoing above-the-knee amputation
Gottschalk noted that loss of the adductor magnus leads to for ischemia is very poor.
References
1. Reichle FA, Rankin KP, Tyson RR, et al: Long- amputee survival. Prosthet Orthot Int 16:11, 1992 8. Gottschalk F: Transfemoral amputation: biome-
term results of 474 arterial reconstructions for 5. Inderbitzi R, Buttiker M, Pfluger D, et al:The fate of chanics and surgery. Clin Orthop 361:15, 1999
severely ischemic limbs: a fourteen year follow- bilateral lower limb amputees in end-stage vascular 9. Gottschalk FA, Stills M: The biomechanics of
up. Surgery 85:93, 1979 disease. Eur Vasc Surg 6:321, 1992 trans-femoral amputation. Prosthet Orthot Int
2. Maini BS, Mannick JA: Effect of arterial reconstruc- 6. Nehler MR, Coll JR, Hiatt WR, et al: Functional 18:12, 1994
tion on limb salvage. Arch Surg 113:1297, 1978 outcome in a contemporary series of major lower
3. Ellitsgaard N, Andersson AP, Fabrin J, et al: Out- extremity amputations. J Vasc Surg 38:7, 2003
come in 282 lower extremity amputations: knee sal- 7. Pinzur MS, Pinto MA, Smith DG: Controversies Acknowledgment
vage and survival. Acta Orthop Scand 61:140, 1990 in amputation surgery. Instr Course Lect
4. Stewart CPU, Jain AS, Ogston SA: Lower limb 52:445, 2003 Figures 1 through 10 Tom Moore.
6 VASCULAR SYSTEM 20 VARICOSE VEIN SURGERY — 1
20 VARICOSE VEIN SURGERY

John F. Golan, M.D., F.A.C.S., Donald M. Glenn, P.A.-C., John J. Bergan, M.D., F.A.C.S., and Luigi Pascarella, M.D.
Varicose veins are a common problem, accounting for approximate- recommended in the Committee’s consensus statement; however,
ly 85% of the venous conditions treated. Over the past decade, man- these changes have little bearing on the current discussion and thus
agement options for varicose veins and venous insufficiency of the are not addressed further here.
lower extremity have become more diverse. Operative vein stripping
is rapidly being replaced with a variety of endovenous techniques,
ranging from laser vein obliteration to radiofrequency (RF) closure Indications for Varicose Vein Surgery
to foam sclerotherapy. Conventional surgical stripping has a poor The indications for surgical treatment of varicose veins are well
image with the public, being associated with large unsightly inci- established [see Table 1]. Although many physicians believe that vari-
sions, severe postoperative pain, and a significant risk of recurrence. cose veins are nothing more than a cosmetic nuisance, this is in fact
Current evidence indicates that patients experience less pain and re- true only for some men. Women, for the most part, have specific
turn to work more quickly after endovenous treatment of varicosities symptoms (e.g., aching, burning pain, and heaviness) that are relat-
than after surgical vein stripping.1 In addition, the elimination of the ed to their varicose veins and are exacerbated by the presence of
word stripping from the technical description has facilitated the progesterone. Such symptoms develop with prolonged standing or
public’s growing preference for endovenous therapy over conven- sitting and reach maximal levels on the first day of the menstrual pe-
tional surgical therapy (even though the basic therapeutic principles riod, when progesterone levels are at their peak. Men, lacking prog-
are essentially similar for the two approaches). esterone, have few such symptoms until the varicose veins progress
As a consequence of the minimally invasive nature of endovenous with aging to the point where they press on somatic nerves. In gen-
therapy, treatment of vein disease is moving from the hospital to the eral, the severity of the symptoms bears no relation to the size of the
office.This shift has allowed a diverse group of physicians (e.g., der- vessels being treated.Telangiectasias can produce symptoms identi-
matologists, gynecologists, and cardiologists) to enter a field that cal to those of varicose veins, and such symptoms can be relieved by
previously had been left to surgeons. Accordingly, to remain up to simple sclerotherapy [see 6:21 Sclerotherapy].
date with respect to the treatment of vein disease, it is essential for Longitudinal studies have shown that large varicose veins can
surgeons to acquire the knowledge and skills required to use the produce venous ulcerations within 15 years. Given that the inci-
new endovenous techniques. In this chapter, we review the proce- dence of venous ulceration is 20% in patients who are first seen with
dures, results, and complications associated with endovenous thera- large varicose veins, large varicosities constitute an indication for
py, as well as traditional surgical techniques. surgery.Various skin changes characteristic of chronic venous insuf-
ficiency precede the development of venous ulceration.
Varicose thrombophlebitis is followed by recurrent varicose
Terminology thrombophlebitis in nearly every case, at intervals ranging from a
All physicians treating lower-extremity venous disease should be few weeks to many months. Nevertheless, superficial throm-
familiar with the current names for the veins of the thigh and leg, as bophlebitis, which can be quite disabling, can be prevented by re-
specified in the 2001 revision of the official terminologia anatomica moving varicose vein clusters.
by the International Interdisciplinary Consensus Committee on Ve- It is true that for many women, the undesirable appearance of
nous Anatomical Terminology.2 Failure to employ current standard- varicose veins is a major reason for seeking surgical treatment.When
ized terminology can hinder data exchange in translated research questioned, however, such patients often admit to having symptoms
studies. In addition, retention of the traditional nomenclature can such as pain, heaviness, and fatigue. Typically, they do not relate
result in potentially dangerous clinical scenarios. For instance, ultra- these symptoms to the varices themselves but instead attribute them
sonographically diagnosed thrombosis of the superficial femoral to prolonged standing during daily work.
vein might, because of the term used for the vein, be erroneously in-
terpreted as superficial thrombophlebitis instead of true deep vein
thrombosis (DVT).To prevent these and other errors, a more accu-
rate delineation of the branches of the common femoral vein is re-
quired.Thus, the terms femoral vein (instead of superficial femoral Table 1 Indications for Varicose Vein Surgery
vein) and deep femoral vein (instead of profunda femoris) are now
Pain: leg aching, leg heaviness
employed. Patchy burning (venous neuropathy)
Of particular significance for the purposes of this chapter is that Swelling: foot, ankle, leg
the greater (long) saphenous vein is now referred to as the great Dermatitis: focal, extensive
saphenous vein (GSV), and the lesser (short) saphenous vein is now Lipodermatosclerosis
referred to as the small saphenous vein (SSV). In addition, the terms Ulceration: present or healed
saphenofemoral junction and saphenopopliteal junction have been Superficial thrombophlebitis
accepted into the official nomenclature—a change that is especially External hemorrhage
relevant to endovenous treatment of varicose veins. Various other Appearance
changes in the names of lower-extremity and pelvic veins were also
DUPLEX MAPPING
Table 2 Interrogation Points in the
Venous Reflux Examination
Over the years, surgical treatises have devoted a great deal of space
to clinical examination of the patient with varicose veins. Numerous Common femoral vein
clinical tests have been described, many of which carry the names of Femoral vein
famous persons interested in venous pathophysiology. This august Upper third
history notwithstanding, the Trendelenburg test, the Schwartz test, Distal third
the Perthes test, and the Mahorner and Ochsner modifications of Popliteal vein
Sural veins
the Trendelenburg test are, for the most part, useless in preoperative
Saphenofemoral junction*
evaluation of patients today.3 There is no doubt that clinical evalua-
Saphenous vein, above the knee
tion can be improved by using handheld Doppler devices. In our Saphenous vein, below the knee
view, however, preoperative evaluation is best performed by combin- Saphenopopliteal junction†
ing duplex scanning with physical examination.4 Duplex mapping Mode of termination, lesser saphenous vein
defines individual patient anatomy with considerable precision and
provides valuable information that supplements the physician’s clin- *Record diameter of refluxing long saphenous vein.
†
ical impression.This information allows the physician to develop a Record distance from floor.
strategy that will treat abnormal refluxing veins while leaving normal
portions of the venous system in place, thereby minimizing operative
trauma and reducing long-term recurrence. ed for subsequent use in selecting the proper endovenous catheter
A protocol for duplex mapping of incompetent superficial veins during saphenous ablation.
has been published.4 In essence, the examination consists of inter- The GSV is identified on the basis of its relation to the deep and
rogating specific points of reflux with the patient standing [see Table superficial fascia that ensheathe it to form the saphenous compart-
2]. Forward flow is produced with muscular compression, and re- ment. High-resolution B-mode ultrasonographic imaging of the su-
verse flow is then assessed in the crucial areas that are important to perficial fascia in the transverse plane has shown that this structure
subsequent procedural planning. reflects ultrasound strongly, yielding a characteristic image of the
The patient is placed in an upright position so that the leg veins GSV known as the saphenous eye [see Figure 1].The saphenous eye
are maximally dilated. No clothing is worn on the lower extremities is a constant marker that is clearly demonstrable in transverse sec-
from the waist down, except for nonconstricting underwear. The tions of the medial aspect of the thigh and that readily differentiates
patient is instructed to inform the sonographer of any sensation of the GSV from varicose tributaries and other superficial veins. Casu-
light-headedness, faintness, dizziness, or nausea.These symptoms al examination of the thigh often reveals an elongated, dilated vein
seem to be associated with the overall atmosphere of the room and that is incorrectly assumed to be the GSV.This mistaken assump-
the presence of Doppler velocity signals; they appear to be less like- tion can be corrected by means of ultrasound scanning with the
ly to occur when the examination itself is performed silently. If a saphenous eye as an anatomic marker.
tendency to fainting because of vagovagal reflux is encountered, the Venous reflux can be elicited manually by calf muscle compres-
examination may have to be modified so that the patient is in a sion and release, by the Valsalva maneuver, or by pneumatic tourni-
semiupright position instead. quet release. In terms of efficacy, there is no difference between
Examination should include both lower extremities, though post- pneumatic tourniquet release and manual compression and release.
treatment examinations may target a single extremity or a single However, pneumatic tourniquet release is cumbersome and re-
area of an extremity.The full length of the axial venous system from quires two vascular sonographers, which makes the manual com-
ankle to groin is examined.The probe is aligned transversely so that pression and release method very attractive by comparison. If
specific named veins can be identified and their relations to other saphenofemoral reflux lasting longer than 0.5 second is present, the
limb structures determined.The veins are scanned by moving the diameter of the GSV is recorded 2.5 cm distal to the sapheno-
probe up and down along their courses. Double segments, sites of femoral junction.
tributary confluence, and large perforating veins (along with their The examination continues distally along the GSV, with distal
deep venous connections) are identified. (Perforating veins are augmentation of flow performed at intervals to check for reflux. Re-
those that course from the subcutaneous tissue through deep fascia flux frequently ends in the region of the knee.The point at which re-
to anastomose with one of the named deep venous structures; com- flux stops is recorded in terms of distance from the floor in centime-
municating veins are those that anastomose with one another with- ters. The femoral vein (i.e., the vessel formerly termed the
in a single anatomic plane.) Varicose veins are often arranged in superficial femoral vein) is checked at midthigh for reflux and vein
multiple parallel channels. It is unnecessary to follow reflux into all wall irregularities.
of the varicose clusters, because these are obvious to the treating The posterior examination is also done on the non–weight-bear-
physician. Augmentation of flow (distal compression) is done ing lower extremity, with attention paid to reflux in the popliteal
sharply, quickly, and aggressively, and pressure is applied to the calf vein, the saphenopopliteal junction, and the SSV.The Valsalva ma-
to activate the gastrocnemius-soleus pump.When a color or pulsed- neuver may be used to stimulate reflux, as may distal augmentation
wave Doppler device is used, the probe is angled to provide an in- and release.Valsalva-induced reflux is halted by competent proxi-
sonation angle of 60º or less. mal valves.The SSV is followed from its retromalleolar position on
For the anterior examination, the patient faces the sonographer the lateral aspect of the ankle proximally to the saphenopopliteal
with his or her weight borne on the lower extremity that is not being junction, and augmentation maneuvers are performed every few
examined. The non–weight-bearing extremity is then evaluated. centimeters.
The common femoral vein and the saphenofemoral junction are as- The termination of the SSV is noted. If the vein terminates prox-
sessed with the Valsalva maneuver and with distal compression and imally in the vein of Giacomini, the femoropopliteal vein, or anoth-
release. If reflux is present, the diameter of the refluxing GSV is not- er vein, a specific check is made for a connection to the popliteal
vein. If the SSV shows reflux, the distance from the sapheno- thetized (and consequently obliterated) at one time. Epinephrine
popliteal junction to the floor is measured and recorded. can be added to the solution to improve postoperative hemostasis,
A search for incompetent perforating veins is necessary only in increase venous contraction around the heat-generating catheter,
limbs with chronic venous insufficiency (CVI) manifested by hyper- and lengthen the duration of postprocedural analgesia. A common
pigmentation, atrophie blanche, woody edema, scars from healed ul- formula for the tumescent anesthesia solution is 450 ml of normal
ceration, or actual open ulcers. Incompetent perforating veins in saline mixed with 50 ml of 1% lidocaine with epinephrine
limbs without CVI are associated with varicose veins and can be (1:100,000 dilution) and 10 ml of sodium bicarbonate to buffer the
controlled with varicose phlebectomy. Identification of perforating acidity of the lidocaine.
veins in the lower extremity can be difficult even for the experienced Duplex ultrasonography has revolutionized treatment of varicose
sonographer. veins. It dramatically enhances physicians’ ability to evaluate the
cause of varicosities and to tailor treatment so that only the diseased
vein segments are ablated while the normal segments are preserved.
Procedural Planning It also serves to guide placement of sheaths and heat-generating
For varicose vein treatment to be successful, two goals must be catheter tips, allowing these devices to be situated very precisely
met: (1) reflux must be ablated from the deep veins to the superficial within the vein.
veins, and (2) all branch varicosities must be removed. Reflux must
TECHNIQUE
be eliminated from all major problem areas, including the saphe-
nofemoral junction, the saphenopopliteal junction, and the
Laser Vein Ablation
midthigh Hunterian perforator vein. To identify these problem ar-
eas, careful preoperative duplex mapping of major superficial venous Laser vein ablation [see Figure 2] may be performed either in the
reflux is essential. All varicose vein clusters are meticulously marked office or in the hospital. Reimbursement issues make in-office treat-
before operation; they may be difficult to identify during the proce- ment advantageous for most physicians. Neither conscious sedation
dure, when the patient is supine. nor noninvasive monitoring is required. On occasion, a nervous pa-
At present, three techniques are approved for the elimination of tient may benefit from administration of an oral anxiolytic agent 1 to
axial reflux in the GSV and the SSV: (1) traditional surgical strip- 2 hours before the procedure.
ping, (2) laser vein ablation (i.e., endovenous laser therapy [EVLT]), Standard surgical preparation and draping are indicated, including
and (3) radiofrequency (RF) ablation. Regardless of which tech- the use of sterile gowns, masks, drapes and aseptic technique. De-
nique is employed, the principal goals of treatment (see above) are pending on the results of the preoperative physical examination and
the same. In addition, the procedure must be done in a manner that duplex ultrasonography, the GSV, the SSV, the anterior accessory
optimizes cosmetic results and minimizes complications. saphenous vein, or the posterior accessory saphenous vein may be
treated, either alone or in combination with other vessels as neces-
sary.The GSV is usually treated from the upper third of the calf to
Endovenous Procedures the saphenofemoral junction. If the calf portion of the GSV is to be
Current endovenous techniques for treating varicose veins are treated, tumescent anesthesia should be liberally employed to reduce
based on three major developments: (1) the availability of laser and the risk of saphenous nerve injury.The SSV is treated from the distal
RF probes that deliver heat endovenously, (2) the introduction of third of the calf to the point where it angles toward the popliteal vein
tumescent anesthesia, and (3) the evolution of duplex ultrasonogra- in the popliteal fossa.The relation of the sural nerve to the distal third
phy. Tumescent anesthesia allows physicians to use large volumes of the SSV precludes safe treatment of this portion of the vein, and
(500 ml) of dilute (0.1%) lidocaine in a single session while achiev- the proximity of the popliteal nerve to the SSV in the popliteal fossa
ing anesthesia levels equivalent to those achieved with 1% lidocaine. precludes safe treatment of the most proximal portion of the vein.
In this way, the entire thigh portion of the GSV can be safely anes- The procedure does not allow flush ligation of the saphenofemoral
junction, but current evidence suggests that this measure may not be
indicated: flush ligation eliminates normal venous drainage from the
saphenofemoral junction and may increase the risk of neovasculariza-
tion of the saphenofemoral junction and recurrence of varicosities.
The saphenous vein being treated is accessed with a microp-
uncture system after a small amount of lidocaine (sufficient to
raise a small skin wheal) is injected into the dermis.The position
of the 0.015-in. wire in the saphenous vein is confirmed by means
of ultrasonography. A 4 French catheter is then passed over the
wire, allowing the placement of a 0.035-in. wire for access to the
proximal portion of the saphenous vein. Next, the 0.035-in. wire is
positioned at the appropriate saphenous junction, and a 5 French
vascular sheath is advanced over the wire to the junction. The
sheath is positioned either just below the superior epigastric vein
or 1 to 2 cm distal to the junction of the GSV; if the SSV is being
treated, the tip is positioned 2 to 3 cm below the junction at the
point where the vein makes its transition from an oblique course
to a parallel path under the fascia of the leg. The 600 μm laser
Figure 1 Shown is an ultrasonographic image of the so-called fiber is then passed to the tip of the sheath, which is pinned and
saphenous eye. Correct identification of this marker is crucial to pulled to expose the tip of the laser fiber.The rigidity and sharp-
correct performance of the preoperative ultrasonographic reflux ness of the laser fiber makes advancing its tip dangerous. Most
examination. laser systems allow the fiber to be locked to the sheath, so that the
Saphenofemoral Figure 2 Ablation of great saphenous vein. Shown is percutaneous place-

Junction ment of a quartz fiber for laser ablation of the GSV. In practice, the catheter
used for RF ablation is placed in a similar fashion. Both laser ablation and
Femoral RF ablation deliver electromagnetic energy to the vein wall to destroy the
Artery vessel and remove it from the circulation.
Femoral
Vein
Laser
Fiber
Greater
Saphenous
Vein
two devices can be advanced and positioned as a single unit. solution are administered when the vein being treated lies in close
To this point in the procedure, no anesthesia other than the initial proximity to one or more nerves (e.g., the SSV and the calf portion
dermal injection has been employed.The next step, accordingly, is of the GSV). As a rule, we prefer not to treat the subdermal portions
to initiate tumescent anesthesia, with or without epinephrine, along of the GSV with laser ablation; the presence of an inflamed and ten-
the saphenous compartment. The addition of epinephrine to the der vein just beneath the dermis is likely to lead to increased postop-
anesthetic solution results in improved constriction of the vein erative pain and noticeable skin discoloration. The superficial seg-
around the laser sheath, particularly when a saphenous vein larger ments of the GSV are best treated with phlebectomy at the time of
than 12 mm in diameter is being treated; it also prolongs the anal- laser ablation.
gesic effect of lidocaine, providing pain relief for as long as 6 to 8 When administration of the tumescent anesthesia solution is
hours after the procedure. A particular benefit of tumescent anes- complete, the position of the laser fiber’s tip is again confirmed. As
thesia is that the large volume of the injectate constitutes a heat sink the vein constricts, it also shortens, and this process may advance the
that absorbs the heat created by the laser, thereby eliminating injury tip of the laser fiber into the saphenofemoral or saphenopopliteal
to surrounding soft tissue structures (e.g., nerves, fat, and skin). Fur- junction. If the tip is found to have moved in this manner, it is with-
ther protection against injury is provided by rapid pullback of the drawn until it is again 1 to 2 cm below the junction. A quick scan
laser fiber. As a result, the reported incidence of thermal skin or down the vein is done to confirm that the entire vein is surrounded
nerve injuries with laser vein ablation is almost zero. by the anesthetic solution and is at least 1 cm from the skin.
Administration of the tumescent anesthesia solution starts at the At this point, the laser may be safely activated.The laser is always
sheath entry site and continues proximally until the entire vein seg- used in the continuous mode.The power setting may range from 10
ment to be treated exhibits a circumferential zone of echolucence. to 12 W, depending on the physician’s personal preference.We typi-
The vein is generally treated in the saphenous compartment be- cally employ a 10 W setting for veins smaller than 10 mm and a 12
tween the superficial and deep fasciae of the leg. The anesthetic is W setting for veins larger than 10 mm.The essential point is that be-
administered via a 22-gauge needle with a 20 ml syringe or, alterna- tween 50 and 100 J must be delivered to each centimeter of vein
tively, via a 10 ml autofill syringe or a Klein pump (both of which treated; according to one study, 70 J/cm is the ideal amount for reli-
have the advantage of allowing more rapid administration with less able long-term vein obliteration.5 Energy delivery can easily be de-
risk of needle-stick injury to the staff).The needle is kept in a static termined as the laser fiber is withdrawn. Most laser sheaths have
position during administration, and the fluid is allowed to dissect up markings 1 cm apart, and the laser machines have digital readouts
and down the fascial compartment. that indicate the total amount of energy (J) delivered in real time. A
Besides providing pain relief, tumescent anesthesia serves to simple calculation after 10 cm of the catheter has been withdrawn
move the saphenous vein being treated away from any structure that provides instant feedback on the energy delivered per centimeter of
might be injured by the heat produced by the laser (e.g., the skin vein. On the 12 W power setting, delivery of the recommended
and the femoral vein). A 1 cm distance between the skin and the amount of energy generally necessitates a pullback rate of 1 cm
laser fiber is optimal. More liberal amounts of tumescent anesthesia every 4 to 5 seconds (2.0 to 2.5 mm/sec). One group has advocated
delivery of 140 J/cm proximally (pullback rate of 1 mm/sec) and taining the benefits of saphenous vein ablation, RF alternating cur-
roughly 70 J/cm distally (pullback rate of 3 mm/sec), theorizing that rent has been employed to effect rapid thermic electrocoagulation of
for long-term success, more energy is required proximally.6 At the the vein wall and its valves.This approach is exemplified by the Clo-
completion of the procedure, the laser is deactivated before the fiber sure procedure (VNUS Medical Technologies, Inc., San Jose, Cali-
is withdrawn from the skin. Ultrasonography is then performed to fornia). Prolonged exposure to the high-frequency energy results in
confirm that the common femoral vein and the superficial epigastric total loss of vessel wall architecture, disintegration, and carboniza-
vein are patent and that the GSV is occluded. tion.12 Ultrasonographic follow-up shows that treated saphenous
An adhesive strip (e.g., Steri-Strip; 3M, St. Paul, Minnesota) cov- veins disappear after the 2-year point. Clinical observations suggest
ered by a transparent surgical adhesive dressing is applied over the that patients are much more comfortable after RF ablation than af-
entry site.The patient is then placed in a prescription compression ter surgical stripping.13
stocking, which is worn for 1 to 2 weeks after the procedure.Where- The technique of RF ablation is somewhat similar to that of laser
as most physicians use a class 2 (30 to 40 mm Hg) compression ablation [see Figure 2] but differs in several important respects [see
stocking, we have switched to using a class 1 (20 to 30 mm Hg) Laser Vein Ablation, above].After percutaneous access is obtained, ei-
stocking without observing any changes in complications (e.g., post- ther a 6 or an 8 French RF radiofrequency catheter is placed 1 to 2
operative pain and swelling) or results.This switch has enhanced pa- cm from the saphenofemoral junction, and tumescent anesthesia is
tient satisfaction, in that a class 1 stocking is easier to don and more instituted.The probe is connected to the RF generator box, the tines
comfortable to wear. of the probe are exposed, and the unit is activated. The catheter is
A 2003 study that followed 499 limbs over 2 years demonstrated pulled back slowly (1 cm every 30 seconds) while its temperature
a varicosity recurrence rate of less than 7% after ablation of the GSV and impedance are monitored. In the procedure as originally per-
with an 810 nm diode laser.7 This rate is comparable to or lower formed, the catheter was heated to 85° C, but current approaches of-
than those reported after traditional surgical stripping, RF ablation, ten involve heating the catheter to 90° or 95° C with the aim of short-
and ultrasound-guided sclerotherapy. Several smaller studies docu- ening the pullback time (to compete with the shorter pullback times
mented similar outcomes, making it evident that laser vein ablation characteristic of laser ablation). In general, however, pullback times
is both effective and safe when compared to other means of treating are still somewhat longer with RF ablation than with laser ablation,
varicose veins [see Table 3].1,6,8-11 allowing more dissemination of heat to surrounding tissue; postpro-
At present, the question of how to manage residual varicosities af- cedural paresthesia continues to be reported in about 12% of cases.14
ter laser ablation remains controversial. The two main options are The technical results of RF ablation are excellent: with the Closure
(1) to perform phlebectomy simultaneously with laser vein ablation procedure, the closure rate at 4 years is 89%.14 However, the contin-
and (2) to perform laser ablation alone, then observe the patient for ued occurrence of paresthesias and the slower pullback times associ-
spontaneous regression of varicosities.When the residual varicosities ated with RF ablation still appear to make laser vein ablation a safer
are left untreated, 10% to 20% of patients show sufficient regression and more rapid procedure.
to render further intervention unnecessary; however, 5% to 10% of The issue of recurrent varicosities after obliteration of the GSV
patients experience superficial thrombophlebitis in the residual vari- without disconnection of the saphenofemoral junction tributaries is
cosities as a consequence of stasis from altered venous drainage. If unsettled at present. It does appear, however, that endovenous RF
delayed treatment of residual varicosities proves necessary, it may be ablation of the GSV (e.g., with the Closure procedure) prevents
accomplished with either phlebectomy or sclerotherapy, depending subsequent neovascularization in the groin. Many centers have re-
on the physician’s preference. Our treatment of choice is laser vein ported that neovascularization does not occur in the absence of a
ablation with concurrent phlebectomy.This approach adds only 10 groin incision.
to 20 minutes to the length of the procedure while offering the pa- The specific goal of endoluminal treatment of venous reflux is
tient a more rapid and complete resolution of visible varicose veins obliteration of the saphenous vein. Follow-up to 4 years shows that
and greatly reducing the risk of secondary thrombophlebitis. RF ablation with the Closure procedure accomplishes this goal.14
Radiofrequency Ablation OUTCOMES AND COMPLICATIONS
In an attempt to minimize postoperative discomfort while main- Both EVLT and RF ablation have proved to be effective and safe
Table 3—Complications of Laser Vein Ablation and Radiofrequency (RF) Ablation in Selected Studies15
Ablation
Method Study LimbsTreated (N) Skin Burn (%) Paresthesia (%) Phlebitis (%) DVT (%) Recanalization (%)
Navarro43 40 0 0 0 0 0
Proebstle44 109 0 0 10 0 10
Laser
Min7 504 0 0 5 0 2
Perkowski45 154 0 0 0 0 3
Weiss46 140 0 4 0 0 10
Merchant47 318 4 15 2 1 15
RF
Hingorani48 73 0 0 0.3 16 4
Merchant14 1,078 2 12 3 0.5 11

Circumflex It is true that the GSV is largely preserved after proximal ligation17;
Iliac Vein
however, reflux continues, and hydrostatic forces are not con-
trolled.18 Recurrent varicose veins are more frequent after saphe-
nous ligation than after stripping.19 Varicosities also recur more fre-
quently after ligation and sclerotherapy than after stripping and
Femoral sclerotherapy.20 A prospective, randomized trial that compared
Vein proximal GSV ligation and stab avulsion of varices with stripping of
the thigh portion of the GSV and stab avulsion of varices showed
Epigastric
the latter approach to be superior.21,22 Routine GSV stripping re-
Vein duces the rate of recurrent varicosities and the need for reoperation
for recurrent saphenofemoral incompetence.
External Although it can be argued that the GSV should be retained for
Pudendal
Artery
possible use in arterial bypass grafting, the relatively high (> 20%)
reoperation rate makes this strategy undesirable. Almost three quar-
ters of limbs that undergo GSV ligation alone have an incompetent
GSV on follow-up duplex imaging. Until studies show a clear ad-
vantage to retaining the GSV in defined patient populations, surgi-
cal stripping should remain a routine part of primary GSV surgery.
Greater
Saphenous
In several studies, preservation of the patency of the GSV and con-
Vein tinuing reflux in this vein were found to be the factors most fre-
quently associated with recurrence of varicosities.23-25 In one study
Anterolateral of patients who underwent reoperation for relief of recurrent variceal
Tributary Vein symptoms, two thirds of the patients required removal of the GSV
as part of the procedure.23
Posteromedial
Tributary Vein
Over the past 100 years, ankle-to-groin stripping of the GSV has
been the dominant approach to treatment of varicose veins.26-28 It
has been argued, however, that routine stripping of the leg (i.e., an-
Figure 3 Shown are a typical saphenofemoral junction and the kle-to-knee) portion of the GSV is inadvisable. One argument
most important tributary vessels. The classic surgical approach
against this practice is that there is a significant risk of concomitant
dictates total disconnection of all tributaries at this junction.
saphenous nerve injury [see Figure 4].19 Another argument is that
whereas the objective of GSV removal is detachment of perforating
for the treatment of venous reflux disease. Several studies that fol- veins emanating from the GSV in the thigh, the perforating veins in
lowed treated limbs for 2 years or longer have shown that with re- the leg are actually part of the posterior arch vein system rather than
spect to efficacy, these modalities are equivalent or superior to stan- of the saphenous vein system.This latter argument notwithstanding,
dard surgical techniques.7,11,15,16 It is noteworthy that neovasculari- preoperative ultrasonography often demonstrates that the leg por-
zation seems to be almost nonexistent with endovenous procedures; tion of the GSV is in fact directly connected to perforating veins. It is
this result appears to be related exclusively to standard ligation clear, however, that elimination of the refluxing thigh portion of the
surgery. GSV frequently eliminates reflux in the calf portion of the vein, even
Multiple studies have reported similar end-point results for when the calf portion is left behind.Therefore, removal of the GSV
EVLT and RF ablation: long-term occlusion of the GSV is consis- from ankle to knee generally is not necessary. If reflux subsequently
tently achieved at rates approaching or exceeding 90%. In general, becomes a problem in this portion of the vein, it can usually be con-
EVLT has somewhat better long-term success rates, ranging from trolled with sclerotherapy.
92% to 95%; RF ablation generally yields success rates between
OPERATIVE TECHNIQUE
85% and 91%.The incidence of DVT (which is more accurately de-
scribed as extension of thrombus from the treated vein into the deep The surgical approach to vein stripping must be tailored to the in-
venous system) is low with both procedures but is slightly higher dividual patient and the individual limb being treated. As a rule,
with RF ablation. No cases of life-threatening pulmonary embolism general or spinal anesthesia is required, though the procedure can
have been reported with either EVLT or RF ablation, and both are also be performed with tumescent anesthesia. Groin-to-knee strip-
associated with only negligible rates of superficial thrombophlebitis, ping of the GSV should be considered in every patient requiring sur-
cellulitis, (excessive) pain, and transient paresthesias. gical intervention.29 In nearly all patients, this measure is supple-
A 2006 study stressed the importance of treating the posterior mented by removal of the varicose vein clusters via stab avulsion or
thigh circumflex vein so as to lower the incidence of recanalization.15 some form of sclerotherapy [see Table 4].
A large posterior thigh circumflex vein can drain cool blood into the
segment being ablated, thus inhibiting proper heating of the reflux- Step 1: Placement of Incisions
ing segment and making adequate closure more difficult. Accord- Preoperative marking, if correctly performed, will have docu-
ingly, the authors recommended ablating any posterior thigh cir- mented the extent of varicose vein clusters and identified the clinical
cumflex veins larger 4 mm in tandem with the primary procedure. points where control of varices is required. Incisions can then be
planned. As a rule, incisions in the groin and at the ankle should be
transverse and should be placed within skin lines. In the groin, an
Surgical Vein Stripping oblique variation of the transverse incision may be appropriate.This
Ligation of the GSV at the saphenofemoral junction [see Figure 3] incision should be placed high enough to permit identification of the
has been widely practiced in the belief that it would control gravita- saphenofemoral junction [see Figure 3].The use of a portable ultra-
tional reflux while preserving the vein for subsequent arterial bypass. sound unit in the operating room facilitates placement of the inci-
sion directly over the saphenofemoral junction. Generally, through-

out the leg and the thigh, the best cosmetic results are obtained with Table 4 Methods of Variceal Ablation
vertical incisions.Transverse incisions are used in the region of the
knee, and oblique incisions are appropriate over the patella when the Formal ligation, division, and excision
incisions are placed in skin lines. Stab avulsion
A major cause of discomfort and occasional permanent skin pig- Sclerotherapy
With liquid sclerosant
mentation is subcutaneous extravasation of blood during and after
With foamed sclerosant
saphenous vein stripping. Such extravasation can be minimized by
Sclerotherapy aided by transillumination
using tumescent anesthesia around the vein to be stripped. Sclerotherapy aided by ultrasound guidance
The practice of identifying and carefully dividing each of the trib-
utaries to the saphenofemoral junction has been dominant over the
past 50 years.The rationale for this practice is to avoid leaving be-
hind a network of interanastomosing inguinal tributaries. Accord- scriptions of residual inguinal networks as an important cause of
ingly, special efforts have been made to draw each of the saphenous varicose vein recurrence.23 Currently, however, this central principle
tributaries into the groin incision so that when they are placed on of varicose vein surgery is under challenge, on the grounds that
traction, their primary and even secondary tributaries can be con- groin dissection can lead to neovascularization and hence to recur-
trolled.The importance of these efforts has been underscored by de- rence of varicosities [see Outcome Evaluation, below].
Step 2: Introduction of Stripping Device
Preoperative duplex studies having already demonstrated incom-
petent valves in the saphenous system, a disposable plastic Codman
stripper can be introduced from above downward; alternatively, an
Oesch stripper can be employed.30 Both of these devices can be
used to strip the GSV from groin to knee via the inversion technique
[see Figure 5]. This approach has been shown to reduce soft tissue
trauma in the thigh.31
In the groin, the stripper is inserted proximally into the upper end
of the divided internal saphenous vein and passed down the main
channel through incompetent valves until it can be felt lying distally
approximately 1 cm medial to the medial border of the tibia at a
point approximately 4 to 6 cm distal to the level of the tibial tuber-
cle.The GSV is anatomically constant in this location, just as it is in
the groin and ankle. If the GSV is removed from the groin to this
level, both the midthigh perforating vein, which usually enters the
GSV, and the most distal incompetent perforating veins, which are
in the distal third of the thigh, will be treated.
A small incision is made over the palpable distal end of the strip-
per. The GSV will subsequently be divided through this incision,
and the stripper and the inverted vein will be delivered through it. In
exposing the GSV at knee level, the superficial fascia must be in-
cised because the vein lies between this structure and the deep fascia
of the thigh.
If the stripper passes unimpeded to the ankle, it can be exposed
there with an exceedingly small skin incision placed in a carefully
chosen skin line. Passage of the stripper from above downward to
the ankle serves to confirm the absence of functioning valves, and
stripping of the vein from above downward is unlikely to cause
nerve damage. At the ankle, the vein should be carefully and cleanly
dissected to free it from surrounding nerve fibers. If this is not done,
saphenous nerve injury will result, and the patient will experience
numbness of the foot below the ankle.
Step 3: Removal of Saphenous Vein
The previously placed stripper is pulled distally to remove the
GSV. Although plastic disposable vein strippers and their metallic
equivalents were designed to be used with various-sized olives to
remove the GSV, in fact, a more efficient technique is simply to tie
the vein to the stripper below its tip so that the vessel can then be
Figure 4 Surgical stripping of great saphenous vein. Illustrated inverted into itself and removed distally, usually at knee level.
is an early attempt to minimize distal incisions and prevent
Phlebectomy for Management of Residual Varicosities
saphenous nerve injury at the knee. The stripper and its obturator
are pulled to knee level, then retrieved through the groin incision. Management of residual varicose veins after vein stripping tradi-
(Note division of perforating and communicating veins.) tionally has been done at the same time as the surgical procedure.
Figure 5 Surgical stripping of great saphe-

nous vein. Inversion stripping of the GSV
decreases soft tissue trauma in the thigh.
However, tearing of the vein occurs on occa-
sion. This problem may be largely prevented
Saphenous by attaching a corner of a 2 in. gauze roll
Vein
soaked in lidocaine-epinephrine solution to
the end of the stripper. As the stripper is
Posterior Arch
pulled, the gauze is drawn into the vein,
Vein
thereby assisting hemostasis. The gauze can
then be left in place for 10 to 20 minutes
while the stab wounds from the avulsion part
of the procedure are being closed.
COMPLICATIONS
Management of residual varicose veins after vein ablation is more
controversial. Currently, many physicians who treat vein disease are Surgical removal of the GSV on an outpatient basis still requires
not familiar with the surgical technique of phlebectomy and there- two incisions, one in the groin and the other near the knee. Postoper-
fore elect to wait for varicosities to regress after vein ablation. In 10%
to 20% of cases, enough regression of varicose veins occurs after ab-
lation that no further treatment is required. If delayed treatment
proves necessary, it may be accomplished by means of either phle-
bectomy or sclerotherapy, depending on the physician’s preference.
The technique of phlebectomy is easy to learn. A tumescent anes-
thesia solution is infused between the skin and the superficial fascia of
the leg in the area of the previously marked varicosities.The infusion a
of the anesthetic tends to dissect the GSV away from the surround-
ing tissue and causes vasoconstriction.Vertical incisions 1 to 3 mm in
length are made where appropriate. In the anterior knee and ankle
regions, where skin lines are obviously horizontal, incisions are hid-
den in the lines [see Figure 6].Varicosities are exteriorized by means of
hooks or forceps; particularly useful for this purpose are specially de-
signed vein hooks such as the Varady dissector, the Muller hook, and 1–3 mm
the Oesch hook [see Figures 7 and 8].32 Nothing should penetrate the
skin other than the small end of the hook. Usually, the vein is easily
distinguished from the surrounding fat by its taut rubber band feel.
The vessel is brought out of the skin, then removed proximally and
distally by using a hand-over-hand technique with mosquito clamps.
Eventually, the vein tears in each direction, but because of the epi-
nephrine in the tumescent anesthesia solution, very little bleeding oc-
curs.The procedure is continued in a proximal-to-distal direction un-
til all varicose clusters have been removed; generally, between 10 and b
15 incisions are required for removal of all clusters.Veins of any size
can be removed by means of this technique, even in the office setting.
In patients who have had superficial phlebitis or have previously un-
dergone sclerotherapy, the veins typically are fibrotic and adherent to
the surrounding tissue and cannot be easily removed. If treatment of
such veins proves necessary at some point in the future, sclerotherapy
is generally the method of choice.
When all phlebectomies have been completed, small elastic strips
are used to close the skin incisions. A compressive dressing is applied
for 24 hours to minimize bleeding, bruising, and swelling.When the Figure 6 Surgical stripping of great saphenous vein: phlebectomy
procedure is done properly, the incisions are invisible by 6 to 8 weeks for residual varicosities. (a) Skin incisions for stab avulsion of
and the patients are very happy with the results. Experienced work- varicosities are limited with respect to both length and depth. (b)
ers in Europe have achieved marked refinements of phlebectomy The dissector blade facilitates mobilization of the vein before
techniques for varicose clusters.33 removal.
In addition to the four principal causes of recurrent varicosities,

there is a fifth cause, which is beyond the operating surgeon’s con-
trol—namely, the genetic tendency to form varicosities.This tenden-
cy results in the development of localized or generalized venous wall
weakness, localized blowouts of venous walls, or stretched, elongat-
ed, and floppy venous valves.35,36
OUTCOME EVALUATION
As a rule, when undesirable outcomes occur after surgical saphe-

nous vein stripping, they become evident quite early.21 As noted (see
above), it has long been accepted practice to dissect tributary vessels
at the saphenofemoral junction very carefully, taking each of the ves-
sels back beyond the primary and even the secondary tributaries if
possible.31 In practice, however, such dissection appears to cause
Figure 7 Surgical stripping of great saphenous vein: phlebectomy
for residual varicosities. Shown are tools used for exteriorizing
neovascularization in the groin37; surveillance with duplex ultra-
varicosities: a Hartman clamp with its single tooth placed distally, sonography supports this finding.38 It has now been amply con-
two Muller clamps, and a Varady hook and dissector (left to right). firmed that neovascularization causes recurrent varicose veins.
Clearly, this is a significant disadvantage of standard surgical treat-
ment of varicosities.This disadvantage has been a major impetus for
ative compression bandaging is standard, and most patients experi- the development of less invasive alternatives to surgical saphenous
ence little downtime. Some, however, do experience hematoma, vein stripping [see Endovenous Procedures, above, and Foam Scle-
pain, and extensive bruising.These three complications are linked; rotherapy, below].These alternatives are proving to be effective and
thus, every effort should be made to prevent oozing.The most feared may be superior to surgical stripping, if only because they are not fol-
complication of varicose vein surgery is venous thromboembolism, lowed by groin neovascularization.
but the incidence of this complication is quite low (probably about
1%). In countries where postoperative immobilization, hospitaliza-
tion, and delayed ambulation are employed for patients with vari- Foam Sclerotherapy
cosities, prophylaxis against venous thromboembolism is common. The prospect of a rapid, minimally invasive, and durable treat-
In the United States, however, this measure is generally considered ment of varicose veins is an attractive one. Current evidence suggests
unnecessary in these patients. The most common complication of that these objectives may be achieved without operative intervention
varicose vein surgery is recurrence of varicosities, which is experi- by using sclerosant microfoam [see Figure 9]. In 1944 and 1950, E. J.
enced by 15% to 30% of patients treated.24 Orbach introduced the concept of a macrobubble air-block tech-
To speak of permanent removal of varicosities implies that all po- nique to enhance the properties of sclerosants in performing
tential causes of recurrence have been considered and that surgical macrosclerotherapy.39,40 At the time, few clinicians evinced much in-
management has been planned so as to address them.There are four terest in the subject, and the technique languished.
principal causes of recurrence of varicose veins, three of which can
be dealt with at the time of the primary operation.
One cause of recurrent varicosities is failure to perform the prima-
ry operation correctly. Common errors include missing a duplicated
saphenous vein and mistaking an anterolateral or accessory saphe-
nous vein for the GSV. Careful and thorough anatomic identification
will help minimize such errors. It has long been held that a second
cause of recurrent varicose veins is failure to do a proper groin dis-
section; however, it is now known that such dissection causes neo-
vascularization in the groin, leading to recurrence of varicose veins
[see Outcome Evaluation, below]. A third cause is failure to remove
the GSV from the circulation. A reason often cited for this failure is
the desire to preserve the GSV for subsequent use as an arterial by-
pass, but it is clear that the preserved GSV continues to reflux and
continues to elongate and dilate its tributaries, thereby producing
more varicosities even after primary operative treatment has re-
moved the varicose veins present at the time. A fourth cause of re-
current varicosities is persistence of venous hypertension through
nonsaphenous sources—chiefly perforating veins with incompetent
valves. Muscular contraction generates enormous pressures that are
directed against valves in perforating veins.Venous hypertension in-
duces a leukocyte endothelial reaction, which, in turn, incites an in-
flammatory response that ultimately destroys the venous valves and
weakens the venous wall.34 The perforating veins most commonly as-
sociated with recurrent varicosities are the midthigh perforating vein,
the distal thigh perforating vein, the proximal anteromedial calf per- Figure 8 Surgical stripping of great saphenous vein: phlebectomy
forating vein, and the lateral thigh perforating vein, which connects for residual varicosities. The varix is exteriorized with a hook, then
the deep femoral vein to surface varicosities. divided to permit proximal and distal avulsion.
a b
Telangiectasia
Dermis
Varicose
Tributary Recticular
Vein
Saphenous Perforating
Vein Vein
Supericial
Fascia
Perforating
Vein Deep c
Fascia
Deep Vein
Figure 9 Microfoam sclerotherapy. (a) The relationships among the venous

structures in a lower extremity with varicosities explain why microfoam
sclerotherapy can succeed. Injections into varices, reticular veins, or perfo-
rating veins can place the foam into varicose structures and even into
telangiectatic blemishes. (b) Sclerosant foam is made by mixing room air
with 0.5% sodium tetradecyl sulfate (STS) in a 2:1 ratio via a three-way
stopcock. The syringes are emptied 35 times to create a foam that lasts
about 5 minutes. (c) A halogen light (vein light), as used here during a foam
injection, is helpful for treating persistent or recurrent varices along with
the GSV in situations where surgery is undesirable.
Half a century later, the work of Juan Cabrera and colleagues in limbs could be safely and effectively treated by means of foam scle-
Granada attracted the attention of some phlebologists and reawak- rotherapy combined with compression.42 In this study, limbs affect-
ened interest in using foam technology for the treatment of venous ined by lipodermatosclerosis, atrophie blanche, or even open venous
sufficiency.41 These investigators showed that foam sclerotherapy was ulcers showed statistically significant improvement after the injec-
technically simple and worked well in small to moderate-sized vari- tion of a foamed sclerosant followed by compression with a medical-
cose veins, and they demonstrated that the limitations of liquid scle- grade stocking or an Unna boot.The study results also underscored
rotherapy could be erased by using microfoam.Their 5-year report the importance of applying compression immediately after the injec-
represents the longest observation period to date for microfoam scle- tion of the sclerosant. Limbs that underwent foam sclerotherapy and
rotherapy for varicose veins. In most of the cases, a single injection compression healed better and more quickly than limbs that were
sufficed to treat saphenous veins and varicose tributaries. Extensive treated by sclerotherapy alone.
vasospasm was seen immediately, but compression was applied after If subsequent work continues to confirm these favorable results, it
treatment. Complete fibrosis of the saphenous vein was achieved in may be that microfoam sclerotherapy will eventually replace all oth-
81% of cases, and patency with reflux persisted in only 14%.Tribu- er methods of varicose vein treatment. As of December 2006, how-
tary varicosities disappeared in 96% of cases.Vessels that remained ever, foam sclerotherapy had not been approved by the United
open and were refluxing were successfully closed with retreatment. States Food and Drug Administration, because of concerns about
A subsequent study demonstrated that even severely affected potential air embolization after the injection of the sclerosant.
References
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extensions, refinements, and clinical application. 2004 years after endovenous laser treatment? J
J Vasc Surg 41:719, 2005 6. Min R, Khilnani N: Endovenous laser ablation Endovasc Ther 12:731, 2005
3. Ballard JL, Bergan, JJ, DeLange M: Venous of varicose veins. J Cardiovasc Surg 46:395, 10. Proebstle T, Gul D, Kargl A, et al: Endovenous
imaging for reflux using duplex ultrasonography. 2005 laser treatment of the lesser saphenous vein with
Noninvasive Vascular Diagnosis. AbuRahma AF, 7. Min R, Khilnani N, Zimmet S: Endovenous a 940-nm diode laser: early results. Dermatol
Bergan JJ, Eds. Springer-Verlag, London, 2000, laser treatment of saphenous vein reflux: long- Surg 29:357, 2003
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Endovenous laser therapy and radiofrequency 23. Stonebridge PA, Chalmers N, Beggs I, et al: 38. Fischer R, Linde N, Duff C, et al: Late recurrent
ablation of the great saphenous vein: analysis of Recurrent varicose veins; a varicographic analy- saphenofemoral junction reflux after ligation and
early efficacy and complications. J Vasc Surg sis leading to a new practical classification. Br J stripping of the greater saphenous vein. J Vasc
42:488, 2005 Surg 82:60, 1995 Surg 34:236, 2001
12. Petrovic S, Chandler JG: Endovenous oblitera- 24. Darke SG: The morphology of recurrent vari- 39. Orbach EJ: Sclerotherapy of varicose veins: uti-
tion: an effective, minimally invasive surrogate cose veins. Eur J Vasc Surg 6:512, 1992 lization of intravenous air block. Am J Surg
for saphenous vein stripping. J Endovasc Surg 25. Conrad P: Groin-to-knee down stripping of the 66:362, 1944
7:11, 2000 long saphenous vein. Phlebology 7:20, 1992 40. Orbach EJ: Contribution to the therapy of the
13. Goldman MP: Closure of the greater saphenous 26. Mayo CH: Treatment of varicose veins. Surg varicose complex. J Intl Coll Surg 13:765, 1950
vein with endoluminal radiofrequency thermal Gynecol Obstet 2:385, 1906 41. Cabrera J, Cabrera J, Garcia-Olmedo MA:
heating of the vein wall in combination with Treatment of varicose long saphenous vein with
ambulatory phlebectomy: preliminary 6-month 27. Babcock WW: A new operation for extirpation of
varicose veins. NY Med J 86:1553, 1907 sclerosant in microfoam form: long term out-
followup. Dermatol Surg 26:105, 2000
comes. Phlebology 15:19, 2000
14. Merchant RF, Pichot O, Myers KA: Four-year 28. Keller WL: A new method for extirpating the
internal saphenous and similar veins in varicose 42. Pascarella L, Bergan J, Mekenas L: Severe
follow-up on endovascular radiofrequency oblit-
conditions: a preliminary report. NY Med J chronic venous insufficiency treated by foam
eration of great saphenous reflux. Dermatol Surg
82:385, 1905 sclerosant. Ann Vasc Surg 20:83, 2006
31:129, 2005
29. Goren G, Yellin AE: Primary varicose veins: 43. Navarro L, Min RJ, Bone C: Endovenous laser:
15. Almeida J, Raines J: Radiofrequency ablation
topographic and hemodynamic correlations. J a new minimally invasive method of treatment
and laser ablation in the treatment of varicose
Cardiovasc Surg 31:672, 1990 for varicose veins—preliminary observations
veins. Ann Vasc Surg 20:4, 2006
using an 810 nm diode laser. Dermatol Surg
16. Pannier F, Rabe E: Endovenous laser therapy 30. Goren G, Yellin AE: Invaginated axial saphenec- 27:117, 2001
and radiofrequency ablation of saphenous vari- tomy by a semirigid stripper: perforate-invagi-
nate stripping. J Vasc Surg 20:970, 1994 44. Proebstle TM, Gul D, Lehr HA, et al: Infrequent
cose veins. J Cardiovasc Surg 47:3, 2006
early recanalizaion of greater saphenous vein
17. Rutherford RB, Sawyer JD, Jones DN: The fate 31. Bergan JJ: Saphenous vein stripping by inver- after endovenous laser treatment. J Vasc Surg
of residual saphenous vein after partial removal sion: current technique. Surg Rounds 23:118,
38:511, 2003
or ligation. J Vasc Surg 12:422, 1990 2000
45. Perkowski P, Ravi R, Gowda RC, et al:
18. McMullin GM, Coleridge Smith PD, Scurr JH: 32. Bergan JJ:Varicose veins: hooks, clamps and suc-
Endovenous laser ablation of the saphenous vein
Objective assessment of high ligation without tion: application of new techniques to enhance
for treatment of venous insufficiency and vari-
stripping the long saphenous vein. Br J Surg varicose vein surgery. Semin Vasc Surg 15:21,
cose veins: early results from a large single-cen-
78:1139, 1991 2002
ter experience. J Endovasc Ther 11:132, 2004
19. Munn SR, Morton JB, MacBeth WAAG, et al:To 33. Ricci S, Georgiev M, Goldman MP: Ambulatory
46. Weiss RA, Weiss MA: Controlled radiofrequency
strip or not to strip the long saphenous vein? A Phlebectomy: a Practical Guide for Treating
endovenous occlusion using a unique radio fre-
varicose veins trial. Br J Surg 68:426, 1981 Varicose Veins. Mosby, St Louis, 1995
quency catheter under duplex guidance to elim-
20. Neglen P: Treatment of varicosities of saphenous 34. Ono T, Bergan JJ, Schmid-Schönbein GW, et al: inate saphenous varicose vein reflux: a 2-year fol-
origin: comparison of ligation, selective excision, Monocyte infiltration into venous valves. J Vasc low-up. Dermatol Surg 20:38, 2002
and sclerotherapy. Bergan JJ, Goldman MP, Eds. Surg 27:158, 1998
47. Merchant RF, DePalma RG, Kabnick LS:
Varicose Veins and Telangiectasias: Diagnosis 35. Thulesius O, Ugaily-Thulesius L., Gjores JE, et Endovascular obliteration of saphenous reflux: a
and Management. Quality Medical Publishing, al: The varicose saphenous vein, functional and multicenter study. J Vasc Surg 35:1190, 2002
St Louis, 1993, p 148 ultrastructural studies, with special reference to
48. Hingorani AP, Ascher E, Markevich N, et al:
21. Sarin S, Scurr JH, Coleridge Smith PD: smooth muscle. Phlebology 3:89, 1988
Deep venous thrombosis after radiofrequency
Assessment of stripping the long saphenous vein 36. Rose SS, Ahmed A: Some thoughts on the aeti- ablation of greater saphenous vein: a word of
in the treatment of primary varicose veins. Br J ology of varicose veins. J Cardiovasc Surg caution. J Vasc Surg 40:500, 2004
Surg 79:889, 1992 27:534, 1986
22. Dwerryhouse S, Davies B, Harradine K, et al: 37. Jones L, Braithwaite BD, Selwyn D, et al:
Stripping the long saphenous vein reduces the Neovascularization is the principal cause of vari-
rate of reoperation for recurrent varicose veins; cose vein recurrence: results of a randomized Acknowledgments
five-year results of a randomized trial. J Vasc trial of stripping the long saphenous vein. Eur J
Surg 29:589, 1999 Vasc Endovasc Surg 12:442, 1996 Figures 2 through 6, 8, and 9a Tom Moore.
6 VASCULAR SYSTEM 21 SCLEROTHERAPY — 1
21 SCLEROTHERAPY
William R. Finkelmeier, M.D., F.A.C.S.
Sclerotherapy involves the injection of a caustic solution (a scle- sclerotherapy of the greater saphenous vein.3 Obliteration of the
rosant) into an abnormal vein so as to cause localized destruction of greater saphenous vein was noted in only 20% of the injected limbs
the venous intima and obliteration of the vessel. It is not a new tech- and in only 6% of the limbs below a refluxing junction.These poor
nique, having been practiced since the early 20th century, but it has results from sclerotherapy were confirmed in a subsequent study.4
evolved significantly over the past 50 years.1 Improvements in the The superiority of surgical treatment was also demonstrated in a ran-
technology used (e.g., hypodermic syringes, fine needles, sclerosants, domized 10-year study comparing surgery with sclerotherapy alone.5
compression technique, and duplex ultrasonography) have greatly Ultrasound-guided sclerotherapy has also been advocated. The
enhanced the results achievable with sclerotherapy.To ensure opti- advantages of this approach are that it allows much higher con-
mal results, it is essential to have a thorough knowledge not only of centrations of the sclerosant solution and that it permits direct
the technique but also of the indications, expected outcomes, and visualization of the injections. Reported recurrence rates are still
possible complications associated with the procedure. quite high, however: 22.8% at 1 year and 27.2% at 2 years..6 A
Sclerotherapy is primarily used to treat small varicose veins, number of authors, primarily in the dermatologic literature, have
reticular veins, and spider veins. The prevalence of varicose and advocated ultrasound-guided foam sclerotherapy for patients with
spider veins is well documented: they affect millions of people in axial reflux.7,8 The longevity of the results achieved with this tech-
the United States alone.1 The incidence is two to three times high- nique is still in question, and further studies (including random-
er in women than in men and increases with age. The precise eti- ized trials) are needed for validation.
ology of varicose veins and spider veins is unknown. Heredity, Given the available data, my preferred approach in patients with
pregnancy, female sex, obesity, an occupation that requires long axial reflux is to ligate the greater saphenous vein, strip the vein at
periods of standing, and a low-fiber diet all have been implicated least to the knee, and then ligate the lesser saphenous vein before
as causative factors. The choice of treatment method for varicose sclerotherapy. Patients who do not have axial reflux and whose
veins and spider veins must be individualized for each patient. vessels are less than 6 mm in diameter can be treated successfully
Although sclerotherapy is only one of a number of techniques with sclerotherapy alone.Varicose veins more than 6 mm in diam-
available for treatment, it is an important therapeutic tool and a eter are best treated surgically by means of phlebectomy, either
key component of a vascular surgeon’s armamentarium. with a hook or with a transilluminated powered phlebectomy
device. The cosmetic results are far better and the recovery time
much shorter with the surgical option.
Proper evaluation of the patient before sclerotherapy is the most
important step in achieving successful results. Such evaluation Operative Planning
should include a thorough clinical arterial and venous examination.
PATIENT PREPARATION
Close attention should be paid to the size, location, and distribution
of vessels; these variables are critical for determining the appropriate Before undergoing sclerotherapy, the patient should receive a
treatment. Any patient who is believed to have axial reflux or whose thorough explanation of the procedure, including the possible risks
clinical complaints far exceed the findings from physical examina- and complications [see Table 1]. He or she should be informed
tion should undergo venous duplex ultrasonography. about the expected outcomes and the length of time needed for
Venous duplex ultrasonography has revolutionized the treatment healing. In particular, it should be emphasized that multiple treat-
of varicose and spider veins. It is reproducible and noninvasive, and it ments are usually necessary to eliminate varicosities. Most patients
can objectively identify areas of reflux in the greater and lesser saphe- can expect to undergo four or five treatments in a 6-month period.
nous systems, as well as detect pathologic conditions in the deep ve- Time and patience are essential for achieving an optimal outcome.
nous system and incompetent perforating vessels. Duplex ultra- Because sclerotherapy is primarily cosmetic and therefore rarely
sonography can also identify the lesser saphenous–popliteal junction reimbursable, it is important to have a clear understanding regard-
and facilitate skin mapping in preparation for surgery. ing costs. A good-faith estimate of the cost per procedure should
Patients with duplex-documented axial reflux or reflux from the be provided to the patient before treatment is initiated. It is advis-
greater or lesser saphenous junction are best managed by means of able to have the patient sign a copy of this estimate so that there is
surgical correction of the reflux rather than primary treatment with no subsequent misunderstanding about the costs to be incurred
sclerotherapy. In a 1993 randomized study, ligation and stripping during the course of therapy.
were compared with compression sclerotherapy in 164 patients who To reduce bruising, aspirin and antiplatelet agents should be
had symptomatic primary varicose veins.2 After 5 years, 74% of the avoided for 10 days before treatment. On the day of the procedure,
patients treated with sclerotherapy were considered to have had treat- the patient should be asked to refrain from applying lotion to the legs
ment failures, compared with only 10% of the patients treated surgi- so that the tape applied after treatment will adhere better to the skin
cally. In a 1991 trial, real-time color duplex ultrasonography was used [see Table 2].The patient should sign and date an informed consent
to evaluate 89 limbs in 55 patients who had previously undergone form. Once informed consent is obtained, photographs of the areas
Table 1 Complications of Sclerotherapy
Complication Comment
Itching Usually mild; lasts for 1–2 days
Hyperpigmentation Occurs in about 20%–30% of patients treated; usually fades in a couple of weeks but
may take several months to a year to resolve totally; lasts longer than 1 yr in 1% of cases
Telangiectatic matting Occurs in approximately 10% of patients treated; usually resolves in 3–12 mo if left
untreated but in rare cases can be permanent
Common
Pain Lasts 1 to, at most, 7 days
Bruising May be minimized by avoiding aspirin and ibuprofen for 10 days before and after each
treatment session
Minor allergic reaction Typically resolves within about 1 hr
Ulceration at injection site Can take 4 to 6 wk to heal completely; small scar may result
Rare Anaphylaxis Incidence is extremely low
PE or DVT Incidence is extremely low

DVT—Deep venous thrombosis PE—pulmonary embolism
to be treated should be taken. Either a digital camera or a conven- with the addition of lidocaine, injection of HS is associated with
tional 35 mm camera may be used. Digital photography offers some degree of patient discomfort. Moreover, HS is more viscous
much greater flexibility, in that there is no need to wait for film de- than STS and thus more difficult to administer. Extravasation of HS
velopment.The pictures should be standardized as much as possible is also associated with a higher risk of skin necrosis.
with respect to lighting and background. The problem areas are
photographed again after treatment, and additional pictures are ob-
tained during subsequent treatments to document progress. The
aim is to give patients a reliable means of objectively comparing the Table 2 Sample Instructions to Patients
legs’ appearance before and after sclerotherapy [see Figures 1 through after Sclerotherapy
3]. Such photographs often reassure patients that significant cos-
metic improvement has been achieved and encourage them to con- NEXT APPOINTMENT TIME
tinue treatments.
Be sure to keep your follow-up appointment so the physician can
monitor your progress.
MATERIALS
Please be considerate and give our office at least 72 hours’ notice if
Sclerosants cause thrombosis and subsequent fibrosis when you are unable to keep an appointment. This will allow us time to call
injected into a blood vessel. An ideal sclerosant would exert this patients who are on the waiting list for an appointment.
effect reliably while also being inexpensive, widely available,
Please walk for a few minutes before driving home.
approved by the Food and Drug Administration (FDA), and non- Wear your support hose for 48 continuous hours.
toxic. In addition, it would be painless on injection and would After 48 hours, remove the hose, cotton balls, and tape before getting
not cause hyperpigmentation or ulceration with extravasation. your legs wet.
Unfortunately, this ideal sclerosant does not exist. All of the solu- After 48 hours, wear your support hose for a minimum of 7 days during the
waking hours. Note, you may continue to wear them longer if you prefer.
tions currently available have disadvantages.
Do not run, do high-impact aerobics, lift weights with your legs, or do
Sclerosants may be classified into two main categories: osmotic sit-ups for 2 weeks. These activities can increase the venous pressure
agents and detergents. Hypertonic saline (HS) is the most widely in your legs.
used osmotic agent. FDA-approved as an abortifacient, it is com- For 2 weeks, do not take hot baths or showers or sit in a hot tub. The
monly employed to treat superficial telangiectasias. HS in a 23.4% heat can cause vein dilatation. You may take a warm shower or bath
after 48 hours.
concentration damages the endothelial cells of the vessel walls Avoid aspirin and ibuprofen products for 10 days before and after each
through hyperosmolarity-induced dehydration. Such damage leads treatment. These products may increase the amount of bruising that
to thrombosis and fibrin deposition. Sodium tetradecyl sulfate may develop from the treatment. Acetaminophen is permitted.
(STS) and polidocanol (POL) are the most widely used detergent For further information regarding sclerotherapy, please refer to the hand-
out “Sclerotherapy Informed Consent and Before and After Treatment
agents in the United States. These agents form aggregates on en- Instructions.”
dothelial cell surfaces and cause endofibrosis by disrupting the in-
tegrity of the cells. Preparation for Your Next Treatment
In the United States, HS has been used to treat spider and vari- Bring your support hose.
cose veins for more than 50 years. Because it is a naturally occurring Do not apply creams, lotions, or powders to your legs the evening before
or the morning of your treatment.
bodily substance, it does not cause allergic reactions; however, it Bring a pair of loose shorts to wear during your treatment.
causes patients much more pain and discomfort than either STS or Avoid aspirin and ibuprofen products for 10 days before and after each
POL does.9 Adding lidocaine to HS reduces the pain associated treatment. These products may increase the amount of bruising that
with the injections without significantly decreasing the effectiveness may develop from the treatment. Acetaminophen is permitted.
of treatment or increasing the incidence of complications.10 Even
a b
Figure 1 Sclerotherapy. Shown is a 63-year-old woman (a) before and (b) after two treatments with
0.2% STS.
STEP 1: POSITIONING AND SKIN PREPARATION

Of the detergent sclerosants, both STS and POL are widely
used in the United States, but only STS is FDA approved. FDA Sclerotherapy is best performed with the patient supine. On
approval of POL has been pending for years, and it is unclear why very rare occasions, it may be necessary to puncture a vein with
it has not yet been granted. POL appears to be a very good scle- the patient standing. However, the sclerosant is not injected until
rosant, comparable to STS: it is safe, relatively painless, and high- the patient has been returned to the supine position, thus allowing
ly effective in all vein types.11,12 In a 2002 randomized study com- the vein to empty.
paring STS with POL, both agents were found to be safe and The skin is wiped with alcohol swabs to increase the visibility of
effective, yielding a 70% clinical improvement, and there were the vessels. The sclerosant is then placed in plastic 3 ml syringes.
no significant differences in adverse effects, aside from a small These syringes fit more easily in the hand than tuberculin syringes
decrease in ulcerations with POL.13 Nevertheless, until POL is do and are less cumbersome to use. In addition, because injection
approved by the FDA, we recommend that it not be used. Two pressure is inversely proportional to the squared radius of the
other FDA-approved detergent sclerosants are available: sodium plunger, a 3 ml syringe generates less pressure than a 1 ml syringe
morrhuate (SM) and ethanolamine oleate (EO). However, both does.The endothelial cells in these small vessels are quite fragile, and
SM and EO are associated with an unacceptably high risk of com- using a syringe that generates less pressure substantially reduces the
plications, including but not limited to ulceration and anaphylac- risk of vessel disruption.
tic reactions, and hence are rarely used. For these reasons, my
STEP 2: CHOICE OF SCLEROSANT CONCENTRATION
practice is to use STS for sclerotherapy, and the ensuing technical
discussion will focus solely on this agent. The solution concentration selected depends on the size of the
Sclerotherapy is an outpatient procedure performed in the physi- vessel. I use 0.2% STS for vessels less than 2 mm in diameter and
cian’s office. Aside from the sclerosant, very few special materials are 0.5% for larger vessels. The volume per injection site is generally
needed [see Table 3]. Because there is a risk of significant allergic reac- less than 0.5 ml, but larger volumes may be preferable for reticu-
tions (albeit an extremely small risk), a fully stocked resuscitation lar or small varicose veins.
cart including intubation equipment should be available and At present, there is enthusiasm in the literature for the use of foam
checked regularly to confirm that all equipment is up to date and sclerotherapy, a technique in which air is repetitively injected into
ready for immediate use. STS to create a foam.14 This technique is ultimately based on the
work of Orbach, who in 1944 advocated expelling blood from the
vein by injecting small boluses of air before injecting the sclerosant.15
Technique The rationale for foam sclerotherapy is that the foam displaces blood
A variety of sclerotherapy techniques have been developed. in the vessel, resulting in less dilution of the solution.The sclerosant
Typically, each individual practitioner develops his or her own then has more contact with the surface area of the venous endotheli-
variation of the procedure. um and thus can sclerose the endothelial cells more efficiently at
a b
Figure 2 Sclerotherapy. Shown is a 52-year-old woman (a) before and (b) after two treatments with
0.5% STS.
lower concentrations. Of the various methods of creating a foam shown that using some type of bandage or pad in addition to sup-
sclerosant solution,16 that described by Tessari and coworkers ap- port hose is beneficial.The degree of compression achieved with
pears to be the easiest.17 In this approach, air is injected into the solu- this approach can be as much as 50% greater than that achieved
tion via a three-way stopcock and two syringes. Because of the size of with support hose alone.18 Gauze pads or cotton balls are more
the bubbles in a foam solution, foam sclerotherapy is best suited to cost-effective than foam pads while providing comparable com-
treatment of reticular and varicose veins. Spider telangiectasias are pressive effects.19
best treated with standard solutions. Compression approximates the endothelial surfaces of the vein
walls after sclerotherapy, thereby reducing thrombus formation
STEP 3: INJECTION OF SCLEROSANT
and promoting sclerosis of the vessel. It also enhances the calf
I use 30-gauge needles for all sclerotherapy treatments; some muscle pump function to help clear any solution that has pro-
physicians prefer 27-gauge needles for larger reticular and small vari- gressed into the deep venous system. Reduction of thrombus for-
cose veins. The needle is bent at a 45º angle, with the bevel up. mation after sclerotherapy is important for minimizing hyperpig-
Countertraction is applied with the nondominant hand, and the nee- mentation. In a multicenter randomized trial that evaluated patients
dle is inserted parallel to the vessel and the skin surface [see Figure 4]. who underwent bilateral sclerotherapy but who received compres-
As the vessel is entered, the sclerosant is gently injected.The slight sion to only one leg, hyperpigmentation and edema were signifi-
reduction of pressure that occurs when the vessel is entered becomes cantly greater in the uncompressed leg.20
increasingly easy to appreciate as the physician accumulates experi- Varying recommendations have been made as to how long com-
ence with sclerotherapy. Blanching of the vein is another signal of en- pression hose should be worn after sclerotherapy. A controlled com-
try into the vessel. If the solution is injected outside the vein, a small parative trial of the effects of compression in patients with reticular
superficial wheal will appear, in which case the injection should be and telangiectatic veins found that patients who wore hose for 3
discontinued and a new site selected for injection. Such wheals are weeks exhibited greater improvement (e.g., less hyperpigmentation)
unlikely to be a problem when STS concentrations lower than than those who wore no hose.21 However, the improvement in pa-
0.25% are used.When more concentrated solutions are used in larg- tients wearing hose for 3 weeks was not appreciably greater than that
er veins, aspiration of blood ensures correct placement of the needle in patients wearing hose for 1 week. I find that it is difficult to get pa-
within the vein before injection. tients to wear compression hose for several weeks.Therefore, I have
adopted the standard practice of instructing the patient first to wear
STEP 4: COVERAGE AND COMPRESSION OF INJECTION AREAS
the hose for 48 hours without removing them, then to wear them
After injection, cotton balls or foam or gauze pads are secured during waking hours only for the next 7 days.
with tape and applied to the injection areas. Compression hose Once the compression hose are in place, the patient is asked to
(20 to 30 or 30 to 40 mm Hg) are then applied. Studies have walk for 15 minutes before leaving the office. This further assists
a b
Figure 3 Sclerotherapy. Shown is a 36-year-old woman (a) before and (b) after four treatments
with a combination of 0.5% and 0.2% STS. Mild hyperpigmentation may be seen on the lateral thigh.
in clearing any solution that may have progressed into the deep release. In the vast majority of cases, such reactions are self-limit-
venous system. ed, typically resolving in less than 1 hour. Itching often accompa-
nies this response, but it usually resolves by the time the patient
STEP 5: SCHEDULING OF RETREATMENT
leaves the office. Should reactions persist, oral antihistamines or,
As noted (see above), multiple treatments are usually required for on rare occasions, steroids may be required.
optimal outcome.Therefore, all patients are instructed to return in 4 With the sclerosants used today, anaphylactic reactions are
to 6 weeks for assessment and possible retreatment. After this inter- extraordinarily rare but can be life-threatening. The incidence of
val, vessels requiring further treatment are apparent, and additional anaphylaxis with STS is not known with precision but is certainly
injections can be performed.The average patient undergoes four or very low. The reaction is usually mediated by immunoglobulin E
five treatments. and occurs within minutes of exposure. Appropriate emergency
Complications
Although sclerotherapy is generally quite safe, complications do
occur. Physicians must therefore be cognizant of the potential risks
and prepared to treat any adverse events that arise. The most sig-
nificant complications of sclerotherapy are allergic reactions
(either minor or major), skin necrosis, hyperpigmentation, deep
venous thrombosis (DVT), and telangiectatic matting. Cramping,
pain, edema, and blistering from tape or compression may be
observed as well.
Minor allergic reactions are quite common. For example, local-
ized urticaria and edema may occur secondary to histamine
Table 3 Materials Needed for Sclerotherapy

Alcohol swabs Cotton balls and tape
Protective gloves 18-gauge needles
3 ml syringes 4 × 4 in. gauze pads Figure 4 Sclerotherapy. Illustrated is the standard hand position
30-gauge needles Adhesive bandages for sclerotherapy. Countertraction is applied with the nondomi-
nant hand.
measures must be undertaken immediately, including subcuta-

neous administration of epinephrine, delivery of supplemental
oxygen, and securing of the airway. The patient should then be
given antihistamines and transferred to an emergency department
for continued evaluation and treatment. As noted (see above), a
properly stocked emergency response cart, including endotracheal
intubation supplies and medications, is essential in any office
where sclerotherapy is performed. Periodic review of procedures
with staff and maintenance of the emergency medications and
supplies is imperative.
Skin necrosis occurs with 0.2% to 1.2% of sclerotherapy injec-
tions.22 It is a potentially devastating complication and is often
unpreventable. Depending on the extent of necrosis, healing may
take months. The main causes of necrosis are extravasation of the
sclerosant into subcutaneous tissue, inadvertent injection into an
arteriole, and vasospasm. Extravasation of the sclerosant can des-
troy tissue, with the degree of damage determined by the type, con-
centration, and amount of sclerosant used [see Figure 5]. Necrosis
is rare when small amounts of dilute (< 0.25%) STS are given, but
extensive skin and soft tissue necrosis has been observed when
higher concentrations of STS (3%) are administered to treat vari-
cose veins.23 Inadvertent injections into the arteriole feeding the
telangiectasia is impossible to prevent and probably occurs fre-
quently. In a 2001 study, pulsatile Doppler sounds could be de-
tected above spider vein complexes in 72% of cases.22 Backwash
of the solution through arteriovenous shunts may cause occlusion
of the arteriole and skin necrosis. Blanching of the skin often
occurs with intra-arteriolar injections. Skin massage or, if spasm
persists, application of nitroglycerin ointment to the skin may
increase microcirculation.Why ulcerations develop in some patients
but not others is unknown.The question of whether it is related to
Figure 5 Sclerotherapy. Shown is skin necrosis on the injection pressure or injectate volume also remains unanswered.
left posterior calf of a 48-year-old woman after ultra- Hyperpigmentation [see Figure 6] is quite common, occurring in a
sound-guided sclerotherapy. significant percentage of patients, and it may be caused by any of the
a b
Figure 6 Sclerotherapy. Shown is residual hyperpigmentation in a 56-year-old woman after treatment

with 0.2% STS.
achieved with weekly subcutaneous injections of the chelating agent

deferoxamine mesylate.24 That various different treatments continue
to be recommended suggests that none of them is clearly superior at
eliminating hyperpigmentation. The passage of time appears to be
the most reliable therapy.
The precise incidence of DVT after sclerotherapy is unknown
but appears to be extremely low overall. The risk is somewhat
higher when more concentrated solutions are used or larger vol-
umes administered; however, it may be minimized by performing
sclerotherapy only for established indications.Treating axial reflux
and larger vessels surgically, with sclerotherapy limited to an
adjunctive role, will reduce the volume and concentration of solu-
tion needed. Ambulation in the physician’s office after treatment
will help wash away any solution that has progressed into the deep
venous system.
The development of tiny new red vessels at an area of previous
injection is called telangiectatic matting [see Figure 7]. Like ulcer-
ation, it is unpredictable. Excessive pressure during injections is
thought to play a causative role, but the exact etiology is unknown.
Telangiectatic matting is very difficult to treat once it has devel-
oped. Occasionally, it resolves spontaneously, but more often, it
must be addressed by means of either repeat sclerotherapy with
treatment of the feeding reticular vein or laser therapy. Treatment
of telangiectatic matting may in fact be the one potential effica-
cious use for laser-type devices in treating diseased leg veins.
Cost Considerations
Figure 7 Sclerotherapy. Shown is telangiectatic I strongly believe that all sclerotherapy, with the exception of
matting in a 43-year-old woman after treatment that performed for spontaneous hemorrhage, is cosmetic.
with 0.2% STS. Accordingly, in the practice to which I belong, patients seeking
sclerotherapy for reasons other than hemorrhage are informed
well in advance that the procedure is cosmetic and not reim-
sclerosants in current use. It is more common in persons with dark bursable, and they receive a good-faith estimate of expected costs
complexions and in those with dark-purple vessels. Fortunately, hy- in writing. As noted (see above), venous ligation is the treatment
perpigmentation usually resolves with time, but the process can take of choice for symptomatic axial reflux and large varicose veins;
months. Postsclerotherapy compression lowers the incidence of hy- therefore, sclerotherapy for these conditions is considered med-
perpigmentation, and removal of any intraluminal thrombi remain- ically unnecessary.
ing after sclerotherapy reduces the degree of hyperpigmentation Obtaining reimbursement from insurance carriers for sclerother-
present.The latter is accomplished by puncturing the skin with an apy performed to treat small varicose veins or hemorrhage is frus-
18-gauge needle and manually expressing the thrombus.There is no trating at best. Both physicians and patients have contributed to the
firm consensus on how hyperpigmentation should be treated once it problem in the past by filing inappropriate claims for reimbursement
develops. Some authorities recommend the use of fade creams, of cosmetic procedures.This past misuse of insurance coverage has
whereas others advocate laser treatments to lighten the pigmen- made it difficult to obtain reimbursement even for the one solid
tation. A 2001 study found that 80% depigmentation could be medical indication for sclerotherapy, hemorrhage.
References
1. Goldman MP, Bergan JJ: Sclerotherapy: Treat- vascular sclerotherapy, surgery, and surgery plus nique in the management of greater saphenous
ment of Varicose and Telangiectatic Leg Veins, sclerotherapy in superficial venous incompetence: varicosities with saphenofemoral incompetence.
3rd ed. Mosby–Year Book, Inc, St Louis, 2001, a randomized, 10-year follow-up trial—final Phlebology l7:19, 2002
p1 results. Angiology 51:529, 2000
9. McCoy S, Evans A, Spurrier N: Sclerotherapy
2. Einarsson E, Eklof B, Neglen P: Sclerotherapy or 6. Kanter A, Thibault P: Saphenofemoral incompe- for leg telangiectasia—a blinded comparative
surgery as treatment for varicose veins: a prospec- tence treated by ultrasound-guided sclerothera- trial of polidocanol and hypertonic saline. Der-
tive randomized study. Phlebology 8:22, 1993 py. Dermatol Surg 22:648, 1996 matol Surg 25:381, 1999
3. Bishop C, Fronek H, Fronek A, et al: Real-time 7. Cabrera J, Cabrera J Jr, Garcia-Olmedo MA: 10. Bukhari R, Lohr J, Paget D, et al: Evaluation of
color duplex scanning after sclerotherapy of the Treatment of varicose long saphenous veins with lidocaine as an analgesic when added to hyper-
sclerosant in microfoam form: long-term out-
greater saphenous vein. J Vasc Surg 14:505, 1991 tonic saline for sclerotherapy. J Vasc Surg 29:479,
comes. Phlebology 15:19, 2000
4. Goren G: Real-time color duplex scanning after 1999
8. McDonagh B, Huntley DE, Rosenfeld R, et al:
sclerotherapy of the greater saphenous vein (let- 11. Guex J: Indications for sclerosing agent polido-
Efficacy of the comprehensive objective map-
ter). J Vasc Surg 16:497, 1992 ping, precise image-guided injection, anti-reflux canol. J Dermatol Surg Oncol 19:959, 1993
5. Belcaro G, Nicolaides A, Ricci A, et al: Endo- positioning, and sequential sclerotherapy tech- 12. Conrad P, Malouf GM, Stacey MC: The Austra-
lian polidocanol (aethoxysklerol) study. Dermatol 17. Tessari L, Cavezzi A, Frullini A: Preliminary 21. Weiss RA, Sadick NS, Goldman MP, et al: Post-
Surg 21:334, 1995 experience with a new sclerosing foam in the sclerotherapy compression: controlled comparative
13. Goldman M: Treatment of varicose and telang- treatment of varicose veins. Dermatol Surg study of duration of compression and its effects on
iectatic leg veins: double-blind prospective com- 27:58, 2001 clinical outcome. Dermatol Surg 25:105, 1999
parative trial between aethoxysklerol and sotrade- 18. Raj TB, Goodard M, Makin GS: How long do 22. Bihari I, Magyar E: Reasons for ulceration after
col. Dermatol Surg 28:52, 2002 compression bandages maintain their pressure injection treatment of telangiectasia. Dermatol
14. Cavezzi A, Frullini A, Ricci S, et al: Treatment of during ambulatory treatment of varicose veins? Surg 27:133, 2001
varicose veins by foam sclerotherapy: two clinical Br J Surg 67:122, 1980 23. Bergan JJ, Weiss RA, Goldman MP: Extensive
series. Phlebology 17:13, 2002 19. Smith SL, Belmont JM, Casparian JM: Analysis tissue necrosis following high-concentration scle-
15. Orbach EJ: Sclerotherapy of varicose veins: uti- of pressure achieved by various materials used rotherapy for varicose veins. Dermatol Surg
lization of an intravenous air block. Am J Surg for pressure dressings. Dermatol Surg 25:931, 26:535, 2000
66:362, 1944 1999 24. Lopez L, Dilley R, Henriquez J: Cutaneous hyper-
16. Frullini A: New technique in producing scleros- 20. Goldman MP, Beaudoing D, Marley W, et al: pigmentation following venous sclerotherapy treat-
ing foam in a disposable syringe. Dermatol Surg Compression in the treatment of leg telangiecta- ed with deferoxamine mesylate. Dermatol Surg
26:705, 2000 sia. J Dermatol Surg Oncol 16:322, 1990 27:795, 2001
6 VASCULAR SYSTEM 22 VASCULAR AND PERITONEAL ACCESS — 1
22 VASCULAR AND PERITONEAL

ACCESS
Bernard Montreuil, M.D.
Vascular Access via Arteriovenous Fistulas

vein catheterization should also be avoided because of the risk of
The number of patients with end-stage renal disease (ESRD) in central vein stenosis, which may preclude the use of any part of the
the United States has increased steadily since 1980. The preva- ipsilateral arm for vascular access.
lence of ESRD in the United States population has quintupled
since 1980, from 271 to nearly 1,400/million. It is estimated that Assessment of Venous System
by 2030, there may be 2.24 million patients with ESRD. Almost A history of subclavian vein cannulation or transvenous pace-
60% of these patients are expected to be diabetic, half to be 65 or maker placement is associated with a 10% to 40% rate of central
older, and half to be nonwhite.1 vein stenosis or thrombosis.8 Previous injuries or operative proce-
Extracorporeal dialysis of blood was introduced in 1943 by dures involving the arm, the neck, or the chest, including previ-
Kolff and associates2; however, application of this approach was ous vascular access, also may give rise to significant venous
hindered by the requirement for repeated and routine access to abnormalities. Physical signs of venous outflow obstruction
the circulation. The full potential of hemodialysis for patient sal- include extremity edema, differences in arm size, and develop-
vage was realized only after the introduction of the external arte- ment of collateral veins. All of these historical and physical find-
riovenous (AV) shunt by Quinton and colleagues in 19603 and of ings call for investigation by means of phlebography or color flow
the endogenous AV fistula (AVF) by Brescia and coworkers in duplex scanning.9 Central vein stenosis greater than 50% is a
1966.4 The subsequent introduction of synthetic vascular pros- contraindication to creation of an ipsilateral distal AVF: it is a pre-
theses has permitted continued access in patients who have dictor of venous hypertension and edema in the arm and of poor
exhausted peripheral venous sites5; however, the long-term per- function in the fistula.
formance of such prostheses remains inferior to that of autoge- Selection of the ideal vein for access is facilitated by distending
nous fistulas. The creation and maintenance of functioning vas- the veins with a tourniquet around the upper arm. In particular, the
cular access, along with the associated complications, constitute cephalic vein is palpated from the region of the anatomic snuff-box
the most common cause of morbidity, hospitalization, and cost in to the area above the elbow. Percussion of the vein is performed to
patients with end-stage renal disease. confirm that it is patent and to rule out stenosis from previous
The ideal vascular access route permits a flow rate that is ade- venipuncture. The fingertips of one hand are positioned over the
quate for the dialysis prescription (≥ 300 ml/min), can be used for vein at the elbow, and the vein is gently tapped distally with the
extended periods, and has a low complication rate. The native other hand. If the vein is patent and of substantial diameter, a fluid
AVF remains the gold standard. In 1997, the National Kidney wave is felt over the proximal vein.
Foundation Dialysis Outcome and Quality Initiative (NKF-
DOQI)6 organized multidisciplinary work groups that evaluated Assessment of Arterial System
all available data on vascular access and concluded that quality of A history of arterial trauma or catheterization, diabetes mellitus,
life and overall outcome could be improved significantly for or peripheral arterial disease may be associated with chronic dam-
hemodialysis patients if two primary goals were achieved: age to the arterial system. Physical examination involves palpation
of the pulses (including both brachial and axillary pulses) and
1. Increased placement of native AVFs: a minimum of 50% of
comparison of blood pressure in the arms. A difference of more
new dialysis patients should have primary AVFs.
than 20 mm Hg between the two sides suggests proximal arterial
2. Detection of dysfunctional access before thrombosis of the
occlusive disease, which may cause the AVF to fail as a result of
access route occurs.
inadequate inflow. An Allen test is also performed to confirm that
This report, which contains clinical practice guidelines on all the palmar arch is patent, to determine which artery is the domi-
aspects of vascular access, was updated in 2001.7 nant vascular supply to the hand, and to ensure that the ulnar
artery can support the hand if the radial artery must be divided.
Any abnormality on physical examination should be further inves-
At least 4 to 6 weeks—preferably 3 to 4 months—is required for tigated by means of arterial studies in the vascular laboratory; in
a native AVF to heal and mature before it can be used.Therefore, select cases, angiography may be indicated.
access planning should be done early in the course of progressive
renal failure. Patients should be referred for surgical treatment Noninvasive Preoperative Assessment
when creatinine clearance approaches 25 ml/min, the serum cre- Systematic use of noninvasive evaluation in the vascular labo-
atinine level reaches 4 mg/dl, or dialysis is likely to be necessary ratory permits objective assessment of arterial and venous con-
within 1 year. Every effort should be made not to puncture fore- duits. If necessary, venous conduits other than the cephalic and
arm veins, particularly the cephalic veins of the nondominant arm; basilic veins may be identified,10 and both arterial and venous
the dorsal hand veins may be used for venipuncture. Subclavian segments may be mapped with skin marks to facilitate the oper-
ative procedure. The aims are to increase the use of autogenous

fistulas and to raise the early and late patency rates by decreasing Table 1 Noninvasive Criteria for Selection
the use of suboptimal veins and arteries.When an all-autogenous of Upper-Extremity Arteries and Veins for
policy is followed, approximately 80% of patients are candidates
for a native AVF.
Dialysis Access Procedures10
Complete noninvasive assessment includes segmental pressure Venous examination
measurements of the upper extremity, arterial waveform record- Venous luminal diameter ≥ 2.5 mm for autogenous AVFs, ≥ 4.0 mm for
ing, and arterial and venous duplex studies. A tourniquet should bridge AV grafts
be placed on the arm, and tapping and stroking maneuvers Absence of segmental stenoses or occluded segments
should be used to distend the vein maximally. Established crite- Continuity with the deep venous system in the upper arm
ria [see Table 1] are then applied to determine whether venous Absence of ipsilateral central vein stenosis or occlusion
outflow and arterial inflow are likely to be satisfactory. Arterial examination
Arterial luminal diameter ≥ 2.0 mm
OPERATIVE PLANNING Absence of pressure differential ≥ 20 mm Hg between arms
Patent palmar arch
Choice of Type of AVF
Multiple varieties of AV fistulas have been used in hemodialy-
sis patients. According to the NKF-DOQI report,6 the order of ration of a radiocephalic fistula. In fact, some authors consider an
preference for AV fistulas in patients requiring long-term upper-arm autogenous AVF (either a brachiocephalic or a trans-
hemodialysis is as follows: posed basilic vein fistula) the preferred approach in this particu-
lar subgroup of patients13; however, this view has been challenged
1. Wrist (radiocephalic) primary AV fistula.
by studies that found no difference between diabetic and nondi-
2. Elbow (brachiocephalic) primary AV fistula.
abetic patients with respect to prognosis for wrist fistulas.14,15
If neither of these can be constructed, access may be achieved via Disadvantages of brachiocephalic fistulas include higher fre-
either of the following: quencies of arm swelling and steal syndrome than are seen with
forearm fistulas.
3. AV graft of synthetic material.
If the cephalic vein in the upper arm is unsuitable, the remain-
4. Transposed brachiobasilic AV fistula.
ing options include prosthetic grafting and basilic vein transposi-
All of these fistulas should be established in the nondominant tion. An AVF using transposed basilic vein has all the attributes
arm, if possible. of an autogenous fistula and consequently is preferred to a graft
The distal radiocephalic AVF remains the gold standard in despite being more difficult to create. Its protected, deep subfas-
terms of ease of creation and long-term results. Its advantages cial position and large caliber make it a high-quality conduit for
considerably outweigh its disadvantages—namely, a higher pri- hemodialysis access. Its advantages over a prosthetic graft include
mary failure rate (10% to 15%) and a long maturation time (1 to the avoidance of the distal venous anastomosis (which causes the
4 months). Radiocephalic AVFs may be constructed either in the majority of stenoses in synthetic graft fistulas) and higher prima-
anatomic snuff-box or just above the wrist crease. Although the ry and secondary patency rates.16,17 Flow rates are high in basil-
radial artery is smaller in the snuff-box than it is at the classic ic vein fistulas because of the large size of the vein, and the in-
Brescia-Cimino fistula site, the long-term results at the two sites fection rate is relatively low. Furthermore, thrombosis of a bra-
are comparable if only arteries of adequate diameter are used.11 chiobasilic fistula does not compromise the integrity of the axil-
An alternative method of creating an AVF in the forearm that lary vein and thus does not preclude subsequent use of a pros-
was not mentioned in the NKF-DOQI report is vein transposi- thetic conduit at the same site.Therefore, when a functional bra-
tion.12 Preoperative duplex ultrasonography often identifies veins chiocephalic fistula cannot be achieved, a transposed bra-
that, except for their deep subcutaneous location, are suitable for chiobasilic fistula should be considered before an upper arm
AVF formation. In addition, the basilic vein in the forearm is often graft is placed.18
spared and is frequently suitable for AVF formation; however, use If no veins in either upper extremity are suitable for a native
of this vein in situ for needle cannulation and hemodialysis may AVF, then the use of prosthetic material should be considered.
necessitate placing the forearm in an uncomfortable position. In Two options are available. First, if a segment of vein at least 15 cm
the great majority of cases, such veins can be successfully trans- long is available but is too far from the artery to be used in the cre-
posed to a superficial tunnel in the midportion of the volar aspect ation of a fully native fistula, a jump graft can be constructed
of the forearm, and the resulting fistula theoretically has the same between the artery and the vein, and the arterialized vein can be
advantages as a radiocephalic fistula in terms of long-term paten- used as the needle conduit for dialysis. Second, the graft itself can
cy and complication rates. This aggressive approach to autoge- be used as the needle conduit for dialysis.The data currently avail-
nous forearm fistula formation also has the advantage of preserv- able suggest that extruded polytetrafluoroethylene (ePTFE) is
ing more proximal vessels for future access placement. preferable to other biologic and synthetic materials: ePTFE grafts
If duplex ultrasonography does not identify an adequate fore- are less likely to disintegrate with infection, they are more widely
arm vein conduit, a brachiocephalic primary AVF is the next available, they remain patent longer, and they are easily handled
choice. It is easy to create and has the advantage of providing by surgeons. Grafts may be placed in straight, looped, or curved
higher blood flow than the wrist fistula. The cephalic vein in the configurations on either the forearm or the upper arm.
upper arm, because of its position and superficial location, is easy
OPERATIVE TECHNIQUE
to cannulate and easily covered (a potential cosmetic benefit).
The elbow AVF has a theoretical advantage in diabetic patients,
in whom medial calcification of the distal radial artery common- Autogenous AVFs
ly prevents the gradual arterial dilatation required for full matu- Radiocephalic fistula The arm is placed on an arm board
in 90º of abduction. A tourniquet is applied to the upper arm to Radial Artery Cephalic Vein
distend the cephalic vein, and the vein’s course is marked on the
skin. The tourniquet is then released.
Local anesthesia using 0.5% or 1% lidocaine without epineph-
rine is usually adequate for construction of an autogenous AVF at
the wrist or the antecubital fossa. General anesthesia may depress
cardiac output and thus may, by reducing fistula flow, exert a neg-
ative impact on the success of the fistula. Conversely, brachial or
supraclavicular regional anesthesia may cause peripheral vasodi-
latation and thus increase arterial blood flow.
A longitudinal incision is placed either in the anatomic snuff-
box, between the tendons of the extensor pollicis longus and the
extensor pollicis brevis [see Figure 1], or midway between the
cephalic vein and the radial artery, proximal to the wrist skinfold
[see Figure 2]. In the anatomic snuff-box, the cephalic vein overlies
the radial artery, so that minimal mobilization is required to ap-
proximate the two vessels. Slightly more mobilization is required Figure 2 Vascular access via AVFs: radiocephalic fistula. Shown
to approximate the cephalic vein to the radial artery above the is the Brescia-Cimino fistula. An incision is made midway
between the radial artery and the cephalic vein, and the end of
wrist without kinking or twisting. A comparable length of radial
the vein is anastomosed to the side of the artery.
artery, found under the deep fascia, is also isolated. Care is taken to
preserve the superficial branch of the radial nerve, which lies later-
al to the radial artery and is separated from it by the brachioradialis fistula, thereby converting the anastomosis to an end-to-end
muscle. configuration.
Four types of anastomoses can be constructed: side to side, end Vascular control is obtained with small vessel loops or Heifets
of vein to side of artery, end to end, and end of artery to side of clamps. Heparinization is not needed unless the artery is an end
vein.The side-to-side anastomosis [see Figure 3a] yields the highest artery. A 1 cm arteriotomy is performed, and the vein is ligated and
flow through the fistula but may be associated with venous conges- divided distally and tailored to match the arteriotomy. Coronary
tion of the hand. Over time, arterial pressure may render the valves dilators are then inserted gently to verify patency and to ensure that
of the distal vein incompetent, resulting in retrograde flow toward the vessel lumina are large enough: the artery should easily admit a
the hand and venous hypertension. The end of artery–side of vein 2 mm dilator; the vein, a 3 mm dilator. The vessels are then anas-
anastomosis [see Figure 3b] also presents a risk of venous hyperten- tomosed in the desired configuration with a fine continuous
sion. This configuration reduces the risk of distal steal by prevent- monofilament suture (6-0 or 7-0 polypropylene) placed by means
ing retrograde flow into the fistula, but at the price of lower flow of standard techniques. The vessels can be probed with the coro-
through the fistula. Of the four options, the end of artery–end of nary dilators before the anastomosis is completed, to confirm that
vein variation [see Figure 3c] produces the least distal arterial steal the vein is not twisted or to overcome any arterial spasm. Once vas-
and venous hypertension but yields the lowest flow. cular control is released, a thrill should be easily felt over the fistu-
The preferred configuration of the anastomosis is end of vein to la and for a moderate distance along the venous conduit.The skin
side of artery [see Figure 3d]. Dividing the vein reduces the risk of is closed with an absorbable suture.
venous congestion in the hand; moreover, by allowing retrograde
flow from the distal radial artery and the ulnar artery into the vein, Vein transposition in the forearm The artery and the vein
which contributes approximately 30% of the total flow of the fis- selected for the primary AVF are identified and mapped preopera-
tula, this approach yields maximal blood flow through the fistula. tively by means of duplex ultrasonography. Positioning and anes-
There is a risk of steal syndrome with such fistulas, but this prob- thetic considerations are essentially the same as for a radiocephalic
lem is easily corrected by ligating the radial artery distal to the fistula.
A longitudinal incision is made directly over the mapped vein,
beginning at its distal end and extending toward the antecubital
fossa for a distance of at least 15 cm [see Figure 4a].The vein is gent-
ly skeletonized and mobilized by ligating and dividing all side
Cephalic Vein branches.The targeted artery (either the radial or the ulnar) is iden-
tified and dissected through a separate incision. A superficial sub-
cutaneous tunnel is made between the two incisions with a blunt
tunneling instrument, and the vein is passed through the tunnel [see
Figure 4b].The vein should be marked along its length with a mark-
ing pen before tunneling; this step provides a usual visual check that
allows the surgeon to confirm that the vein is not twisted as it pass-
es through the tunnel. A 1 cm anastomosis is then carried out in
the same fashion as for a radiocephalic fistula (see above).
An alternative technique that may be employed in patients with
atherosclerotic disease of the forearm arteries involves mobilizing
Radial Artery the forearm segment of either the cephalic or the basilic vein,
Figure 1 Vascular access via AVFs: radiocephalic fistula. transposing it to form a U-shaped loop, and anastomosing it to
Shown is the anatomic snuff-box fistula, with the end of the the brachial, proximal radial, or proximal ulnar artery in the ante-
cephalic vein anastomosed to the side of the radial artery. cubital fossa.19
a b
c d
Figure 3 Vascular access via AVFs: radiocephalic fistula. Four anastomotic configurations are possible
for an autologenous radiocephalic fistula: (a) side of artery to side of vein, (b) end of artery to side of
vein, (c) end of artery to end of vein, and (d ) end of vein to side of artery (the preferred configuration).
Brachiocephalic fistula After adequate local anesthesia, a through a superficial tunnel, and then to anastomose it in an end-
transverse incision is made 1.5 cm distal to the antecubital crease to-side fashion to the brachial artery, which has been exposed
to expose the superficial antecubital venous system [see Figure 5a].20 above the elbow through a separate incision. The second, which
If the median cubital vein is patent, sufficiently wide, and in conti- avoids extensive dissection of the cephalic vein, is to place two short
nuity with the cephalic vein, it is dissected so that the perforating longitudinal incisions over the brachial artery and the cephalic vein
branch of the antecubital venous system (vena mediana cubiti pro- a few centimeters above the elbow crease, to tunnel a short segment
funda) can be located.The bicipital aponeurosis is divided, and the of 6 mm ePTFE graft between the two incisions, and to anasto-
perforating branch is followed down to the deep system. In the mose the ePTFE graft to both the brachial artery and the cephalic
process, the brachial artery is also exposed, as are the origins of the
radial and ulnar arteries.
Once the patient is fully heparinized, the confluence of the
brachial vein and the perforating vein is identified, and part of the a
brachial vein is excised so as to form a venous patch.The perforat-
ing vein is gently dilated, so that any valves are rendered incompe-
tent, and the proximal median cubital vein is ligated to prevent
diversion of blood flow into the basilic vein.The perforating vein is
then anastomosed to the brachial artery in an end-to-side fashion
[see Figure 5b].21 To prevent subsequent steal syndrome, the arteri-
otomy should be no larger than 5 to 6 mm.
Other techniques may be used if the perforating vein is very large
or very small. If the perforating vein is 5 mm or more in diameter,
it may be anastomosed directly to the artery without a patch. If the b
vein is less than 2.5 mm in diameter, it should not be used; instead, Radial Artery
the median cubital vein should be ligated and divided and the
cephalic end of the vein anastomosed directly to the brachial artery
in an end-to-side fashion [see Figure 5c]. If the median cubital vein
is too small, the incision is extended laterally and proximally to
allow mobilization of the cephalic vein. The length of this incision
depends on the extent to which the cephalic vein must be mobi-
lized to ensure a tension-free end-to-side anastomosis. The acces-
sory cephalic vein, though located far laterally, may also be used.
Repeated venipunctures in the antecubital fossa frequently ren- Figure 4 Vascular access via AVFs: vein transposition in the
der the antecubital venous system unsuitable for AVF construction. forearm. (a) The selected vein, identified by duplex ultrasonogra-
In such cases, two options are available if the patient has at least 15 phy, is completely mobilized. (b) The vein is transposed through a
cm of good-quality cephalic vein in the upper arm.The first option superficial tunnel in the midportion of the volar aspect of the
is to mobilize a sufficient length of the cephalic vein in the distal forearm and anastomosed to the radial artery in an end-to-side
upper arm through a longitudinal incision, to transpose it medially fashion.
a b
Median Accessory
Cubital Cephalic
Vein Vein
Cephalic
Basilic Vein
Vein
Perforating
Vein c
Brachial
Artery
Figure 5 Vascular access via AVFs: brachiocephalic fistula. (a) A transverse incision exposes the antecubital venous
system (including the perforating branch) and the brachial artery under the bicipital aponeurosis. (b) An end-to-side
anastomosis is made between the perforating vein and the brachial artery. (c) If the perforating vein is too small, the
cephalic vein is mobilized and anastomosed to the brachial artery in an end-to-side fashion.
vein in an end-to-side fashion [see Figure 6].22 The cephalic vein is vein is then passed through a subcutaneous tunnel on the anterior
used as the needle conduit for this type of bridge AV graft. surface of the arm and anastomosed in an end-to-side fashion to
the brachial artery in the antecubital fossa with 6-0 or 7-0
Brachiobasilic fistula The technique for constructing a polypropylene [see Figure 7b]. This transposition places the vein in
brachiobasilic fistula was described first by Dagher and associates a more superficial location and positions it anterolaterally on the
in 197623 and then by LoGerfo and colleagues in 1978.24 Local arm, thereby facilitating cannulation during hemodialysis sessions.
anesthesia can be used, but an axillary block eases the procedure Closure involves approximating the fascia and the subcutaneous
considerably. An oblique incision overlying the median basilic vein tissue in two separate layers.
is made in the antecubital fossa, and the vein is mobilized. The A modification of the procedure just described is the so-called
brachial artery is exposed as usual by dividing the bicipital elevated basilic vein arteriovenous fistula.25 In this variant, the
aponeurosis. The incision is extended along the medial aspect of vein is left in situ rather than transposed anterolaterally, but it is
the upper arm (the so-called hockey-stick incision), and the basil- elevated by closing the deep fascia and the subcutaneous tissue
ic vein is mobilized from beneath the fascia, with care taken to beneath the vein. The brachial artery anastomosis is created, and
preserve the medial cutaneous nerve of the forearm [see Figure the overlying skin is reapproximated with clips or interrupted
7a]. The basilic vein usually pierces the brachial fascia just below sutures. Although the vein remains in its medial location, its new
the middle of the upper arm, then parallels the course of the superficial position facilitates cannulation for dialysis.
brachial artery and vein while remaining superficial to them. It should be mentioned that the basilic vein can be elevated
At the axillary level, the basilic vein joins the brachial vein to form either at the time of brachiobasilic AVF creation (the one-stage
the axillary vein; this junction constitutes the proximal limit of the technique) or as part of a second procedure (delayed elevation)
dissection. approximately 4 weeks later. The advantage of the latter
The distal end of the conduit vein may consist of either the basil- approach is that operative dissection is facilitated by the use of an
ic vein or a section of the median cubital vein, which is already arterialized thick-walled vein. In addition, delayed elevation
exposed. All venous tributaries are ligated and divided. Once this is allows assessment of the fistula for size and flow rate before the
done, the vein is divided distally, and its anterior surface is marked second stage, which can be abandoned if the vein has failed to
to help the surgeon avoid axial rotation during transposition. The mature.26
TROUBLESHOOTING
Autogenous AVFs
Although the quality of the AV conduit is assessed preopera-
Brachial Artery
tively by means of physical examination and noninvasive studies,
it should also be confirmed intraoperatively for optimal results.
ePTFE Jump Graft Arterial inflow Normally, a strong pulse is felt over the tar-
geted artery; however, dissection may cause spasm, which can
render intraoperative assessment difficult. The following three
measures will help minimize this problem:
1. Elimination of epinephrine from the anesthetic solution.
2. Gentle dissection and avoidance of direct manipulation of the
arterial wall. It may be preferable to use a proximal tourniquet
Cephalic Vein for inflow occlusion so that there is no need to place clamps on
small arteries.
3. Local application of a papaverine solution, which relaxes vas-
cular smooth muscle.
If spasm occurs, gentle probing of the artery with coronary dila-
tors may help relieve the spasm and restore full flow.
Stiff, calcified arteries can sometimes be successfully used in
Figure 6 Vascular access via AVFs: brachiocephalic fistula. If the creation of fistulas, but it is difficult to assess flow in such ves-
the antecubital venous system is unsuitable for AVF construction, sels. Quantitative and qualitative analyses of the arterial waveform
one option is to place an ePTFE interposition graft between the and the intraluminal diameter by means of duplex scanning can
brachial artery and the cephalic vein.
Bridge AV Grafts
Bridge AV graft procedures involve placing an interposition
graft between an artery and a vein and using that graft as the nee- a
dle conduit for dialysis. In the forearm, the most common config-
urations are loop grafts between the brachial artery and an ante-
cubital vein (including the brachial veins)27 and straight bridge AV
grafts from the radial artery to an antecubital vein. Most studies
report superior patency rates with a loop configuration.28
Adequate results may be obtained with a straight graft in the fore-
arm if the radial artery is at least 2.5 to 3.0 mm in diameter.
Secondary options for bridge AV graft construction include a
variety of unusual configurations, including reverse grafts between
the axillary artery and the brachial or the antecubital vein and axil- Basilic Vein
loaxillary grafts, which may be looped in the upper arm or may
cross the sternum. It is also possible to construct a looped graft
between the proximal superficial femoral artery and the proximal Median Cubital
Vein
saphenous vein or a straight, reversed graft between the distal
superficial femoral or popliteal artery and the proximal saphenous
or femoral vein [see Figure 8]. Generally, such lower-limb AV grafts Basilic Vein
b
are associated with an increased risk of potentially life- or limb-
threatening infection; however, infection rates as low as 22% have
been reported, making these grafts a viable option when a bridge
AV graft in the upper extremity cannot be constructed.29
Either local anesthesia or axillary block is usually appropriate
for upper-extremity bridge AV grafts. A single dose of a
cephalosporin should be given before the procedure. Separate
longitudinal incisions are placed to expose the artery and the
vein—except when the procedure involves the brachial artery and
the antecubital venous system, which are better exposed through Brachial Artery
a single transverse incision. A 6 mm or a tapered 4 to 7 mm
Figure 7 Vascular access via AVFs: brachiobasilic fistula. (a) The
ePTFE graft is then passed through a superficial tunnel between basilic vein is completely mobilized from underneath the fascia in
the two incisions. Both anastomoses are constructed in an end-to continuity with a section of the median cubital vein in the antecu-
side fashion, beginning with the venous side. Systemic bital fossa. (b) The vein is transposed in a subcutaneous tunnel on
heparinization is used if an end artery is occluded for the arterial the anterior surface of the arm and anastomosed to the brachial
anastomosis. artery in an end-to-side fashion.
a b c d
e f g h
Figure 8 Vascular access via AVFs: bridge AV grafts. Options for bridge graft construction include (a) straight fore-
arm AV graft, (b) loop forearm AV graft, (c) brachioaxillary AV graft, (d ) loop axilloaxillary AV graft, (e) axillary
artery–contralateral axillary vein AV graft, (f) axillary artery–iliac vein AV graft, (g) distal superficial femoral or
popliteal artery–saphenous vein AV graft, and (h) proximal superficial femoral artery–saphenous vein loop AV graft.
help confirm the adequacy of the vessel. Arteries smaller than 1.5 ened, nondistensible vein wall proximally. Intraoperative phlebog-
mm are less likely to provide sufficient flow for a fistula. It is par- raphy is indicated in any doubtful situation.
ticularly important not to place clamps on calcified arteries; a
tourniquet is always preferred in this situation. AV anastomosis Both the artery and the vein should be
mobilized sufficiently to ensure that the anastomosis is tension-
Venous outflow A venous diameter of at least 2.5 to 3.0 mm free once completed. As noted (see above), marking the most
is required for successful maturation of an autogenous fistula. superficial aspect of the vein with a sterile pen before mobilization
The diameter of the target vein should be known preoperatively helps ensure that the vein is not rotated when it is approximated
from the duplex examination and should be confirmed intraop- to the artery.The ideal anastomosis is constructed by transecting
eratively by calibration with coronary dilators. No attempt should the vein just distal to a bifurcation and using the branch vessel as
be made to dilate the vein, however, because endothelial injury a patch. Such a spatulated venous conduit facilitates the anasto-
may result. mosis and minimizes the risk of anastomotic stenosis.
Webs, thickened valve leaflets, and areas of sclerosis from pre- For a distal AVF, the anastomosis should be about 10 mm long
vious phlebitis or punctures are common in upper-extremity veins to ensure that a gradual increase in flow through the fistula can
and may be the cause of poor venous outflow and fistula failure. occur. An anastomosis that is too small may impair the normal
Passage of the coronary dilator helps to localize such obstructive dilation of the artery and the vein. For AVFs in the antecubital
lesions, which should be corrected when found. The patency of space and the upper arm, in contrast, the arteriotomy should be
the proximal vein can be demonstrated by free flow of injected limited to 5 to 6 mm to prevent excessive shunting.
heparinized saline or by successful passage of a Fogarty catheter. The anastomosis can be performed with standard vascular
The evoked thrill is also a useful maneuver: intermittent, pulsatile techniques. However, construction of the anastomosis with a sin-
injection of saline into the vein, mimicking arterial flow, should gle continuous suture may have a purse-string effect; according-
produce a palpable thrill over the proximal vein.30 The absence of ly, the use of two separate running sutures may be preferable for
an evoked thrill suggests the presence of stenosis or areas of thick- small vessels. Interrupted stitches are preferable for very small
vessels. Loupes and microvascular instruments are helpful in this

setting.
When the anastomosis is completed, vascular control should
be released from the proximal vein and the distal artery first; the
resultant back-bleeding will confirm the patency of the palmar
arch and reveal any major anastomotic defects. Gentle compres-
sion is usually sufficient to obtain hemostasis. Any additional
sutures deemed necessary should be placed with great caution
because of the risk that they may narrow the anastomosis.
The presence of a pulse rather than a thrill in the arterialized
vein indicates inadequate outflow, whereas the absence of either a
Figure 9 Vascular access via AVFs: bridge AV grafts. With a loop
thrill or a pulse indicates poor inflow.The draining vein should be forearm graft, tunneling of the graft is facilitated by making an
examined for kinking, twisting, or compression by a fibrous band. incision 1.5 cm distal to the elbow crease to expose the brachial
If the vein appears to be satisfactory, the anastomosis and the dis- artery and the antecubital venous system, followed by a counter-
tal vein are inspected and probed with dilators through a venous incision at the apex of the tunnel 3 to 4 cm proximal to the wrist
side branch or a transverse phlebotomy. If no abnormality is iden- skinfold.
tified, the fistula is examined with I.V. contrast studies and fluo-
roscopy. Focal lesions may be corrected by placement of a vein
patch or a short interposition graft or by resection and primary than 6 mm long to prevent distal ischemia. ePTFE sutures are
reanastomosis. Alternatively, a short segment of the vein may be useful for arterial anastomoses: because they have the same diam-
excised and the anastomosis repositioned more proximally. eter as the attached needles, needle-hole bleeding is minimized.
Before the arterial anastomosis is completed, the graft is
AV Grafts unclamped and allowed to fill with venous blood; this step pre-
Skin incisions Incisions should be placed so that neither the vents air embolism when arterial control is released. When the
graft nor the anastomoses lie directly beneath them. Proper place- anastomosis is complete, a thrill should be palpable over the
ment reduces the risk of skin erosion, minimizes the risk that the venous outflow tract rather than directly over the graft.
graft will become infected if a surgical site infection occurs, and
maximizes the length of conduit available for needle insertion.The Graft type The choice between a tapered 4 to 7 mm ePTFE
subcutaneous tissue and skin should be closed in separate layers to graft and a 6 mm straight graft is a matter of personal preference.
minimize the risk of graft infection in the event of skin dehiscence. The tapered graft was introduced to reduce the incidence of steal
syndrome by increasing the resistance to flow through the pros-
Tunneling The tunnel should be made atraumatically with a thesis; however, it has not been shown to provide consistent pro-
Kelly-Wick bidirectional tunneler. It should be superficial to the tection from ischemic complications. Both types of graft are also
muscle fascia but no more than 5 mm beneath the skin surface.To available in either a standard or a thin-wall configuration; the only
decrease the risk of hematoma, there should be a close fit between randomized study published to date reported superior results with
the diameter of the graft and that of the tunnel, and the graft the standard configuration.31 Stretch ePTFE appears to yield bet-
should be placed before systemic heparinization is initiated. ter results than the older, nonstretch grafts.32
For a loop configuration, a counterincision at the apex of the
FOLLOW-UP
tunnel permits the tunnel to be created in two passes of the Kelly-
Wick tunneler.This approach gives the tunnel a smooth curve and Upon discharge, the patient is instructed to elevate the arm so as
limits kinking of the graft. In the forearm, this transverse counter- to reduce edema. Regular hand and arm exercise, though not of
incision is usually made 3 to 4 cm proximal to the wrist skinfold proven benefit, is nonetheless recommended until the fistula
[see Figure 9]. Careful observation of the stripe on the graft as it is matures.
passed through the tunnel helps prevent twisting. Physical examination of the fistula, including inspection and
palpation for pulse and thrill, should be done on a weekly basis.
Venous anastomosis To minimize arterial occlusion time, The patient should also be advised to seek prompt medical atten-
the venous anastomosis is usually performed first. The vein must tion if the quality of the thrill changes. Normally, a thrill is palpa-
be at least 4 mm in diameter; venous diameter and patency are ble throughout the cardiac cycle, though it is more intense during
verified by passing coronary dilators or a Fogarty catheter systole. Disappearance of the diastolic component of the thrill is
through the vessel and irrigating it with heparinized saline. Before generally a consequence of outflow obstruction. Such obstruction
the anastomosis is performed, the vein and all distal branches are (usually from venous or anastomotic stenosis) may also cause
ligated to prevent venous hypertension and arm edema. intensification of the thrill or bruit. In addition, diminished flow or
If no veins of adequate diameter are available, either two adja- outflow stenosis may cause the thrill to be converted to a pulse.
cent veins or a portion of a transverse communicating vein can be Any of these abnormal findings is an indication for a diagnostic
used to construct a venoplasty that will increase the net diameter procedure: salvage attempts are much more likely to succeed if
of the venous outflow tract. Alternatively, the deep brachial or axil- carried out before thrombosis has occurred.
lary veins can be used for outflow. The latter option is often ePTFE AV grafts should not be used until at least 14 days have
required when the superficial veins have been exhausted in a passed since placement or until the swelling has subsided enough
patient who has previously had AVFs. to allow palpation of the graft. This waiting period allows adhe-
sions to form between the subcutaneous tunnel and the graft,
Arterial anastomosis Systemic heparin is given only if an thereby decreasing the risk of hematoma in the graft tunnel, which
end artery is occluded for anastomosis. The artery should have a may ruin the access site. A minimum of 1 month is required before
lumen of at least 3 mm, and the arteriotomy should be no more a primary AVF may be cannulated. It is preferable, however, to
wait until the fistula matures fully, which may take 3 to 4 months. conduit. The following are the most common causes of early
thrombosis:
COMPLICATIONS
1. Inadequate arterial inflow caused by proximal arterial disease.
Venous Stenosis 2. Narrowing of the anastomosis during construction.
3. Kinking or twisting of the vein proximal to the anastomosis or
Venous stenosis, either at the anastomosis (particularly with
in a subcutaneous tunnel.
ePTFE grafts) or in the body of the vein, is a common complica-
4. Undetected occlusion of venous outflow.
tion of AVF construction. Prophylactic intervention for venous
5. Compression of the fistula by a hematoma resulting from either
stenoses reduces the rate of thrombosis and graft loss, and
inadequate hemostasis during the procedure or early puncture of
stenoses detected before thrombosis occurs are more responsive
the fistula with subsequent extravasation of blood.
to therapy than those detected afterward. Intervention is indicat-
ed when stenosis of 50% or greater (documented by duplex ultra- If early thrombosis is thought to be caused by technical compli-
sonography or fistulography) is accompanied by a hemodynam- cations and not by the use of marginal vessels, reexploration is
ic, functional, or clinical abnormality (e.g., decreased access worthwhile. Reexploration usually involves takedown of the anas-
blood flow, elevated static or dynamic venous pressure, increased tomosis, thrombectomy of the conduit, reevaluation of both arteri-
recirculation, reduced delivered dialysis dose, or arm edema). al inflow and venous outflow, corrective measures as needed, and
Prophylactic intervention for anatomic stenosis is not warranted reanastomosis. Both autogenous AVFs and AV grafts may be prof-
when such findings are absent.33 itably reexplored. With an autogenous AVF, reexploration should
Although the question of whether angioplasty or surgical revi- be done within 24 hours of thrombosis to minimize ischemic
sion is the preferable method of intervention remains controver- endothelial injury.
sial, experience to date suggests that surgical revision tends to
provide better long-term results. This difference may derive from Late Thrombosis
the elasticity of intimal hyperplastic lesions, whose rapid recoil Autogenous AVFs Little information is available on success
may limit the efficacy of angioplasty. As a rule, if angioplasty is rates for treatment of thrombosis in autogenous AVFs; however, it
required more than twice within 3 months, the patient should be seems that neither percutaneous nor surgical techniques offer
referred for surgical revision. Treatment options include patch good results.Thrombosis of an autogenous AVF most commonly
angioplasty for localized or anastomotic stenoses, bypass for results from an aneurysm of the fistula, hyperplastic stenosis at the
longer stenoses, relocation of the venous anastomosis to a new anastomosis or in the vein just distal to the anastomosis, fibrosis
vein, and resection of the stenotic segment with interposition at an area of repeated needle punctures, or kidney transplantation.
grafting. The surgical approach should include exposure of the vein just
distal to a clinically apparent or suspected venous stenosis. The
Central venous stenosis Stenotic or occlusive lesions of vein is opened longitudinally and the thrombus evacuated.
the central veins develop in as many as 40% of patients who have Adequacy of venous outflow is assessed with a Fogarty catheter
previously undergone subclavian hemodialysis catheter place- or coronary dilators. If a segment less than 4 mm in diameter is
ment for temporary vascular access.8 When a vascular access graft encountered, the problem is corrected with patch angioplasty,
or fistula is placed distal to these lesions, they may become symp- vein bypass, or resection and primary anastomosis. (The last of
tomatic, resulting in venous hypertension, arm edema, low access these three approaches is often easy to perform because the tor-
flow, or thrombosis. Percutaneous intervention with transluminal tuosity of the vein allows easy mobilization and length extension.)
angioplasty is the preferred treatment; the tendency for central Central vein stenosis is corrected with intraoperative balloon
venous stenosis to recur soon after treatment34 may be circum- angioplasty.
vented by the addition of a stent. Stents are particularly helpful When the venous side of the AVF is in satisfactory condition,
for treating rigid or kinked stenoses, for sealing dissections or cir- the thrombus is removed from the arterial limb. Any suspected
cumscribed perforations, and for reestablishing the patency of anastomotic or proximal arterial stenosis should be corrected [see
chronically occluded veins. Surgical repair of central venous AV Grafts, below]. If the thrombosis resulted from a fistula
obstruction is a major undertaking and is reserved for those occa- aneurysm containing adherent thrombus, the aneurysm should
sional cases in which percutaneous procedures have failed in a be repaired to prevent its recurrence.
patient with no alternative access site.
AV grafts About 85% of AV graft thromboses are caused by
Arterial Stenosis stenosis of the venous anastomosis or of the draining vein (as a
Arterial stenosis is relatively uncommon. It should be corrected result of intimal hyperplasia), and most instances of graft loss are
if it is associated with diminished access flow and elevated arterial attributable to such stenosis.Treatment of a thrombosed graft has
prepump pressure. Arterial stenosis may be suspected even before only a 10% chance of success if the underlying venous stenosis is
dialysis is initiated if a patent vein does not enlarge significantly not addressed. Although arterial stenoses are less common caus-
within several weeks of fistula creation. Angiography provides a es of late thrombosis, they should be sought out and corrected as
definitive diagnosis. Stenosis of the distal artery, the anastomosis, well. Before treatment is initiated, information about recent graft
or the distal vein is best treated with reanastomosis proximal to the performance should be obtained. Signs of venous or outflow
stenotic area. More proximal stenosis may have to be treated with stenosis include increasing venous resistance and prolonged
conventional arterial reconstruction. bleeding from puncture sites. Inadequate flow rates and increased
negative pressures during dialysis are associated with stenosis of
Early Thrombosis the arterial inflow. Hypotension or excessive graft compression
Early thrombosis is defined as thrombosis occurring within 3 can explain spontaneous thrombosis in a previously well-func-
months of access construction. It is usually the result of techni- tioning graft.
cal factors or of inadequate assessment of the arterial or venous Graft thrombosis may be corrected either with surgical
thrombectomy or with pharmacomechanical or mechanical diversion of arterial flow into the low-pressure venous outflow of
thrombolysis. On the whole, technical success and long-term the fistula. When collateral arterial flow is inadequate or when
patency rates are similar for the two approaches, though there is proximal or distal occlusive arterial disease is present, distal
some evidence for a trend toward longer primary patency with ischemia occurs. In some cases, the flow into the venous side of the
surgical management.35 The choice between these two approach- fistula is sufficient to induce reversal of the flow in a portion of the
es continues to be controversial, and the decision should general- artery distal to the fistula, a phenomenon referred to as steal.
ly be based on local expertise. To date, neither surgical treatment Unfortunately, there is no reliable method of predicting the devel-
nor endovascular management has produced unassisted patency opment of symptomatic steal after the construction of an autoge-
rates higher than 50% at 6 months. If graft thrombosis occurs nous AVF or AV graft.
repeatedly in a given patient, plans for a new access site should be The ischemia is usually mild and is characterized by coldness,
considered. numbness, and pain during dialysis. In most cases, the problem
If surgical treatment is chosen, it should be carried out in an resolves without treament within a few weeks. If the patient expe-
operating suite with the capacity for intraoperative fluoroscopy. riences constant pain, severe numbness, a nonhealing ischemic
Unless preoperative findings indicate that an arterial lesion is pres- fissure, digital cyanosis or gangrene, or finger contracture, the
ent, the incision is made at the venous anastomosis, and an ade- ischemia should be corrected.The differential diagnosis of vascu-
quate length of graft and outflow vein is mobilized. A transverse lar steal syndrome includes the neuropathies of uremia and dia-
graftotomy is made within 1 or 2 mm of the suture line, any clot betes as well as secondary hyperparathyroidism. Carpal tunnel
found on the venous side is removed with suction and a forceps, syndrome—an uncommon but distinct condition occurring in
and the anastomosis is inspected. The anastomosis is calibrated hemodialysis patients—presents with symptoms similar to those
but not dilated: if a 5 mm dilator passes easily through the venous of vascular steal but can be differentiated from steal on the basis
anastomosis, then thrombectomy alone is often sufficient treat- of the characteristic electromyographic findings.
ment. A 4 French Fogarty catheter is passed proximally into the A classic indicator of clinically significant steal is that digital
right atrium and pulled back slowly with the balloon inflated to pulse waves are absent or markedly diminished on digital photo-
check for proximal venous stenosis and to evacuate clot. Any plethysmography (PPG) or pulse volume recordings (PVR) but
abnormality encountered is an indication for operative phlebog- rise to normal amplitude and contour when the fistula is com-
raphy.The presence of a venous abnormality does not rule out the pressed [see Figure 10]. Digital pressures lower than 50 mm Hg
possibility of a coexisting arterial defect; both should be corrected and a digital-brachial index lower than 0.47 are also indicative of
if found. clinically significant distal ischemia.36 A significant difference in
After the venous anastomosis is examined, a 4 French Fogarty segmental or digital pressure between the two arms with the fis-
catheter is used to evacuate any clot in the graft itself. tula compressed may be indicative of superimposed arterial dis-
Thrombectomy at the arterial anastomosis is delayed until any ease proximal or distal to the fistula, in which case arteriography
structural problems in the body of the graft are corrected; this is indicated before surgical correction. Identification of reversed
delay permits the structural corrections to be carried out in a flow distal to the fistula on duplex studies is not, in itself, suffi-
bloodless field. Narrowing in the body of the graft is usually cient reason to conclude that clinically significant steal is present:
caused by fibrous material adherent to the wall, which can be steal is a common phenomenon and is a physiologic consequence
removed with the aid of a curette, an endarterectomy instrument, of the rheology of the fistula in 73% of autogenous AVFs and
or suction. Once the body of the graft is clear, any thrombus pres- 92% of AV grafts.37
ent at the arterial anastomosis is removed. Free passage of the The goal of treatment is to reduce steal to a level where there
Fogarty balloon catheter suggests that there is no arterial anasto- is both adequate residual flow volume for dialysis and adequate
motic stenosis. The arterial anastomosis may be examined under perfusion to the hand to eliminate ischemic symptoms.Treatment
direct vision if necessary to ensure complete removal of the com- options include the following:
pacted thrombus at the arterial end of the graft.
1. Elimination of the fistula. This is the simplest form of treat-
The graft is filled with heparinized saline before the arterial or
ment and invariably corrects ischemia; however, it raises the
the venous anastomosis is repaired. When the arterial side of the
vexing problem of reestablishing access in another extremity.
graft is involved, a new arterial anastomosis usually suffices to
2. Reducing the flow but maintaining patency. Usually, this
solve the problem. A new arterial site proximal to the old one is
option involves narrowing a portion of the access to reduce
selected, and either the graft is moved to the new site or a new
flow. One technique for accomplishing this narrowing is to
free segment is added.
excise an elliptical portion of the graft or vein just distal to the
More commonly, the defect is at the venous anastomosis. In
anastomosis and reapproximate the edges or to plicate the graft
this case, the graftotomy is extended longitudinally through the
or outflow vein with mattress or continuous sutures [see Figure
anastomosis. If the stenosis is short, smooth, and hyperplastic, a
11a through c].38 Another technique is to band the fistula or
small patch angioplasty is adequate for repair. If the stenosis is
long or if the vein is sclerotic, revision to a new venous outflow
site is preferred.The graft can be reanastomosed to another near-
Before Fistula Compression During Fistula Compression
by vein, or the stenosis can be bypassed by anastomosing an
ePTFE graft of appropriate size to a more proximal segment of
the original vein. Joints may be crossed if necessary, in which case
an externally supported prosthesis is used.
Steal Syndrome
The incidence of symptomatic steal syndrome has been report- Figure 10 Vascular access via AVFs. Shown are digital photo-
ed to be approximately 2% for autogenous AVFs and as high as plethysmographic waveforms on an arm with steal syndrome
4% for AV grafts. Ischemic complications result from preferential before and during fistula compression.
a b c
d e
Figure 11 Vascular access via AVFs. One option for treating steal is to decrease blood flow in the
access conduit. Methods that may be used include (a) excision of a portion of the vein or graft, (b) pli-
cation with mattress sutures, (c) plication with continuous sutures, (d) placement of a crossed ePTFE
band with application of hemostatic clips, and (e) interposition of a 4 mm ePTFE graft.
graft with a crossed ePTFE band.39 The tails of the band are distal to the fistula contributes to the distal ischemic process,
secured with hemostatic clips, and once the appropriate degree because the bypass can be positioned so as to bypass the arte-
of narrowing has been achieved, the clips are held in place with rial stenosis as well.
a figure-eight suture of 5-0 polypropylene [see Figure 11d].
Both techniques should narrow the outflow over a fairly long With any of these techniques, intraoperative assessment is
distance (≥ 1 cm). A third technique involves interposing a required to ensure adequate residual flow volume in the fistula
small-diameter (4 mm) ePTFE graft between the artery and (assessed by intraoperative duplex scanning) and adequate distal
the vein or graft40 [see Figure 11e]; however, this technique does perfusion (assessed by evaluation of digital PPG or PVR wave-
not allow progressive calibration of the narrowing to achieve forms).The goal is to achieve a digital pressure of at least 60 mm
the desired hemodynamic result. Hg, a digital-brachial index of 0.6 or greater, and a residual flow
3. Ligation of the source of steal, with distal revascularization of at least 300 ml/min in the fistula (a level of flow that is ade-
when necessary. When steal occurs in a patient who has a quate both for hemodialysis and for maintenance of patency).44
radiocephalic fistula at the wrist with flow reversal in the radi-
Inadequate Maturation of Vein
al artery distal to the fistula (documented by duplex scans) and
whose ulnar artery and palmar arch are patent and competent Failure of a fistula to mature may result from either inadequate
to perfuse the hand, it is easily treated by ligating the radial inflow or venous abnormality. Physical examination combined
artery distal to the fistula.41 The effect of this treatment is eas- with Doppler ultrasonography or fistulography should identify the
ily demonstrated by compressing the radial artery distal to the underlying cause. If stenosis is not identified in a nonmaturing
fistula, which should relieve the ischemia. With a more proxi- radiocephalic fistula, venous side branches may be draining critical
mal fistula, in which ligation of a terminal artery would flow from the primary vessel; ligation of these branches sometimes
inevitably result in severe distal ischemia, the distal artery is leads to successful maturation. Median cubital vein ligation may be
ligated and an arterial bypass established from a point 5 cm attempted, as may temporary banding of the main venous channel
proximal to the fistula to a point just distal to the ligation [see in the antecubital fossa. Banding is accomplished by narrowing the
Figure 12]. This so-called distal revascularization–interval liga- vein with a 3-0 Vicryl tie over a 4 mm probe.The Vicryl resorbs in
tion (DRIL) procedure, originally reported by Schanzer and 3 to 4 weeks, during which period it is hoped that the increased
coworkers,42 is an elegant way of both preserving adequate resistance to flow will cause dilatation of the vein.45 If none of these
flow through the fistula and reversing the ischemia. The path- measures succeed, another access site should be sought.
way of steal is eliminated, and antegrade flow into the extrem-
True Aneurysm (Autogenous AVFs)
ity is restored through the bypass.43 This technique is particu-
larly helpful when concomitant arterial stenosis proximal or Aneurysmal dilatation of the vein develops in 5% to 8% of autog-
lation of the graft and by avoiding repeated needle insertion at the

same site. On occasion, however, pseudoaneurysms are precipitat-
ed by underlying venous stenosis, which should be documented
and corrected whenever present. Urgent surgical repair is indicat-
ed if the pseudoaneurysm is expanding rapidly or is causing
ischemia of the overlying skin. Elective repair is indicated if the
diameter of the false aneurysm is more than twice that of the graft.
Infection
AV Graft Infection is the second most common cause of loss of AV
access, occurring in 0% to 3% of autogenous AVFs and 6% to
25% of AV grafts. Infection may be acquired during surgery or
cannulation of the conduit and is most often caused by
Staphylococcus aureus.
Autogenous AVFs Infection of an autogenous AVF should

Arterial Bypass be treated aggressively with 6 weeks of antibiotic therapy, much
as subacute bacterial endocarditis would be. Local measures,
such as drainage of a perifistular abscess, may be necessary. In
rare instances, infection-induced anastomotic pseudoaneurysm
or septic emboli necessitate takedown of the fistula.
AV grafts Generally, both antibiotic therapy and surgical

treatment are necessary for cure. An antibiotic regimen that cov-
ers gram-negative organisms, staphylococci, and streptococci
should be given until culture results are available. In most cases,
Arterial Ligature
complete excision of the prosthetic graft is required,46 along with
vein patch reconstruction of the artery. If the anastomosis is not
grossly involved, a small cuff of ePTFE may be left on the arter-
ial side and used to close the arterial defect; this does not seem to
alter the prognosis.
In selected cases of well-localized infection, it is possible to
resect only the infected portion of the graft and to restore the con-
tinuity of the fistula by placing a new conduit in a clean subcuta-
Figure 12 Vascular access via AVFs. Another option for treating
neous tunnel away from the infected area. A useful approach to
steal is to ligate the source. Shown is the so-called DRIL proce-
dure, which involves arterial ligation distal to the takeoff of the AV managing an infected forearm loop graft is to resect the graft and
graft or the autogenous AVF and arterial bypass from a point 5 reconstruct the fistula with an immediate anastomosis between
cm proximal to the fistula to a point just distal to the ligation. the artery and the arterialized vein remaining after graft excision.
Superficial surgical wound infections occurring in the postopera-
tive period can sometimes be treated successfully with aggressive
enous AVFs as a result of high pressure applied to a vein wall weak- local debridement in combination with systemic administration
ened by repeated punctures. Usually, the course of such aneurysms of antibiotics. Deeper wound infections occurring in the postop-
is benign and does not preclude use of the fistula; however, large erative period must be assumed to involve the entire graft, given
aneurysms containing mural thrombus have been reported to that the graft is not yet well incorporated.
cause late thrombosis and embolization. On rare occasions, pro-
gressive enlargement can compromise circulation to the skin above OUTCOME EVALUATION
the aneurysmal vein, leading to incomplete hemostasis when the Thrombotic events are the leading cause of access loss. For the
needle is withdrawn and ultimately to graft rupture. Skin compro- most part, they result from venous outflow stenosis that can be
mise and progressive enlargement are therefore indications for sur- detected before thrombosis occurs. An organized monitoring
gical correction. Surgical revision is also recommended if the approach that includes regular assessment of the clinical parame-
aneurysm involves the arterial anastomosis or is associated with ters of the access and of the adequacy of the dialysis should be
stenosis of the venous outflow. implemented in every dialysis center.6 Such a proactive approach
Options for revision include total excision of the aneurysm can be expected to reduce the incidence of thrombosis and
with primary reanastomosis, exclusion of the aneurysm with vein increase patency.
bypass grafting, and partial excision in which part of the vein wall Physical examination of the AV graft or autogenous AVF
is kept as the arterial conduit.The last option frequently results in should be performed weekly and should include not only inspec-
early recurrence as the vein wall continues to weaken and dilate tion and palpation for changes in the physical characteristics of
with time. the pulse or thrill but also a search for indirect signs of graft dys-
function (e.g., arm swelling, prolonged bleeding after needle
Pseudoaneurysm (AV Grafts) withdrawal, and aneurysm or pseudoaneurysm). In addition to
Pseudoaneurysms occur in prosthetic AV grafts and are usually physical examination, the NKF-DOQI committee recommends
small and asymptomatic. They can be prevented by allowing suf- routine access monitoring at least monthly with one or more of
ficient time after graft placement to ensure firm fibrous encapsu- the following techniques:
1. Intra-access flow assessment using Doppler flow, magnetic res- OPERATIVE PLANNING
onance imaging, or ultrasound dilution online during dialysis.
A trend toward decreasing flow or a flow rate lower than 600 Choice of Type of Catheter
ml/min for an AV graft and lower than 200 to 300 ml/min for Different catheter designs have been studied and used, but at
an autogenous AVF is predictive of a high likelihood of access present, none of them appears to have a proven advantage over
stenosis and eventual thrombosis. the others. Generally, the catheters best suited for hemodialysis
2. Static or dynamic venous pressure measurement. Progressively are high-flow, large-diameter (12 French or larger) devices with
increasing pressures or pressures that exceed the threshold external ports. Silicone catheters are more flexible, are less likely
value determined by each center’s own protocol are predictive to give rise to injury or thrombosis, and remain patent longer
of significant venous outlet stenosis. than polyethylene, polyvinyl chloride, and polytetrafluoroethyl-
3. Urea and nonurea recirculation measurement. Recirculation is ene catheters. Silicone catheters are available in both noncuffed
defined as the percentage of flow that is recirculated from the (temporary) and cuffed (semipermanent) double-lumen config-
venous line into the dialyser inflow by retrograde blood flow urations through which flow rates of 250 ml/min or higher can be
through the fistula. A recirculation value exceeding 10% to achieved [see Figure 13]. The venous and arterial orifices are sep-
20% is significant and usually indicates low arterial blood flow arated by 1 to 2 cm; recirculation is thereby limited to 5%.
or venous stenosis.
4. Delivered dialysis dose. A decrease is associated with venous Noncuffed (temporary) catheters Noncuffed catheters
outflow stenosis. can be percutaneously inserted into the internal jugular, subcla-
5. Arterial prepump pressure. An elevated negative pressure is a vian, or femoral vein without the need for fluoroscopic guidance.
sign of inflow insufficiency. They are suitable for immediate use and provide acceptable flow
Data should be tabulated and tracked within each dialysis center rates (250 ml/min).Their main disadvantages are their high rates
as part of a quality assurance/continuous quality improvement of infection, thrombosis, and venous stenosis and their short use-
(QA/CQI) program.7 life (2 to 3 weeks). For these reasons, noncuffed catheters should
be reserved for patients in whom access is expected to be needed
for less than 3 weeks, and they should be inserted no earlier than
Vascular Access via Percutaneous Catheters required.
Percutaneous venous catheterization is a useful method of
gaining immediate access to the circulation; however, it is associ- Cuffed (semipermanent) catheters Cuffed catheters are
ated with significant risks, and the use-life of this type of access is placed in a subcutaneous tunnel under fluoroscopic guidance.
shorter than that of AVFs. Percutaneous catheterization should They are free of some of the shortcomings of noncuffed
be reserved for patients with acute renal failure who have an catheters; in particular, they are associated with lower infection
immediate need for dialysis and for patients with chronic renal rates and permit higher flow rates. Cuffed catheters are preferred
failure in whom a permanent vascular or peritoneal access route when temporary access is required for longer than 3 weeks, par-
either cannot be established or has not yet matured.
A history is taken, a physical examination is performed, labora- a b

tory data are reviewed, and radiologic studies are ordered as for
AVFs [see Vascular Access via Arteriovenous Fistulas, above]. Any
finding that might affect the integrity of the central venous system
should be noted.
A history or physical signs of previous central venous catheter-
ization, a history of major injury or operation in the area where the
catheter is to be inserted, a body mass index greater than 30 or less
than 20, and an increasing number of insertion attempts are all
known risk factors for perioperative complications from the inser-
tion of venous access devices.6 If there is any question about the
patency of the central venous system, duplex scanning47 or phle-
bography is indicated.
On physical examination, the surgeon should note the patient’s
body type, assess the flexibility of the patient’s neck and shoulders,
and evaluate the patient’s ability to tolerate the Trendelenburg
position without dyspnea or discomfort. Chest x-rays are reviewed
to verify the patient’s pleuropulmonary status and to identify any
bony deformities.
The only laboratory study absolutely necessary is a complete
blood count (including the platelet count and the differential
count); prothrombin and partial thromboplastin times are
required if the patient is receiving anticoagulant therapy. The Figure 13 Vascular access via percutaneous catheters. Catheters
effects of warfarin or heparin should be reversed before the pro- used for hemodialysis include (a) cuffed double-lumen (semiper-
cedure; patients with platelet counts lower than 50,000/mm3 manent) catheters, introduced by means of the peelaway sheath
should undergo platelet transfusion immediately before and dur- technique, and (b) noncuffed double-lumen (temporary)
ing catheter placement.48 catheters, introduced by means of the Seldinger technique.
ticularly for patients in whom a primary AV fistula is maturing allows greater control over the vessel than the percutaneous
but who require immediate hemodialysis. Semipermanent approach does and is preferred in patients who have a bleeding
catheters have been used for as long as 4 years, but long-term fol- diathesis, patients whose body habitus or venous anatomy limits
low-up data on large numbers of patients are lacking.49 Most percutaneous access, and patients in whom a percutaneous
patients readily accept this approach to dialysis: cuffed catheters attempt at placement has failed.
allow so-called no-needle dialysis with high flow rates, they elim- A less commonly used approach is femoral vein catheteriza-
inate the problem of vascular steal, and they have no effect on car- tion. It is technically easy and has few immediate complications,
diac function. In addition, patients appreciate that the access site is but it necessitates hospitalization (because the patient cannot
hidden from view, does not limit physical activity, and does not ambulate) and is associated with high infection rates that limit
require particular care between treatments. use of the catheter to 5 days. Alternatively, access to the inferior
vena cava can be gained by cannulating the greater saphenous,
Choice of Insertion Site inferior epigastric, right gonadal, and lumbar veins. It is also pos-
The subclavian veins have given way to the right internal jugu- sible to cannulate the azygos vein and the right atrium directly via
lar vein as the preferred site of primary central access. This site thoracotomy.
has four main advantages: (1) it offers a consistent, predictable
OPERATIVE TECHNIQUE
anatomic location with palpable landmarks, (2) it provides a
short, straight course to the superior vena cava, (3) success rates
are high, and (4) the risk of complications is diminished in com- Right Internal Jugular Vein Approach
parison with other catheter insertion sites.50 Of particular impor- Step 1: patient preparation Noncuffed catheters may be
tance is that the risk of subclavian vein stenosis is decreased; this inserted at the bedside; cuffed catheters should be inserted in a
complication is a major concern for dialysis patients, who may standard OR with facilities for fluoroscopy.
require subsequent construction of an AVF in the ipsilateral arm. The anatomy is surveyed before preparation and draping.
The right internal jugular vein is preferable to the left as an access Important anatomic landmarks include the sternal notch, the
site because the latter calls for longer catheters, which increase clavicle, and the sternocleidomastoid muscle. The carotid artery
the risk of kinking and diminish flow rates.The left internal jugu- should be palpated lateral to the trachea, under the medial (ster-
lar vein approach is also associated with a high rate of stenosis or nal) head of the sternocleidomastoid muscle. The internal jugu-
thrombosis of the left brachiocephalic vein and may hinder sub- lar vein lies lateral and slightly anterior to the carotid artery,
sequent use of the left arm for an AVF. Placement of the catheter between the sternal head and the clavicular head of the ster-
in a subclavian vein either via the percutaneous approach or via nocleidomastoid muscle.
cutdown on the cephalic vein should be reserved for cases in The patient is placed supine in the Trendelenburg position so
which neither jugular vein can be used.6 that the neck veins are distended and the risk of air embolism is
The right internal jugular vein can be catheterized percuta- minimized.The head is extended and turned slightly to the left to
neously, or it can be surgically exposed and catheterized via direct expose the right side of the neck and keep the chin from interfer-
needle puncture or phlebotomy (venous cutdown).The cutdown ing with the procedure. The neck should not be overextended or
approach on the internal jugular vein or the external jugular vein overrotated, however, because either of these actions flattens out
a d
Figure 14 Vascular access via percutaneous catheters. The equipment used in percutaneous
catheter insertion includes (a) a 5 ml syringe, (b) a 22-gauge finder needle, (c) an 18-gauge nee-
dle, (d ) a guide wire, (e) a dilator, (f) a peelaway sheath, and (g) a plastic subcutaneous tunneler.
the vein, making it more difficult to cannulate, and may increase

the risk of arterial puncture by causing the internal jugular vein
to overlie the carotid artery.
Step 2: cannulation of right internal jugular vein The

jugular vein is located with a 22-gauge finder needle.This needle
is left in place and used to guide the subsequent placement of an
18-gauge needle, through which the guide wire is passed. Use of
the smaller needle minimizes the consequences of arterial or
pleural puncture occurring during blind attempts at venous
puncture.
After local anesthesia is administered, the fingers of the left
hand are gently positioned on the carotid pulse to provide an
anatomic landmark. The right hand locates the internal jugular
vein by applying negative pressure to the 22-gauge finder needle
mounted on a 5 ml syringe [see Figure 14].The needle is inserted
at the apex of the triangle formed by the two heads of the ster-
nocleidomastoid muscle and directed toward the ipsilateral nip-
ple at an angle of 30˚ from the plane of the skin. Alternatively, the
needle may be inserted under the medial border of the ster-
Figure 15 Vascular access via percutaneous catheters: Seldinger
nocleidomastoid muscle and directed toward the thoracic inlet
technique. Shown is a noncuffed (temporary) catheter inserted in
while the carotid artery is dislocated medially, or it may be insert- the right internal jugular vein.
ed under the lateral border of the sternocleidomastoid muscle
and directed toward the contralateral nipple.
Once the vein is located, the syringe is disconnected from the syringe. Entry into the vein is confirmed by the sudden and easy
finder needle, which is left in place.The vein is then repunctured return of venous blood.
with an 18-gauge needle oriented parallel to the finder needle. Pulsatile back-bleeding of bright-red blood from the needle
When venous backflow is obtained, the 18-gauge needle is reori- usually indicates arterial puncture. If any doubt exists, the aspi-
ented at a more acute angle to the skin and is advanced 2 to 3 rated blood can be compared with a simultaneously obtained
mm.The syringe is disconnected and the needle hub occluded to arterial sample, or the 18-gauge needle can be connected to a
prevent air embolism. A 0.035-in. guide wire with either a J tip pressure transducer. Whenever there is any possibility of arterial
or a flexible straight tip is then inserted through the needle, and puncture, it is preferable to withdraw the needle rather than take
the needle is withdrawn over the wire. the risk of creating a large hole in the artery with a dilator.
Troubleshooting. Because of the predictable anatomic location The guide wire should be inserted with caution because any
of the right internal jugular vein, the first attempt at cannulation forceful movement can result in perforation of the vein wall. The
is successful in the majority of cases. If the first attempt fails, the risk is minimized by using a soft-tipped or J-tipped wire. The
finder needle should be withdrawn and its tip reoriented slightly wire should advance easily into the vein without resistance; if it
laterally; however, the needle should not be entirely withdrawn does not, the guide wire and the needle should be withdrawn to-
from the skin puncture site. An orderly, systematic search per- gether to ensure that the tip of the guide wire is not sheared off and
formed in this manner often identifies the vein while posing little does not embolize.
risk of carotid artery injury as long as the carotid artery remains
palpable medially.To avoid lacerating deep structures, the needle Step 3 (Seldinger technique): insertion of noncuffed
orientation should be changed only when the needle is inserted catheter A small nick is made at the point where the guide
very superficially. If the vein cannot be located after several pass- wire enters the skin [see Figure 15]. The dilator is passed over the
es of the needle, the finder needle is withdrawn completely and wire only far enough to enter the vein; it is then removed, and the
the anatomy reassessed. catheter is inserted over the wire. The catheter tip should be
Alternative puncture sites may be attempted. In more techni- placed in the superior vena cava, above the right atrial junction.
cally challenging cases, a cutdown can be performed on the exter- This position is typically 15 to 18 cm from the puncture site if the
nal or internal jugular vein through a small transverse incision. catheter is placed in the right internal jugular vein; an additional
Cannulation of the veins can also be carried out under ultra- 3 to 5 cm is required for the left internal jugular vein approach.
sonographic guidance. In fact, the NFK-DOQI committee rec- The guide wire is then retrieved, venous blood is aspirated from
ommends routine real-time ultrasound-guided insertion to both ports, and each lumen is flushed with heparinized saline.
reduce insertion-related complications. The internal jugular vein The catheter is anchored to the skin.
is usually imaged with the probe placed either parallel or perpen- Troubleshooting. Dilators are relatively inflexible, and their stiff-
dicular to the long axis of the vein. Placing the probe perpendic- ness increases with size. Consequently, they can easily perforate
ularly gives the vessel a more typical circular appearance.51 Aside the vein wall if inserted deeper than the point of entry into the
from the ultrasound-guided vein cannulation, the rest of the pro- vein. Catheters may also cause perforation, though less com-
cedure is performed essentially as previously described. monly. The risk of catheter-related perforation is increased with
When the 18-gauge needle is advanced, the lumen of the jugu- the left internal jugular vein approach and the subclavian vein
lar vein is often compressed; as a result, the needle may transfix approach because catheters inserted from the left side must tra-
the front and back walls almost simultaneously. The needle tip verse the innominate vein and enter the superior vena cava at an
should be advanced only slightly beyond the expected depth, acute angle, and this course increases the possibility that the tip
then slowly withdrawn, with gentle aspiration maintained on the of the catheter will perforate the right lateral wall of the superior
vena cava. No resistance should be felt when the catheter is

inserted. In addition, the guide wire should move freely within the
catheter during insertion; such free movement suggests that the
catheter is not compressing the wire against the wall of the vein.
Manual control of the guide wire must be maintained at all
times; without such control, pushing a catheter or dilator over the
wire can cause the wire to be completely advanced into the vein.
Inadvertent placement of a dilator or catheter into the carotid
artery makes a large hole in the vessel wall, thereby creating the
potential for substantial bleeding when the device is removed. In
such cases, the catheter should be left in the artery, and a vascu-
lar surgeon should be consulted.
Step 3 (peelaway sheath technique): insertion of cuffed

catheter A small transverse incision is made at the point where
the guide wire enters the skin. Once adequate local anesthesia is
achieved, a subcutaneous tunnel is created between the guide-
wire entry point and a site on the chest wall at least 10 cm away
Figure 16 Vascular access via percutaneous catheters: peelaway
[see Figure 16].The position of the catheter is estimated by laying
sheath technique. Shown is a cuffed (semipermanent) catheter
the catheter out along its intended tract; the course forms an inserted in the right internal jugular vein and placed in a subcu-
inverted U, with the apex at the entry point of the guide wire and taneous tunnel.
the tip of the catheter 5 cm caudad to the angle of Louis (at the
second or third intercostal space). The position of the Dacron
cuff is noted, and a stab wound is made in such a way that the which is then replaced. The right internal jugular vein approach
cuff will be positioned in the subcutaneous tunnel, 2 cm from the usually allows easy placement of the catheter through the peel-
wound. This placement simplifies removal of the catheter, pre- away sheath into the right atrium after removal of the dilator and
vents the cuff from eroding through the skin, and reduces the the guide wire. In the left jugular vein approach or the subclavian
incidence of inadvertent catheter dislodgment. The exit wound vein approach, the guide wire should be left in place and the
should be at least 3 to 4 cm from the nipple-areola complex to catheter inserted over the guide wire so that the catheter can be
allow space for the dressing. more readily advanced into the appropriate position.
A plastic subcutaneous tunneler is attached to the catheter and
used to pull the catheter through the tunnel so that the tip Step 4: evaluation The location of the catheter tip should
emerges adjacent to the guide wire. The venous dilator is then be documented with a chest x-ray after the procedure. To reduce
inserted over the wire to effect entry into the vein. Once entry is the risk of complications (e.g., central vein thrombosis or perfo-
effected, the dilator is removed and inserted into the peelaway ration of the right atrium), the tip should be located at the junc-
sheath, and sheath and dilator are introduced together into the tion of the right atrium and the superior vena cava.52
vein over the guide wire. The guide wire and the dilator are
removed, and the open end of the peelaway sheath is occluded Subclavian Vein Approach
with the fingers to prevent air embolism and bleeding. The The patient is positioned and prepared in much the same way
flushed catheter is then inserted into the peelaway sheath and its as for the right internal jugular vein approach.The arms are at the
position confirmed via fluoroscopy. When the catheter is well sides, and a small roll is placed between the shoulder blades to
positioned, the peelaway sheath is cracked, peeled apart, and allow full exposure of the infraclavicular area. An insertion site is
removed. Both lumina are tested for easy aspiration of blood and selected 2 to 3 cm caudad to the midpoint of the clavicle, far
irrigated with heparinized saline. The two incisions are closed enough from its inferior edge to allow the needle to remain paral-
with absorbable sutures, and an adequate dressing is applied. lel to the clavicle as it passes beneath its inferior border. A slightly
Troubleshooting. Because the procedure is performed under lateral position is preferred to prevent kinking of the peelaway
fluoroscopic guidance, fluoroscopy should be used to confirm sheath or compression of the soft silicone catheter between the
that the position of the guide wire is satisfactory before the clavicle and the first rib.
catheter is inserted. If the guide wire is not satisfactorily posi- Local anesthesia should include the clavicular periosteum. The
tioned, a 14-gauge plastic I.V. catheter is placed over the wire into 18-gauge needle is advanced into the space between the clavicle
the vein, and the wire is removed and repositioned through the and the first rib in the direction of a finger placed in the supraster-
catheter. nal notch. The needle is oriented as horizontally as possible, and
The peelaway sheath must be inserted to its full length, which the bevel of the needle is oriented downward to decrease the risk
means that the dilator must be inserted to its full length as well. Bend- that the guide wire will pass upward into the ipsilateral internal
ing the dilator and the sheath into a gentle curve that matches jugular vein.
the curve of the vein minimizes the risk of venous wall perfora- Careful technique helps prevent pneumothorax and puncture
tion, particularly if the left internal jugular vein approach or the sub- of the subclavian vein. For example, “walking” the tip of the nee-
clavian vein approach is used. dle down the clavicle, so that it passes as closely underneath the
If resistance is encountered when the catheter is inserted clavicle as possible, reduces the risk of deep puncture and thus of
through the sheath, the usual cause is a kink in the sheath. In most pneumothorax.The rate of complications is directly related to the
instances, partial withdrawal of the sheath resolves the problem. If number of puncture attempts made; consequently, if the subcla-
this step is taken and the catheter still cannot be advanced, the vian vein is not punctured on the second or third attempt, one
guide wire and the dilator can be reinserted through the sheath, should resist the temptation to make additional needle thrusts.
Once the vein is cannulated, the catheter may be inserted by chest x-ray, occurs in fewer than 1% of all insertions.53 It is usu-
means of either the Seldinger technique or the peelaway sheath ally self-limited in that the bleeding generally tamponades before
technique as previously described [see Right Internal Jugular Vein hemodynamic compromise occurs.
Approach, above]. If both a vascular structure and the parietal pleura are lacerat-
A chest x-ray will confirm the positioning of the tip of the ed, hemothorax may result.The chest x-ray will suggest the diag-
catheter and the presence or absence of kinking. It will also rule nosis.Treatment includes placement of a thoracostomy tube and
out so-called pinch-off, which is a narrowing or notching of the early consultation with a thoracic surgeon. Fortunately, the
catheter as it passes through the tight space between the clavicle bleeding ceases spontaneously in most cases.
and the first rib that may result in transection and embolization of Pericardial tamponade, the most lethal complication of central
the catheter tip. venous catheterization, may arise as a consequence of perforation
into the pericardial space, either through the wall of the vein or
Femoral Vein Approach through the heart. It can occur immediately, or it can appear
Femoral venipuncture is performed below the inguinal liga- hours to days later as a result of delayed perforation by the
ment just medial to the palpated femoral arterial pulse. The catheter tip. Proper positioning of the catheter tip is the key to
catheter is inserted by means of the Seldinger technique. The preventing pericardial tamponade. Treatment involves pericar-
catheter should be at least 19 cm long to reach the inferior vena diocentesis, creation of a pericardial window, or median ster-
cava, thereby minimizing recirculation. notomy, depending on the patient’s clinical status.
Cardiac arrhythmias are frequent during catheter insertion:
COMPLICATIONS
atrial and ventricular arrhythmias occur in as many as 41% and
11% of patients, respectively.54 These arrhythmias are usually
Early
benign; fewer than 1% call for cardioversion.
In more than 5% of catheter insertions, the catheter is improp- Pneumothorax occurs in 1% to 4% of attempts at percuta-
erly positioned. Such malpositioning may cause central venous neous catheter placement. The incidence varies according to the
perforation, venous thrombosis, or device malfunction. The most experience of the operator and the site selected; in particular, it is
common positioning error is entry of a subclavian catheter into the higher with the subclavian approach. The presence of pneumo-
ipsilateral internal jugular vein; less commonly, the catheter tip thorax may be suggested by air in the syringe during attempts at
may inadvertently be placed in an axillary, internal mammary, vein cannulation and may be confirmed by chest x-ray. If the
azygos, or hepatic vein. Placement of the tip within the more pneumothorax is asymptomatic, with less than 25% lung col-
cephalad portion of the superior vena cava at an obtuse angle to the lapse, it can be treated conservatively; if it is large, symptomatic,
venous wall or directly in the heart increases the risk of perforation. or increasing in size, placement of a thoracostomy tube is indi-
Catheter malpositioning is diagnosed by means of fluoroscopy cated. Tension pneumothorax is an unusual but important com-
or chest x-ray; management involves immediate repositioning of plication that calls for immediate chest tube decompression.
the catheter with the help of guide wires and fluoroscopy. Inadvertent puncture of a lymphatic duct may occur during
Guide-wire embolism can be prevented by being careful not left subclavian vein or left internal jugular vein catheterization in
to withdraw the wire through the 18-gauge needle, which can patients with hepatic portal hypertension or superior vena caval
shear off the tip of the wire. Catheter embolism, though rare, obstruction. The diagnosis is usually made when clear or milky
may occur when a subclavian venous catheter is inserted too fluid is aspirated in the syringe during vein cannulation; howev-
medially and as a consequence is compressed between the cos- er, if the duct is punctured at the junction with the vein, the
toclavicular ligament, the clavicle, and the first rib. Such com- appearance of blood mixed in with the lymphatic fluid may mask
pression may lead to biomaterial fatigue, fracture of the catheter, the complication. Once lymphatic duct puncture is recognized,
or embolization. Embolized portions of a guide wire or catheter the procedure should be abandoned, and pressure should be
should be removed by means of interventional radiologic tech- applied to the site until lymphorrhagia abates. If the complication
niques to prevent thrombotic complications. is recognized late on the basis of spontaneous leakage of lymph
Air embolism occurs when air is inadvertently aspirated into around the catheter, either the catheter can be removed or the
the patient’s venous system while the catheter is being inserted, leak can be stopped with a purse-string suture around the
removed, or used. It is easily prevented by using a fingertip to catheter. If persistent fluid drainage, subcutaneous edema, medi-
cover all potential communication sites between the venous astinal enlargement, or chylothorax is noted, the leak is ongoing,
lumen and the outside air, including the needle hub before guide- and the catheter should be removed.
wire insertion, the open end of the peelaway sheath just before
catheter insertion, and the disconnected external ports of Late
catheters. Patients whose pulmonary status is compromised or Central venous thrombosis Catheter-associated central
who have aspirated large volumes of air may experience respira- venous thrombosis is more common than was once believed. It is
tory distress. Cardiovascular collapse, caused by obstruction of often asymptomatic because of the rich venous collateral circula-
right ventricular outflow by gas bubbles, can also result. tion in the area. Central venous thrombosis has been estimated
Auscultation may reveal a characteristic millwheel precordial to occur in 13% to 35% of catheter insertions55 and to carry less
murmur. The patient should be placed in the left lateral decubi- than a 10% risk of pulmonary embolism and a 19% risk of post-
tus position with the foot of the table elevated so as to trap the air phlebitic syndrome. The incidence of catheter-associated throm-
pocket away from the right ventricular outflow tract, and imme- bosis is correlated with the following factors:
diate ventilatory support for hypoxemia should be instituted.
Internal hemorrhage may occur at any site, usually as a result 1. Placement site. The incidence of thrombosis or stenosis is as
of perforation of a central venous or arterial structure during nee- high as 38% with subclavian vein catheters but less than 10%
dle puncture or insertion of a guide wire, a dilator, or a catheter. with internal jugular vein catheters.
Mediastinal hemorrhage, manifested by mediastinal widening on 2. Site of catheter entry. Surgical cutdown causes less endothelial
injury than percutaneous puncture and dilation of the vein and complication of venous catheterization for vascular access, occur-
may therefore be less likely to cause thrombosis. ring in as many as 30% to 40% of patients. It is also one of the
3. Catheter tip position. Catheters placed high in the superior vena leading causes of catheter removal and morbidity in dialysis
cava, near the brachiocephalic vein, are more likely to cause thrombosis. patients. Gram-positive bacteria, principally S. aureus and S. epi-
4. Catheter size. Larger, stiffer catheters are more likely to trau- dermidis, are the most commonly isolated organisms, though
matize the endothelium and to obstruct flow. gram-negative bacteria and fungi may also be involved.
5. Catheter material. Silicone is less thrombogenic than other The clinical spectrum of catheter infection includes exit-site
materials. infection, tunnel infection, systemic line sepsis, and suppurative
6. Duration of catheter placement. The incidence of thrombosis thrombophlebitis.
increases with the duration of catheter placement. Exit-site infection. The characteristic signals are localized ery-
7. Underlying hypercoagulable state. thema, induration, tenderness, and exudate at the catheter exit
8. Associated catheter infection. site. Systemic symptoms are absent, and blood cultures are nega-
tive. Treatment involves local wound care and application of top-
The diagnosis is easily made by means of duplex scanning or ical antibiotics. The catheter need not be removed.
phlebography. Treatment involves removal of the catheter and Tunnel infection. If the inflammatory process extends along the
administration of anticoagulant therapy. Asymptomatic patients entire course of the subcutaneous tunnel, a more extensive cel-
who have no alternative sites for venous access should undergo lulitic process, with or without purulent discharge, results. Initially,
anticoagulation without removal of the catheter. Thrombolytic tunnel infection can be treated with parenteral antibiotics and
therapy through the catheter, though never evaluated in a local measures; however, it usually does not respond to this regi-
prospective randomized study, may be useful if the thrombosis is men, and removal of the catheter is often required. If a new
new or symptomatic, is progressing in the face of standard thera- catheter is called for, it should use a different tunnel and exit site.
py, or is associated with catheter occlusion in a patient with no Systemic line sepsis. This condition is manifested by systemic
alternative site of venous access. symptoms and signs of bacteremia in a patient who has a central
venous catheter in place but exhibits no local evidence of catheter
Catheter malfunction Catheter malfunction is the most or tunnel infection and has no other identifiable source of infec-
common noninfectious complication of central venous catheteri- tion. It is defined on the basis of the following two criteria: (1) in
zation. Malfunction is defined as either (1) failure to achieve a comparison with peripheral blood, a 10-fold increase in colony-
blood flow rate of at least 300 ml/min on two consecutive occa- forming units (CFU)/ml blood drawn from the catheter, or (2) in
sions or (2) failure to achieve a blood flow rate of 200 ml/min on the absence of a positive peripheral blood culture, more than
a single occasion. In addition, partial or complete so-called with- 1,000 CFU from blood drawn through the device. Empirical I.V.
drawal occlusion, in which solutions can be infused but blood antibiotic treatment (including coverage for penicillin-resistant
cannot be withdrawn, may occur, as may complete occlusion. staphylococci) should be administered through the catheter. This
Early catheter malfunction is usually caused by improper posi- measure will eliminate the clinical sepsis syndrome in 70% of
tioning of the catheter tip proximal to the distal superior vena cava, patients. Once the antibiotics are discontinued, however, there is
positioning of the tip against the venous wall, or subcutaneous a 40% risk of reinfection; for this reason, catheter exchange over
kinking of the catheter. The precise cause can be determined via a guide wire, using the same tunnel and exit site, is recommend-
chest x-ray and contrast study. Malpositioning of the catheter tip ed once bactericidal levels have been obtained58 and the sepsis
can be corrected by using a tip deflector wire inserted through the syndrome has resolved. I.V. antibiotics should be continued for 3
lumen of the catheter, by snaring the catheter via the femoral weeks thereafter. If the patient is unstable or still symptomatic
approach and repositioning it, or by replacing the catheter. after 24 to 36 hours of antibiotic therapy, removal of the catheter
Late catheter malfunction is usually caused by intraluminal is mandatory. The catheter should also be removed if fungemia is
thrombi; less commonly, it is caused by extraluminal thrombi (e.g., suspected or confirmed.
fibrin tails or sheaths enveloping the distal portion of the catheter) Suppurative thrombophlebitis. When arm edema occurs in addi-
or central venous thrombosis. Most late catheter dysfunction can be tion to systemic sepsis, suppurative thrombophlebitis of a great
successfully managed with thrombolytic therapy. Thrombolysis vein should be suspected. The diagnosis may be confirmed by
with urokinase was once first-line treatment for this complication means of duplex scanning or contrast phlebography. Treatment
because of its high success rate (up to 90%) and its ease of admin- involves catheter removal, systemic I.V. antibiotic therapy, and
istration.56 However, urokinase is no longer available in the United heparin anticoagulation and is successful in more than 50% of
States market for this indication. (It was reintroduced and approved patients.Vein excision is associated with significant morbidity and
by the FDA in 2002, but only for the treatment of massive pul- consequently is not indicated. Patients who do not respond to
monary emboli and pulmonary emboli accompanied by unstable treatment can be treated with vena caval filter placement and cen-
hemodynamics.) Protocols using tissue plasminogen activator and tral vein thrombectomy.
recombinant urokinase have been employed, with promising
results. If catheter function fails to improve with thrombolysis, Noncuffed catheter infection The presence of exit-site
imaging of the catheter with infused contrast material will allow infection, tunnel infection, or systemic line infection mandates
identification and correction of other problems. Residual thrombus removal of all noncuffed catheters.
in the catheter lumen can be treated by means of intracatheter infu-
sion of a thrombolytic agent, catheter embolectomy, or catheter OUTCOME EVALUATION
exchange over a guide wire. Fibrin sheaths around the catheter can To improve dialysis outcomes and to maintain or improve qual-
be treated by means of thrombolysis, fibrin sheath stripping with a ity of care for dialysis patients, percutaneous catheterization should
snare,57 or catheter exchange. be performed only in selected cases. Given that percutaneous
catheterization is associated with higher complication rates, mor-
Cuffed catheter infection Infection is the most common bidity, and mortality than AV fistulization, the goal should be to use
percutaneous catheters in fewer than 10% of hemodialysis patients OPERATIVE PLANNING

requiring long-term vascular access. In those cases in which central
catheter placement is the best available option, the use of a consis- Choice of Type of Catheter
tent technique by skilled operators should, according to the NFK- The ideal catheter for peritoneal access would be simple, safe,
DOQI, reduce the risk of serious complications necessitating and durable and would provide reliable, rapid flow of the dialysate
intervention to 2% or lower. without leaks or infection. The silicone rubber double-cuff
straight Tenckhoff catheter, first described in 1968,62 remains one
Peritoneal Access of the most widely used catheters for this purpose.
Since the introduction of the Tenckhoff catheter, a number of
Clinical use of peritoneal dialysis was first described back in different catheters have been developed with the objective of min-
1923,59 but it was not until 1976 that technical refinements made imizing the complications inherent in these devices—namely,
this procedure a valid alternative to hemodialysis.60 The advantage infusion or pressure pain, obstruction, catheter migration, exter-
of peritoneal dialysis is that it offers the patient increased autonomy
nal cuff extrusion, and infection. The various catheters may be
and independence, in that all the dialysis sessions are performed
defined according to the characteristics of their intraperitoneal
at home. Moreover, there are fewer dietary restrictions, and antico-
and extraperitoneal segments [see Figure 17].
agulation is unnecessary. According to the NFK-DOQI commit-
tee,61 peritoneal dialysis is indicated for the following patients:
Intraperitoneal segment A straight catheter is, in theory,
1. Patients who prefer peritoneal dialysis or refuse hemodialysis; more traumatic to surrounding tissues, more likely to cause
2. Patients who cannot tolerate hemodialysis (e.g., some patients pain during injection of the dialysate (jet effect), and more sus-
who have congestive or ischemic heart disease or extensive vas- ceptible to obstruction by the intestinal ansa (loops of bowel)
cular disease or in whom vascular access is problematic, includ- or the adjacent omentum. A coiled tip adds bulk to the tubing,
ing the majority of young children); and thus facilitating separation of the parietal and visceral layers of
3. Patients who prefer home dialysis but who have no assistant to the peritoneum, and provides more side holes for outflow.
help with hemodialysis or whose assistant cannot be trained for Although coiled tips are very widely used and are available with
home dialysis. almost all types of catheters, their theoretical advantages, to
Absolute contraindications to peritoneal dialysis are as follows: date, have not translated into superior results in randomized
studies.63,64
1. Loss of more than 50% of the peritoneal surface or the pres- Other catheter modifications are the addition of perpendicular
ence of adhesions too extensive to permit adequate flow of the disks that move the intestine and the omentum away from the lat-
dialysate (a history of laparotomy is not a contraindication in eral holes and the use of the T-fluted design, which has grooved
itself); limbs positioned against the parietal peritoneum for better
2. The absence of an assistant in the home of a patient who does drainage and less risk of migration.
not have the autonomy or intellectual capacity to perform peri-
toneal dialysis on his or her own; Extraperitoneal segment Single versus double cuff. A
3. The presence of a surgically irreparable hernia; Dacron cuff is always positioned in the rectus abdominis. A sec-
4. Loss of integrity of the diaphragm, which can lead to the ond cuff, when present, is positoned in the subcutaneous tunnel
appearance of a hydrothorax; and about 2 cm from the exit site. Use of a second cuff creates an
5. Severe respiratory insufficiency, in which case the increase in additional barrier against bacterial contamination of the subcuta-
intra-abdominal volume caused by the dialysate could compro- neous tunnel and provides solid anchoring that prevents the
mise respiratory function. catheter from moving in a pistonlike fashion. Even though the
Inflammatory bowel disease and frequent episodes of divertic- randomized studies done to date have yielded inconsistent
ulitis are relative contraindications to peritoneal dialysis; it must be results,65,66 double-cuff catheters are generally recommended in
assumed that the risk of transmural contamination with secondary preference to single-cuff catheters.
peritonitis is higher in these patients. Morbid obesity is also a rela- Straight versus permanent bend. The literature demonstrates
tive contraindication because of technical problems related to that orienting the subcutaneous tunnel laterally and caudally in
installation of the dialysis catheter.With a newly implanted vascu- relation to the intraperitoneal entry site significantly reduces the
lar prosthesis, a waiting period of at least 4 months is required to risk of peritonitis associated with exit-site or tunnel infection. It is
minimize the risks of contamination of the prosthesis. reasonable to think that installing a straight catheter in an arcuate
tunnel would increase the risk of migration of the intraperitoneal
PREOPERATIVE EVALUATION segment, as well as the risk of external cuff extrusion resulting
Preoperative patient evaluation includes a complete physical from the pushing force exerted by the catheter’s resilience (shape
examination to look for hernias, eventration, or weakness of the memory). To mitigate this problem, a catheter with an inverted
abdominal wall; if any of these are found, surgical repair must be U–shaped permanent bend between the two cuffs (the so-called
performed, either before or simultaneously with insertion of the swan neck catheter) was developed. The advantage of this device
catheter. Care is taken to determine the catheter’s exit site from is that it can follow the shape of the subcutaneous route in an
the skin in advance, with the patient standing. Ideally, the exit site unstressed state.67,68 It is also available with an additional curva-
should be on the left side to avoid the cecum (either above or ture of 90° at the intraperitoneal entry site, so that it can be ori-
below the belt line), should not lie on a scar, and should not be in ented parallel to the abdominal wall.
an abdominal fold. Patients’ nares should be swabbed to check for Disc-ball deep cuff. With this type of catheter, the parietal peri-
nasal carriage of S. aureus; eradication of nasal carriage has been toneum is sewn between a Dacron disc and a silicone ball. In the-
shown to yield significant improvements in exit-site infection ory, this approach improves the anchoring of the peritoneum and
rates. reduces the risk of leakage and catheter extrusion.
Figure 17 Peritoneal access. Shown are

various configurations for extraperitoneal
and intraperitoneal segments of peritoneal
access catheters. (a) Extraperitoneal seg-
ment configurations (left to right): single-
cuff, double-cuff, disc-bead double-cuff,
swan neck, Cruz “pail handle,” Moncrief-
Popovich. (b) Intraperitoneal segment
configurations (left to right): straight
Tenckhoff, curled Tenckhoff, straight
Tenckhoff with perpendicular discs,
T-fluted.
OPERATIVE TECHNIQUE Step 1: Insertion of Catheter

Of the several insertion techniques described to date, the sur- Surgical approach Any type of catheter may be inserted via
gical approach remains the most widely used. Regardless of which the surgical approach. A longitudinal paramedian incision 2 to 3
approach is used, there are certain well-accepted basic principles cm long is made about 2 to 3 cm below the level of the umbilicus,
that are applicable to all and that must be observed for all peri- then carried more deeply through the anterior rectus sheath. The
toneal access procedures.69 muscle fibers are retracted to expose the posterior rectus sheath
The deep cuff should be positioned in the rectus abdominis, and the peritoneum. A purse-string suture of 2-0 absorbable
and the peritoneum and the posterior rectus sheath must be material is placed in the posterior rectus sheath [see Figure 18a],
sealed around the catheter. The presence of muscle tissue on the and a small incision is made in the peritoneum. The catheter is
perimeter results in better vascularization and stronger fibrous tis- then inserted between the abdominal wall and the omentum, with
sue ingrowth, which reduces the risk of hernia, leakage and its end positioned in the pelvic cavity beyond the lower edge of the
catheter extrusion. The superficial cuff should be positioned omentum. The peritoneum is tightly closed around the catheter
about 2 cm from the exit site. The exit site should be directed below the level of the deep cuff with the purse-string suture [see
downward and laterally in relation to the entry site.The intraperi- Figure 18b].The anterior rectus sheath is then closed over the deep
toneal portion of the catheter should be positioned between the cuff [see Figure 18c], with care taken to orient the catheter upward.
visceral and the parietal peritoneum, with its end in the pelvic cav- Troubleshooting. Exact positioning is the key determining fac-
ity beyond the lower edge of the omentum. tor for proper catheter function. The catheter can be guided into
Most insertion procedures are performed with the patient its desired position with long forceps or with the help of a lubri-
under local anesthesia in an outpatient setting and under sterile cated guide wire. If adhesions impeding catheter insertion are
conditions (as in an OR). On the morning of the procedure, the encountered, they are lysed under direct visual observation, and
patient showers with chlorhexidine soap. Even though no conclu- the incision is extended as needed. Peritoneoscopy or laparoscopy
sive study on this practice has been done, most authorities rec- may be helpful in this situation. If there is any doubt regarding the
ommend giving an antistaphylococcal antibiotic 1 hour before- exact position of the catheter, a plain radiograph will confirm it.
hand and 6 to 12 hours afterward. Bowel preparation and pre-
vention of constipation are essential. Emptying the bladder before Seldinger technique The Seldinger technique does not
the procedure is mandatory as well. allow direct visual observation of the peritoneal cavity and can
a b
c
Figure 18 Peritoneal access: surgical insertion.
(a) A local anesthetic is infiltrated, the anterior
rectus sheath is opened, the rectus abdominis is
split, and a purse-string suture is placed in the
posterior rectus sheath. With the stylet in place,
the catheter is inserted in the direction of the
pelvis. (b) With the inner cuff at the level of the
rectus abdominis, the purse-string suture is tied.
A flow test is performed to confirm satisfactory
catheter position. (c) The anterior rectus sheath
is closed over the inner cuff.
only be used for Tenckhoff catheters. It is contraindicated in is introduced at the same time as the peritoneoscope), the
obese patients and patients with previous laparotomies in whom exact position of the catheter cannot be confirmed visually after-
numerous adhesions are suspected. Initially, the Seldinger tech- ward, because the scope cannot be reintroduced after insertion
nique is similar to the surgical approach, but shorter incisions of the catheter. Another drawback is that the equipment re-
may be used. After the rectus abdominis is split, the peritoneal quired is specific to this technique and therefore is not avail-
cavity is punctured with a needle and prefilled with fluid. A guide able everywhere.
wire is then placed, and a dilator and a split sheath (similar to that
used for internal jugular vein catheters) are inserted over the Laparoscopic approach One of the advantages of laparo-
wire. The guide wire and the dilator are removed, and the scopic catheter insertion is that the equipment required is readi-
catheter inserted blindly through the split sheath. The deep cuff ly available and familiar to most surgeons. Two 5 to 10 mm tro-
is positioned in the rectus abdominis, and the split sheath is sep- cars are used, one in a paramedian location at the catheter inser-
arated and removed. tion site and one in a pararectus location on the opposite side of
the abdomen. This placement allows the catheter to be inserted
Peritoneoscopic approach Peritoneoscopy-assisted im- under continuous videolaparoscopic monitoring.The use of N2O
plantation of dialysis catheters was developed by nephrologists, gas for pneumoperitoneum eliminates pain during insufflation
who remain its primary users.70 In this technique, a peritoneo- and thus permits this procedure to be performed with the patient
scope 2.2 mm in diameter (Y-TEC; Medigroup, Inc., Naperville, under local anesthesia. In addition, laparoscopic insertion gives
Illinois) is inserted through the rectus sheath into the peritoneal the surgeon the option of performing other procedures simulta-
cavity and advanced under direct visual observation into the neously as needed, such as lysis of adhesions, partial omentecto-
largest and clearest area of the intraperitoneal space.The scope is my, fastening of the catheter to the parietal peritoneum, and
then removed, leaving a surrounding guide sheath through which herniorrhaphy.73,74
the peritoneal dialysis catheter is passed to the selected location.
Because of the small diameter of the sheath, the tissues close Step 2:Tunneling of Catheter
tightly around the deep cuff when the sheath is removed. Two Tunneling is accomplished in the same manner regardless of
randomized studies found that peritoneoscopic catheter place- the insertion technique used. The key is to determine and mark
ment reduced the risk of leakage, lowered the rate of catheter- precisely on the skin both the path of the subcutaneous tunnel
related infection, and improved catheter survival.71,72 A drawback and the position of the superficial cuff in relation to the exit site.
to this technique is that whereas the surrounding guide sheath To this end, the surgeon may curve the catheter to the desired
can be positioned under direct visual observation (because it shape and lay it over the skin or may use a stencil designed for
this application. A short incision, no longer than the diameter of

the catheter, is made at the exit site, and a tunneler or a similar
device is advanced into the subcutaneous tunnel, with care taken
to follow the curvature of the tunnel. The end of the catheter is
attached to the tunneler and brought through the exit site [see
Figure 19]. The exact position of the superficial cuff is then con-
firmed. No suture is placed at the catheter exit site. A two-layer
closure is performed on the incision at the insertion site.
Moncrief-Popovich technique A variant technique has

been described in which the extraperitoneal portion of the
catheter is completely buried under the skin in a subcutaneous
tunnel.75 The rationale for this technique is that because of the
absence of an opening in the skin, ingrowth of tissue into the cuffs
of the catheter can occur without risk of bacterial contamination
from the exit site. As initially described, the technique used a
catheter with a superficial cuff 2.5 cm long, but it is now per-
formed with standard dual-cuff Tenckhoff catheters. When a
minimum of 4 to 6 weeks has elapsed or when the patient needs
to be started on dialysis, the catheter end is exteriorized via
an incision positioned 2 cm from the superficial cuff. This tech-
nique appears to have theoretical advantages in terms of rates of
infection and peritonitis, but the evidence available at present is
inconclusive.76,77
Step 3: Maintenance of Catheter
The patency of the catheter must be confirmed during the
insertion procedure. It should be possible to inject 60 ml of 0.9%
saline without resistance and to aspirate 30 to 40 ml without dif- Figure 19 Peritoneal access. The end of the catheter is attached
ficulty. A dry dressing is applied, and the catheter is fastened to to a tunneler and brought out through the exit site, emerging
the skin with tape to prevent trauma to the exit site and the con- downward and laterally.
sequent risk of bacterial contamination. Immobilization of the
catheter should be maintained for 4 to 6 weeks (the approximate Peritonitis Peritonitis [see 8:18 Intra-abdominal Infection] is
time required for complete healing of the subcutaneous tunnel the most common infectious complication of peritoneal access,
and the exit site).The dressing should not be changed more than with about one episode occurring every 20 to 30 patient-months.
once a week for the first 2 to 3 weeks. Daily exit-site care should The causative microorganisms are gram-positive cocci (especial-
not be started until 2 to 8 weeks after the procedure. ly S. aureus and S. epidermidis) in 60% to 70% of cases and gram-
Experience with the Moncrief-Popovich technique has shown negative rods in 15% to 25% of cases. The presence of a polymi-
that there is no advantage in irrigating the catheter on a regular crobial or anaerobic flora or a high level of amylase (> 50 UI/L)
basis before it is actually used for dialysis. The break-in period in the dialysate is strongly suggestive of a perforated viscus, pan-
should be at least 2 weeks; ideally, it should be 4 to 6 weeks to creatitis, or another intra-abdominal catastrophe.
minimize the risk of leakage. Initial empirical treatment should be guided by the results of
Gram staining and adjusted according to the culture results.78 In
Step 4: Removal of Catheter the presence of recurring peritonitis caused by S. aureus, an
When catheter removal is indicated, the initial incision is underlying occult tunnel infection should be excluded. If the
repeated and the catheter is dissected circumferentially to the causative organism is a coagulase-negative staphylococcus, the
deep cuff, which is then dissected out of the rectus abdominis presence of a bacterial biofilm on the catheter wall should be sus-
with the electrocautery. The catheter is sectioned, the intra- pected, a condition that sometimes responds to instillation of a
abdominal portion removed, and the anterior and posterior rec- thrombolytic agent. In the presence of peritonitis refractory to
tus sheath repaired with sutures.The wound is closed.The super- medical treatment, peritonitis associated with a tunnel infection,
ficial cuff is dissected out from the outside, and removal of the fungal peritonitis, or a perforated viscus, removal of the catheter
subcutaneous portion of the catheter is completed. The exit site must be considered.
is left to heal by second intention.
Exit-site infection Exit-site infection is signaled by the
COMPLICATIONS presence of purulent or bloody drainage from the exit site, arising
The complications relevant to the access surgeon may be divid- either spontaneously or after pressure on the sinus; swelling; ery-
ed into infectious and noninfectious complications. thema 13 mm or more in diameter from border to border; and
regression of epithelium in the sinus.79 This condition leads to
Infectious peritonitis in 25% to 50% of cases, and the organisms involved
Infectious complications are directly responsible for as many as are similar to those found in peritonitis.
2% of deaths in patients on peritoneal dialysis, about two thirds Treatment consists of empirical antibiotic therapy based on the
of cases of catheter loss, and one third of transfers from peritoneal results of Gram staining and adjusted according to the culture
dialysis to hemodialysis. results. It must be continued for a minimum of 2 weeks; in some
cases, prolonged treatment (4 to 6 weeks) may be necessary. If to favor downward movement of the catheter; for this reason, tak-
the response to therapy is not satisfactory, an external-cuff or ing laxatives is recommended. If the catheter has migrated into the
tunnel infection should be suspected and treated as appropriate. right upper quadrant, peristalsis favors movement in the opposite
Failure of medical treatment, especially when associated with direction, and spontaneous repositioning is much less likely.
peritonitis involving the same microorganism, is an indication for If conservative treatment fails, the catheter may be reposi-
catheter removal. It should be noted that positive cultures com- tioned under fluoroscopic guidance by means of intraluminal
ing from normal-appearing exit sites indicate colonization and do manipulation with a stiff guide wire. If the problem recurs, surgi-
not call for treatment. cal treatment (most often laparoscopic) is indicated to reposition
the catheter and, if necessary, fasten it to the bladder dome or to
Tunnel infection Tunnel infection is signaled by the pres- the parietal peritoneum.
ence of erythema, edema, or tenderness over the subcutaneous
catheter pathway, sometimes associated with sanguineous, puru- Hernias Because of the increase in intra-abdominal pres-
lent, or thick drainage occurring either spontaneously or when sure inherent in peritoneal dialysis, hernia is a common compli-
pressure is applied to the catheter tunnel. This type of infection cation, affecting 10% to 25% of patients. The main types of her-
often is hidden and develops in association with exit-site infec- nias encountered, in descending order of frequency, are umbili-
tion; in such cases, ultrasonography of the subcutaneous tunnel cal, inguinal (e.g., patent process vaginalis), catheter incision site,
helps to specify the diagnosis. ventral, catheter exit site, epigastric, incisional, cystocele, entero-
Treatment of this condition is more difficult than treatment of cele, and obturator. The clinical importance of this complication
exit-site infection, in that antibiotics are typically inefficacious is that as many as 10% to 15% of hernias, particularly those
when used alone. If the pathogen is a gram-positive organism, located at the catheter site or related to other abdominal inci-
unroofing the infected portion of the catheter tunnel and shaving sions, are associated with intestinal obstruction arising from
the superficial cuff can prolong catheter survival by a few weeks; strangulation. For this reason and because of the tendency of her-
however, if the pathogen is a gram-negative bacterium, this tech- nias to enlarge with time, surgical repair is indicated in all cases.
nique is inefficacious. In most cases, complete removal of the In the postoperative period, intermittent low-volume peritoneal
catheter is the definitive treatment, especially if the deep cuff is dialysis may be continued with the patient in a supine position,
infected. In the absence of underlying active peritonitis, it is pos- but ideally, complete interruption of dialysis for 3 to 4 weeks is
sible to carry out insertion of a new catheter in uninfected terri- advised.
tory simultaneously with removal; to date, the results of this
approach have been promising. A more conservative option is to Obstruction Obstruction-related problems can affect either
leave an interval of about 3 weeks between removal of the old the drain phase alone (isolated outflow failure) or both the infu-
catheter and implantation of the new one. sion and the drain phase (inflow/outflow failure).
Inflow/outflow failure. Obstruction of both the infusion and
Noninfectious the drain phase is usually secondary to an obstruction of the
Early leakage (< 30 days after implantation) Early leak- catheter by fibrin, blood clot, or tissue ingrowth inside the later-
age is the result of failure to close the peritoneum tightly enough al holes. A catheter kink should also be excluded. Forced injec-
around the catheter. It is diagnosed clinically on the basis of the tion of heparinized serum sometimes eliminates the obstruction.
presence of dialysate at the exit site. If it does not, injection of thrombolytic agents into the catheter
Treatment consists of complete stoppage of peritoneal dialysis may be attempted. More invasive treatments that may be
treatments for 1 to 2 weeks to reduce intra-abdominal pressure employed include cleaning out the catheter with a Fogarty
and thereby promote spontaneous healing, coupled with admin- catheter, using an intraluminal brush, or replacing the catheter.
istration of an antistaphylococcal antibiotic to address the associ- Isolated outflow failure. Extraluminal obstruction of the
ated risk of exit-site or tunnel infection. When treatment fails, catheter may be caused by migration out of the pelvic cavity
exploratory surgery with repair of the tissues around the deep (sometimes in fibrous adhesion pockets), omental wrapping,
cuff remains the best option. stool-filled bowel enwrapping the catheter (constipation), or
occlusion of the catheter holes by adjacent organs. Adjacent tis-
Late leakage (> 30 days after implantation) Late leakage sues can act as a ball valve, allowing ingress of fluid but occluding
of dialysis fluid in the subcutaneous tissues is more difficult to catheter pores when drainage is attempted. A plain radiograph,
diagnose than early leakage. It may appear in the form of edema with or without dynamic catheterography, usually clarifies the
of the abdominal wall or genital edema, a condition that should diagnosis. Catheter migration, if present, is treated as described
be distinguished from patent processus vaginalis. It may also be (see above). Constipation is treated with laxatives. For other caus-
manifested by drainage problems during treatment. The exact es of isolated outflow failure, the laparoscopic approach is increas-
site of the leakage is difficult to establish clinically but can usual- ingly used; this approach enables the surgeon to reposition the
ly be determined by means of computed tomography after infu- catheter under direct visual observation and then proceed with
sion of 2 L of dialysis fluid containing radiocontrast material. lysis of adhesions, partial omentectomy, and fastening of the
Treatment consists of surgical repair. If treatment fails, the catheter.
catheter must be removed.
Superficial cuff extrusion Extrusion of the superficial
Malpositioning Migration of the end of the catheter out of cuff most often develops in the presence of an exit-site infection
the pelvic cavity results in pain secondary to irritation of the but may develop in isolation if the cuff is positioned too close
abdominal wall or, more often, in poor catheter drainage. The to the exit site. Such extrusion results in chronic irritation and
diagnosis is made by means of a plain radiograph. If the catheter ischemia with necrosis of the surrounding tissues. Generally,
has migrated into the left upper quadrant, spontaneous reposi- part of the cuff can be exteriorized with simple traction on the
tioning can be expected as a consequence of peristalsis, which acts catheter. In such cases, the cuff should be shaved off the
catheter with a scalpel and the surrounding necrotic tissues team. In fact, despite the development of new insertion tech-
debrided. niques and the availability of increasingly sophisticated catheters,
the most important prognostic factor remains the quality of the
OUTCOME EVALUATION
surgical procedure and the postoperative care. Analysis of the dif-
It is estimated that approximately 20% of transfers from peri- ferent implantation protocols described in the literature shows
toneal dialysis to hemodialysis are secondary to a catheter-related that the so-called center effect is in fact a remarkable confound-
problem. It is therefore essential that the insertion of peritoneal ing factor. Regardless of the technique used, the catheter survival
dialysis catheters be performed by a competent and experienced rate should be at least 80% at 1 year.
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the upper extremity: report of a series and review of 67. Lye WC, Kour NW, van der Straaten JC, et al: A eter technique versus standard technique on the
the literature. Surgery 104:561, 1988 prospective randomised comparison of swan incidence of peritonitis and exit site infection.
56. Suchoki P, Conlon P, Knelson M, et al: Silastic neck, coiled and straight Tenckhoff catheters in Perit Dial Int 22:211, 2002
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access: thrombolytic and mechanical correction 1):333, 1996 peritoneal dialysis-related peritonitis treatment
of HD catheter malfunction. Am J Kidney Dis 68. Eklund BH, Honkanen EO, Kala AR, et al: recommendations: 2000 update. Perit Dial Int
28:279, 1996 Peritoneal dialysis access: prospective ran- 20:396, 2000
57. Crain MR, Mewissen MW, Ostrowski GJ, et al: domised comparison of swan neck and
79. Twardowski ZJ: Catheter exit site care in the
Fibrin sleeve stripping for salvage of failing Tenckhoff catheters. Perit Dial Int 15:353, 1995
long term. Contrib Nephrol 142:422, 2004
hemodialysis catheters: techniques and initial results. 69. Gokal R, Alexander S, Ash S, et al: Peritoneal
Radiology 198:41, 1996 catheters and exit site practice: toward optimum
58. Schaffer D: Catheter-related sepsis complicating peritoneal access: 1998 update. Perit Dial Int
long-term, tunnelled central venous dialysis 18:11, 1998
catheters: management by guidewire exchange. Am Acknowledgments
70. Ash SR: Chronic peritoneal dialysis catheters:
J Kidney Dis 25:593, 1995 procedures for placement, maintenance, and
59. Ganter G: Uber die Beseitigun giftiger Stoffe aus removal. Semin Nephrol 22:221, 2002 Figures 1 through 9, 11, 12, 15, 16, and 19 Jean
dem Blute durch Dialyse. Munch Med Wochen- Montreuil, B.Ing, M.Sc. Digitized and adapted by Tom
71. Gadallah MF, Pervez A, el-Shahawy MA, et al:
schr 70:1478, 1923 Moore.
Peritoneoscopic versus surgical placement of
60. Popovich RP, Moncrief JW, Decherd JF, et al: peritoneal dialysis catheters: a prospective ran- Figure 17 Jean Montreuil, B.Ing., M.Sc.
The definition of a novel portable-wearable domised study on outcome. Am J Kidney Dis The author thanks Rafik Ghali, M.D., for his valuable
equilibrium peritoneal technique. ASAIO J 5:64, 33:18, 1999 comments on this iteration of the chapter.
6 VASCULAR SYSTEM 23 ENDOVASCULAR PROCEDURES FOR LOWER-EXTREMITY DISEASE — 1
23 ENDOVASCULAR PROCEDURES
FOR LOWER-EXTREMITY DISEASE
Heather Y.Wolford, M.D., and Mark G. Davies, M.D., Ph.D., F.A.C.S.
Endovascular procedures are increasingly being applied to the agent to decrease total nephrotoxic dye volumes (see below) may
treatment of lower-extremity vascular disease: for many common be considered. Patients taking oral hypoglycemic agents are asked
vascular conditions, minimally invasive approaches have become to stop doing so on the day of the procedure and not to resume
important supplements to (or even supplanted) conventional open for 48 hours after the procedure. In general, to prevent bleeding
surgical approaches.1 The evolution of these endovascular tech- complications, it is preferred that the international normalized
niques is likely to result in a corresponding evolution in the thera- ratio (INR) be lower than 1.6 and the platelet count higher than
peutic decision-making process for patients with lower-extremity 50,000/mm3 at the time of intervention.
vascular disease. Research into the long-term outcomes of lower- If a therapeutic intervention is planned, the patient should be
extremity endovascular procedures will be necessary for a better given aspirin, 81 mg/day, and clopidogrel, 75 mg/day, for at least 3
understanding of the indications for treatment and of the risks and days beforehand. If there is not enough time to do this, the patient
benefits for patients. may be given clopidogrel, 150 to 300 mg, within the 2 hours pre-
ceding the procedure.
Arterial Procedures Investigative studies Imaging is required before any inter-
Arterial conditions of the lower extremity that may be treated with vention. Noninvasive vascular ultrasonographic studies document
endoluminal therapy include chronic ischemia, acute ischemia, and the initial status of the arterial blood supply and allow localization
aneurysmal disease. The fundamental skill set and the basic tech- of the culprit lesions. The ankle-brachial index (ABI) (or, in dia-
niques employed are the same for all of these conditions. Accor- betics and patients with incompressible ankle vessels, the toe-brachial
dingly, the ensuing discussion first reviews the basics of endovas- index), pulse-volume recordings (PVRs), and segmental pressures
cular therapy and then focuses on specific areas of chronic, acute, quantify arterial perfusion and define areas of stenosis or occlu-
and aneurysmal arterial disease of the lower extremity that are sion within each leg. Duplex ultrasonography is an alternative to
amenable to endoluminal intervention. PVRs and segmental pressures and provides further diagnostic
information that allows the interventionalist to identify involved
BASIC ENDOVASCULAR PROCEDURES
vessel segments and lesions amenable to percutaneous therapy.
These objective measurements serve as a baseline against which
Preprocedural Evaluation postinterventional results may be assessed.
Clinical evaluation The first step in the intervention con- Generally, noninvasive studies provide sufficient information to
sists of a thorough history and a careful physical examination. allow one to proceed with diagnostic angiography and possible
Patients should be specifically asked about chronic renal insuffi- endoluminal intervention. In many cases, however, additional
ciency, current or past anticoagulant therapy, and previous vascu- studies are required to refine the interventional plan and to reduce
lar and endovascular interventions. Lower-extremity pulses should the time and resources required. Computed tomographic angiog-
be assessed, and the degree of ischemia present should be deter- raphy (CTA) provides two-dimensional images of the arterial sys-
mined [see Table 1]. Basic serum biochemical and hematologic tem, which are then postprocessed to generate three-dimensional
data should be obtained and reviewed.The results of any previous reconstructions. It is particularly effective for imaging tibial ves-
imaging studies should also be obtained and reviewed. Patients sels.The main drawbacks of CTA are the time necessary to recon-
with serum creatinine concentrations higher than 1.5 mg/dl struct the images, the possibility of interference from metal im-
should be considered for a renal protection protocol [see Table 2], plants, and the contrast load involved. Magnetic resonance angiog-
and at the time of the procedure, the use of an alternative contrast raphy (MRA) also provides potentially helpful preprocedural
Table 1—Classification of Critical Ischemia
Arterial Venous
Grade Limb Status Prognosis for Limb Capillary Refill Motor Changes Sensory Loss Doppler US Doppler US
I Viable Not threatened Intact None None + +
IIa Threatened Salvageable Slow None Partial – +
IIb Threatened Salvageable with emergency intervention Slow or absent Diminished function Partial – +
III Irreversible Nonsalvageable Absent No function Complete – –
US—ultrasonography
Table 2 Renal Protection Strategies 5 French multi–side-hole diagnostic catheter (in a straight, curv-
ed, or pigtail configuration) is then placed over a wire into the jux-
Oral Therapy Other Strategies
tarenal aorta. After the initial aortic films are obtained in the an-
teroposterior (AP) projection, the diagnostic catheter is moved
N-acetylcysteine, 600 mg p.o., b.i.d., Hydration with normal saline, starting down to a point 2 to 3 cm above the aortic bifurcation, and a
for total of four doses; first dose 1 hr before procedure and continued series of pelvic images are taken in the AP and lateral projections.
given 12 hr before procedure for 3 hr after procedure
Theophylline, 200 mg I.V., given 30 Sodium bicarbonate drip, 154 mEq/L,
The aortic bifurcation is generally traversed with a curved
min before procedure, or 200 mg starting 1 hr before procedure and catheter; the curve of the tip should be similar to the angle of the
p.o., b.i.d., starting 24 hr before continued for 6 hr after procedure bifurcation. A wire is maneuvered into the iliac system and posi-
procedure and continued for 48 hr Use of alternative contrast agent
after procedure tioned in the external iliac artery or the CFA, and the curved diag-
nostic catheter is advanced to the point where its tip lies within the
distal external iliac artery and its holes are beyond the ostium of
information and has the advantage of using gadolinium, which is the internal iliac artery.
a relatively low risk contrast agent for patients with renal insuffi- Once the catheter has been correctly positioned, further con-
ciency. The main drawbacks of MRA are relatively poor patient trast injections are performed. Complete lower-extremity images,
tolerance of the machine, the tendency to overestimate lesion which should include tibial and pedal vessels (in AP and magni-
severity, the long image acquisition time, and the variability in fied lateral foot views), are taken before the intervention so that
image quality as one proceeds distally in the leg. Patients with lim- preprocedural status can be compared with postprocedural status
ited arterial access will benefit from a cross-sectional imaging and any distal complications can be recognized. Contrast doses com-
algorithm: such an approach allows one to perform a focused monly employed for digital subtraction arteriography (DSA) depend
angiogram and to make more efficient use of resources during a on the specific arterial segment being addressed [see Table 3].
therapeutic intervention.
Alternative contrast agents. Standard angiography is performed
Preprocedural Planning with an iodinated nonionic contrast agent. In patients with creati-
Choice of arterial access site The common femoral artery nine concentrations higher than 1.5 mg/dl, an alternative contrast
(CFA) contralateral to the affected side is the arterial access site agent may be preferable. Carbon dioxide may be used to image
most commonly employed. If the patient has an occluded CFA or the abdominal aorta, the iliac arteries, and, occasionally, the prox-
a “hostile groin,” a radial, high brachial, or axillary artery imal leg arteries. As the vessels become smaller, however, CO2
approach may be chosen instead; however, access at these sites is images become less clear. Elevating the legs may help in obtain-
associated with a relatively higher incidence of complications. ing adequate imaging to the level of the knees. For CO2 imaging,
Ideally, to facilitate manual compression, the access site should lie a 60 ml syringe is connected to a three-way stopcock, and CO2
over a flat bony prominence. An antegrade ipsilateral CFA ap- from a tank is loaded into the syringe through the stopcock assem-
proach is a useful alternative to contralateral access if there is a bly while the stopcock is submerged in normal saline and manu-
contraindication to working from the contralateral side (e.g., sig- ally kept under pressure. The submerged system is flushed with
nificant contralateral iliac disease, a heavily scarred groin, recent CO2 several times to purge any residual air. The CO2-containing
application of a vascular closure device, or a bifurcated aortic syringe is connected to an indwelling catheter, and the CO2 is
graft) and if preoperative imaging has demonstrated that there is then injected forcefully by hand while the fluoroscopy unit is acti-
an adequate working distance (generally, at least 15 to 20 cm) vated. The resulting images must undergo postprocessing to be
between the CFA access point and the target lesion. If an ante- viewed correctly. CO2 imaging should not be used above the
grade approach fails, a retrograde approach may be employed to diaphragm or in the visceral artery segment of the aorta.
target ipsilateral iliac arterial disease from the CFA or superficial Gadolinium may also be used to image the pelvic vessels and
femoral artery (SFA) disease from the popliteal artery. the proximal leg arteries. Like CO2 images, gadolinium images
become less clear as the lower-extremity arteries become smaller
Selective Lower-Extremity Angiography and more distal. Gadolinium is loaded into the power injector or
Technique Standard methods of obtaining vascular access injected by hand, like standard contrast agents. Doses higher than
for angiography are described in more detail elsewhere [see 6:8 0.3 mmol/kg may be nephrotoxic.2
Fundamentals of Endovascular Surgery]. For selective angiography
of the lower extremity, a 4 or 5 French diagnostic sheath is initially Troubleshooting If crossing the aortic bifurcation proves
placed in the CFA contralateral to the affected extremity. A 4 or difficult, changing to a hydrophilic wire (e.g., a 0.035-in. soft or
Table 3 DSA Imaging Techniques with Power Injector
Arterial Segment Imaged View Contrast Dosage Delay
Infrarenal aorta AP 10–20 ml/sec for 2 sec No
Iliac arteries AP/oblique 3–10 ml/sec for 2–3 sec No
CFA and SFA AP 3–10 ml/sec for 2–3 sec Flow dependent
Tibial arteries AP 3–5 ml/sec for 3–4 sec Yes
Pedal artery AP/lateral foot 3–6 ml/sec for 3–4 sec Yes
AP—anteroposterior CFA—common femoral artery SFA—superficial femoral artery
stiff glide wire) may help. Occasionally, if one has trouble advanc- wire may be preferred, in that hydrophilic wires tend to create dis-
ing the 5 French catheter, using a 4 French hydrophilic catheter section planes. Often, the occlusion cannot be crossed, and a
may mitigate the problem. Attempts at passing the bifurcation subintimal plane must be developed. A glide wire is used to gain
should not be abandoned until several different angled catheters access near the proximal portion of the lesion at a branch point
have been tried. If all such attempts fail and contralateral access is and allowed to deform in such a way as to form a loop; the wire is
imperative, ipsilateral puncture with introduction of a snare to then pushed forward, supported by a 4 or 5 French catheter.
grasp the contralateral wire in the abdominal aorta should be con- Often, the true lumen is accessed without any difficulty, and the
sidered. Alternatively, DSA may be performed from the aortic location of the wire within the lumen is confirmed by contrast
bifurcation; however, the contrast loads will be significantly high- injections. Occasionally, however, reentry into the true lumen
er in this situation. proves difficult. Various manipulations and techniques may be
employed to help with this technical issue. In addition, two sys-
Crossing of Lesion tems have been developed with this potential problem in mind.
The diagnostic imaging studies and the preliminary angiogram The CrossPoint IVUS catheter (Medtronic, Minneapolis, Minnesota)
should suffice to identify a lesion that is amenable to endovascular combines an intravascular ultrasound probe with a puncture nee-
therapy. Once such a lesion is identified, wire access across the dle and allows one to visualize the true lumen, enter it with a hollow
target lesion is required to establish a platform for subsequent needle, and pass a wire to maintain access. The Outback catheter
intervention. (LuMend, Redwood City, California) has a special tip that micro-
dissects the plaque to facilitate reentry into the true lumen. If these
Technique Iliac lesions may be approached either in a retro- options fail, retrograde puncture and retrograde passage of a wire,
grade fashion from the ipsilateral CFA or in an antegrade fashion with interval snaring to “floss” the occlusion, may be considered.
from the contralateral CFA if there is adequate working distance
between the bifurcation and the iliac lesion. For more distal Troubleshooting In crossing occlusions, the following three
lesions, when a contralateral CFA approach is used, a guide sheath points must be emphasized.
is required to stabilize catheters and wires. A wire is placed in the
1. Care must be taken to ensure that the operator is in the true
external iliac artery on the affected side (see above), and the diag-
lumen.
nostic catheter placed across the bifurcation is replaced with a stiff
2. To preserve subsequent bypass targets, the next segment of
sheath, such as a 6 French Balkin sheath (Cook Incorporated,
the vessel must not be compromised by an overly aggressive
Bloomington, Indiana), which has a curve that naturally rests over
attempt to regain access from a subintimal dissection plane.
the bifurcation. Occasionally, it is difficult to get the sheath to cross
3. Wire access across the lesion must be maintained at all times.
the bifurcation. In such a situation, the initial wire may be
exchanged for a stiffer wire, such as a 0.035-in. Amplatz wire A low-dose intravenous bolus of heparin (2,000 to 5,000 IU)
(Cook Urological, Spencer, Indiana), and the sheath may be must be given before any intervention to help prevent the throm-
placed over this wire. The use of a reinforced or stiff guide sheath bosis that may result from manipulation and transient occlusion of
eliminates the mechanical disadvantage of a wire that moves away the lesion.
from the limb with all manipulations, and it solidifies unilateral
limb access for subsequent angiography during the therapeutic Angioplasty and Stenting
portion of the procedure. Technique Angioplasty. Angioplasty is the initial treatment
Once the sheath is in place, a long, angled end-hole catheter and for most lower-extremity lesions. It may be the only therapeutic
a glide wire are directed toward the specific vessel segment being intervention required, or it may be employed as a prelude to stent
treated and carefully manipulated so as to cross the target lesion. deployment as a means of ensuring that the arterial lumen is wide
Road mapping, fluoroscopy fade, or intermittent puffing of con- enough to allow free passage of a platform. Angioplasty balloons
trast material through the guide catheter can delineate the con- exist in several varieties, which are reviewed in more detail else-
tours of the vessel, identify the correct path to take, and help keep where [see 6:8 Fundamentals of Endovascular Surgery]. In general, a
the wire within the true lumen. In general, a stenosis can be noncompliant balloon is chosen that is 1 to 2 mm smaller than the
crossed by a curved or J-tip wire, a 0.035-in. hydrophilic glide normal or anticipated final vessel diameter for the area of the vas-
wire, or a Wholey wire (a 0.035-in. wire with a floppy tip; culature being addressed.The normal vessel diameter may be esti-
Mallinckrodt, St. Louis, Missouri).The hydrophilic coating on the mated on the basis of operator experience, measured with a
glide wire makes it more prone to dissection than the other wires radiopaque ruler placed alongside the vessel, or quantitated with
are. With angled catheters, it is essential to use torque devices to the calibration software available on most imaging systems.
direct the tip of the wire in the appropriate direction. In some Once the balloon has been successfully maneuvered into posi-
cases, using a TAD II wire with a 0.018-in. distal tip and a 0.035- tion across the lesion, it is inflated with a manual inflation device
in. main body (Mallinckrodt, St. Louis, Missouri) makes access to allow controlled delivery of a defined pressure load. Inflation is
through a tight lesion easier to obtain; in addition, it provides a continued until the waist of the balloon disappears or maximal
transition to a larger, more robust wire, which can be a very effec- balloon inflation pressure (8 to 15 atm on most standard balloons)
tive platform. For tibial stenoses, a 0.014-in. or 0.018-in. system is is reached. If an optimally sized balloon or stent will not cross a
generally employed to cross tighter lesions. To stabilize the 0.014- highly stenotic lesion, preangioplasty dilatation with a lower-pro-
in. wire, a 3 or 4 French catheter may be used as a guide catheter, file, smaller-diameter balloon is required.
placed just proximal to the lesion. If the lesion is in close proximity to or involves a bifurcation
Occlusions can be difficult to cross, particularly when signifi- (e.g., the aortic bifurcation, the femoral bifurcation, or the
cant calcification is apparent on the plain films obtained before tibioperoneal trunk), care must be taken to prevent occlusion of
angiography.The techniques employed are the same as those used the other branching vessel during dilatation of the target lesion.To
to cross a stenosis. The goal is to traverse the occlusion and gain this end, most interventionalists advocate use of the so-called kiss-
access to the true lumen distally; accordingly, a J-tip or Wholey ing balloon technique, which involves simultaneous dilatation or
a b
Figure 1 Basic endovascular techniques: angioplasty and stenting. Shown is the so-called kissing balloon
technique. The patient presented with bilateral claudication, a decreased ABI on exercise treadmill testing,
and a duplex ultrasonogram that suggested iliac occlusive disease. (a) Illustration shows two balloons “kiss-
ing” in the common iliac arteries. (b) Radiograph shows two stents “kissing” in the iliac arteries.
stenting of both branching vessels of the bifurcation to preserve and concomitantly promotes apoptosis and reduces the restenosis
both lumina. This technique is most commonly employed for response. To date, the PolarCath has been employed mainly in the
proximal common iliac artery lesions [see Figure 1]. Alternatively, SFA; it is currently being tested for use in the tibial vessels. In initial
one may place a guard wire in the unaffected vessel and use this reports, anatomic patency rates in the femoropopliteal arteries have
wire as a safety measure if there is a danger of luminal compro- exceeded 80% at 1 year for TransAtlantic Inter-Society Consensus
mise, or one may deploy a balloon in the unaffected ostium while (TASC) grade A, B, and C lesions.3
the affected ostium is treated. Another such device is the Peripheral Cutting Balloon (Boston
Scientific, Natick, Massachusetts) [see Figure 2b], which is increas-
Stenting. Basic stent choices are discussed more fully else- ingly being used on lower-extremity vascular lesions, particularly
where [see 6:8 Fundamentals of Endovascular Surgery]. Stents may those that proved resistant to balloon angioplasty.This device con-
be placed either primarily or as a secondary procedure when ini- sists of a noncompliant balloon that has four thin blades placed
tial angioplasty yields inadequate results (generally defined as longitudinally around it; it is available in sizes ranging from 2 mm
either greater than 30% residual stenosis or the occurrence of an to 8 mm, and it operates over a 0.018-in. platform. The theoreti-
angioplasty-related complication, such as arterial wall perfora- cal rationale for its use is that fracturing or cutting the lesion in a
tion or flow-limiting dissection). Stents are generally sized controlled pattern may reduce the severity of the vessel injury
according to the normal diameter of the adjacent vessel; 10% to while achieving a satisfactory luminal response and mitigating the
15% oversizing is acceptable. If the stent will be crossing two restenosis response. Initial results in stenotic vein grafts have been
vessel segments with mismatched diameters (e.g., the common encouraging, with 95% patency reported at 11 months’ follow-up
iliac artery and the external iliac artery), it is preferable to use a in one small study.4
self-expanding stent, which is better able to adjust to such mis- Directional atherectomy devices are being used to treat chronic
matching. Treatment of specific arteries is discussed more fully atherosclerotic leg ischemia in the belief that debulking the lesion
in connection with management of chronic lower-extremity will allow greater increases in luminal diameter than the conven-
ischemia [see Procedures for Chronic Lower-Extremity Ische- tional methods of angioplasty and stenting, which merely displace
mia, below]. plaque. Multiple different systems are available, all of which
appear to be yielding roughly equivalent results. One of the more
Adjuncts to angioplasty and stenting. Over the past few years, sev- widely used directional atherectomy devices is the SilverHawk
eral innovative devices have been developed that expand on the Plaque Excision System (FoxHollow Technologies, Redwood
basic concepts of angioplasty and stenting in the lower extremities. City, California), which consists of a catheter that is compatible
One such device is the PolarCath cryoplasty balloon (Boston with a 0.014-in. wire and that has a rotating blade at the tip. As the
Scientific, Natick, Massachusetts) [see Figure 2a].This device deliv- blade shaves plaque off the vessel wall, the shavings are stored in
ers cold thermal energy to the vessel wall in the form of nitrous oxide the tip of the catheter. When the storage unit in the tip becomes
(−10° C) and is inflated to a pressure of 8 atm. It is presumed that full, the catheter is removed and cleaned, then reinserted. Initial
the freezing of the vessel allows a more controlled vessel wall injury intermediate-term results have been satisfactory; however, wider
a b
Figure 2 Basic endovascular techniques: angioplasty and

stenting. (a) Shown is the PolarCath peripheral dilatation
system, comprising an inflation unit, a cryoplasty bal-
loon, a cord attached to a separate power module, and
a nitrous oxide cartridge. (b) Shown is the Peripheral
Cutting Balloon, with an enlarged view of an atherotome.
(Images provided courtesy of Boston Scientific, Natick,
Massachusetts).
use of this device will depend on the results of the multicenter a possible nonthrombotic embolic event, aspiration or open
TALON registry.5 embolectomy may be required to achieve satisfactory reconstitu-
Drug-eluting stents have become popular for use within the tion of flow.
coronary circulation, but at present, they are only in the initial When a vessel is heavily calcified, a self-expanding stent may be
stages of investigation for treatment of lower-extremity arterial dis- unable to deploy and may be effectively “jailed” in the lesion. In
ease. Initial trials with the sirolimus-coated S.M.A.R.T. stent this situation, wire access must be maintained, and a low-profile
(Cordis, Miami Lakes, Florida) showed a nonsignificant trend balloon should be used to enlarge the operating lumen so that a
toward decreased restenosis rates.6 high-pressure balloon can then be introduced.The introduction of
a series of balloons with successively larger diameters will eventu-
Troubleshooting Angioplasty can result in either non–flow- ally allow the stent to be deployed. Balloon perforation often
limiting or flow-limiting dissections. If dissection occurs, reinfla- occurs in these cases, and care should be taken to extract the per-
tion of the balloon over the dissection for 5 to 10 minutes may forated balloon intact.
anneal the flap to the wall. If balloon reinflation fails and flow is Unplanned stent dislodgment is rare but not unknown. If it
still disrupted, a stent should be placed. occurs, the errant stent may be fixed in place by placing an addi-
In situ thrombosis of the vessel occasionally occurs after angio- tional overlapping stent. Alternatively, a balloon may be inflated
plasty or stent placement. If it develops in a patient who under- distal to the tip of the dislodged stent and used to move the stent
went angioplasty alone, the thrombosed vessel may be stented to another vessel, where it may be safely deployed.
open. If this measure fails or if the in situ thrombosis develops
after stent placement, a thrombolysis catheter is placed across the Complications The most common complications of angio-
lesion and a single bolus of a thrombolytic agent administered. If plasty and stenting in the lower extremities are access-related
this approach yields suboptimal results, an indwelling catheter is issues, including hematoma, arteriovenous fistula formation, and
placed for a 12- to 24-hour infusion [see Procedures for Acute pseudoaneurysm. The incidence of hematoma can be minimized
Lower-Extremity Ischemia, below]. Alternatively, mechanical by using the smallest sheath possible, waiting for normalization of
thrombectomy with a rheolytic catheter may be considered. the activated clotting time before pulling the sheath, and holding
Finally, restenting with an open or covered stent is an option, but manual pressure for 30 minutes after the procedure. Devices
it may result in distal embolization. designed for vessel closure after percutaneous intervention are
Perforation of the vessel can occur during angioplasty or recan- available but have not been proved to reduce the incidence of
nulization. Perforations that are small or that occurred during a access-related complications.7 With several of these closure de-
failed recannulization need not be treated. Perforations associated vices, it is recommended that access of the groin not be attempt-
with persistent extravasation of contrast may be managed primar- ed for up to 90 days after insertion.
ily with balloon tamponade (20 minutes of inflation, with inter-
PROCEDURES FOR CHRONIC LOWER-EXTREMITY ISCHEMIA
mittent deflations to allow distal circulation and reversal of anti-
coagulation) and secondarily with placement of a covered stent.
Endoluminal intervention to treat plaque can result in distal Preprocedural Evaluation
embolization of cholesterol or plaque or distal dislodgment of Patients presenting with chronic lower-limb ischemia are eval-
thrombi. Mechanical or pharmacologic thrombolysis remains the uated as previously outlined [see Basic Endovascular Procedures,
mainstay option in such cases. If, however, one is concerned about Preprocedural Evaluation, above]. Patients with claudication are
should also be subjected to a chemical challenge. Local intra-arte-

Patient has chronic arterial ischemia rial delivery of a vasodilator (e.g., papaverine, 30 mg; priscoline, 25
mg; or nitroglycerin, 200 µg) will create distal vasodilatation, ac-
Assess severity of ischemia. centuate the translesional gradient, and, in many cases, unmask a
significant lesion that might otherwise be missed.
Iliac lesions may be treated either by means of primary angio-
plasty, with stenting reserved for cases in which angioplasty yields
unsatisfactory results, or by means of primary stenting. Either bal-
Patient has limb Patient has critical
claudication limb ischemia loon-expandable or self-expanding stents may be used in the iliac
vessels. Highly calcified lesions and lesions in smaller iliac vessels
Treat medically: Determine whether (< 7 mm) generally are best treated with self-expanding stents.
• Risk-factor modification patient is a candidate Lesions in the external iliac artery or the femoral artery (including
• Exercise therapy for intervention.
• Smoking cessation
the CFA, the profunda femoris [PF], and the SFA) are best treat-
ed with angioplasty alone. In these vessels, stents usually are
placed only when angioplasty has been unsuccessful or dissection
or vessel rupture has occurred. As a rule, stenting for SFA lesions
is best done with self-expanding stents, though very focal lesions
Claudication is Claudication continues may be treated with balloon-expandable stents. Stenting is rela-
managed and is disabling tively contraindicated in the popliteal artery; the extended range of
motion across the nearby joint often leads to stent fracture. At pres-
Determine whether patient is
a candidate for intervention. ent, stents are not used as primary therapy in infrapopliteal vessels.
If stenting is required at infrapopliteal sites, coronary balloon-
mounted platforms are the only available choices.
Postprocedural Care
After the procedure, patients require at least 2 to 12 hours of bed
rest. Hydration with I.V. infusion of normal saline should be initi-
Patient is not a candidate Patient is a candidate ated, and appropriate dosages of renal-protective agents should be
for intervention for intervention given. Aspirin, 81 mg/day, should be given on a long-term basis,
Perform diagnostic angiography.
and clopidogrel, 75 mg/day, should be administered for 30 days.
Amputate limb.
Determine whether lesion is Outcome Evaluation
amenable to endovascular
therapy. In most series, rates of technical success (defined as less than
30% residual stenosis) have exceeded 90%. Secondary patency
rates for iliac interventions at 10 years have exceeded 50%.9
Angioplasty and stenting in the SFA have been studied, for the
most part, in a retrospective fashion. Intermediate-term data have
Lesion is amenable to Lesion is not amenable
endovascular therapy
suggested patency rates of 70%, 60% and 50% at 1, 3, and 5 years,
to endovascular surgery
respectively. The reported clinical benefit has generally exceeded
Treat with angioplasty, stenting, Treat surgically. the anatomic patency rates.10-12 None of the randomized studies
or both as appropriate. published to date have found primary stenting to have any advan-
tage over primary angioplasty in the femoral vessels.13-16 Factors
Figure 3 Algorithm illustrates workup of patients with chronic indicative of a poor prognosis include intervention for more
lower-extremity ischemia. advanced limb ischemia, diabetes, complete occlusion (as opposed
to stenosis), lesions longer than 10 cm, and poor distal runoff.8
The use of TASC criteria to stratify lesions anatomically helps
managed medically by controlling risk factors, instituting exercise predict which patients are likely to benefit most from endovascu-
therapy, and providing advice on smoking cessation.8 In patients lar therapy in the SFA.17 In one study that included almost 400
with disabling claudication, rest pain, or tissue loss, diagnostic SFA interventions, patients who had TASC A and B lesions expe-
imaging studies are performed with the intent of identifying and rienced significantly better outcomes than those who had TASC C
subsequently treating any lesion that is amenable to endovascular and D lesions, with an overall 6-year patency rate of 52%.10
therapy [see Figure 3]. If an intervention is indicated, patients are Currently, angioplasty is being evaluated for use in infrapopliteal
pretreated with antiplatelet agents as appropriate. disease. Some initial success has been reported, though it still
appears that this approach is best reserved for patients in whom
Technique
open surgical management is relatively contraindicated.18
Techniques and protocols for diagnostic angiography and
accessing the target lesion have been outlined [see Basic Endo- PROCEDURES FOR ACUTE LOWER-EXTREMITY ISCHEMIA
vascular Procedures, above]. If it is unclear whether a vessel has a
hemodynamically significant stenosis, arterial pressures can be Preprocedural Evaluation
measured across the lesion by connecting an end-hole catheter to The initial decision in managing acute lower-extremity
a pressure transducer. A drop of more than 10 mm Hg in systolic ischemia limb should be whether to proceed directly to surgery or
blood pressure or more than 5 mm Hg in mean arterial pressure to obtain a diagnostic angiogram and consider endovascular ther-
across the lesion is considered significant. The area in question apy. The Working Party on Thrombolysis developed a consensus
Table 4 Contraindications to Thrombolysis fibrin.21,22 To prevent buildup of clot around the sheath, all
patients undergoing pharmacologic thrombolysis also receive
Relative Contraindications Absolute Contraindications heparin in a continuously administered low dosage (200 to 500
U/hr); higher dosages are associated with a substantially increased
Recent surgery (within 2 wk) Active internal bleeding risk of hemorrhagic complications.
Recent trauma (within 1 mo) Recent stroke (within 2 mo)
History of coagulopathy Intracranial pathology Mechanical adjuncts to thrombolysis. Several mechanical ad-
Pregnancy or recent delivery
juncts are available to reduce thrombolytic time or enhance the
completeness of clot dissolution. These adjuncts can also be ben-
eficial when thrombolytic therapy is contraindicated.
on how to approach patients with acute arterial ischemia. The Various mechanical thrombectomy systems are commercially
main message of this consensus was that classifying patients available. One such system is the AngioJet system (Possis Medical,
according to their grade of ischemia is essential to forming treat- Minneapolis, Minnesota). The Angiojet consists of a pump drive
ment plans [see 6:5 Pulseless Extremity and Atheroembolism].19 unit and a 4 to 6 French catheter, which is passed over a 0.035-in.
Grade IIa and early grade IIb ischemia may be amenable to endo- wire to the target area.The catheter has two lumens: one is used to
luminal therapy, including thrombolysis. Established grade IIb pulse heparinized normal saline at a pressure of 10,000 psi, and the
ischemia is best treated by means of surgical embolectomy or other contains the wire and serves as the route by which clot debris
thrombectomy, with intraoperative angiography, intraoperative
thrombolysis, and over-the-wire embolectomy as options. Grade
III ischemia is nonsalvageable and generally necessitates amputa-
tion [see 6:19 Lower-Extremity Amputation for Ischemia].
Arterial Thrombolysis
Thrombolysis, either pharmacologic or mechanical, is the main-
stay of endovascular therapy for acute arterial ischemia.20 Relative
and absolute contraindications to thrombolytic therapy have been
established [see Table 4].
Technique An initial diagnostic angiogram of the affected

limb is obtained, with care taken to gain arterial access in such a
way that thrombolytic therapy is not prevented. The standard
approach is from the contralateral groin (see above).To reduce the
chances of access site hematoma during administration of a
thrombolytic agent, access should be gained at a substantial dis-
tance from the occlusion. Crossing the lesion involves identifying
the origin of the occlusion. In cases of native vessel occlusion, this
is generally a straightforward process. If a bypass graft is occlud-
ed, one may be able to visualize a stump of the graft, which will
aid in direct management [see Figure 4].The standard methods of
crossing a stenosis or an occlusion [see Basic Endovascular Proce-
dures, Crossing of Lesion, above] should be employed.
Once the lesion has been crossed securely with a wire, an infu-
sion catheter (e.g., a 3 French multi–side-hole catheter) is advanced
over the wire and situated in the occlusion. An infusion wire may
also be inserted through the infusion catheter in a coaxial fashion and
placed distally to increase the area of direct lysis, to protect the
outflow vessel, or to address two separate lesions [see Figure 5].
The position of the catheter and the wire are then documented by
means of fluoroscopy. With the infusion catheter left securely in
place, the thrombolytic infusion is begun. Often, it helps to insert
a guide sheath into the contralateral iliac system to prevent dis-
lodgment and facilitate subsequent access.
Pharmacologic agents. The use of thrombolytic drugs has been

refined over the past decade. In the United States, urokinase and
tissue plasminogen activator (t-PA) have been the most widely
used agents. Urokinase was popular in the 1980s and 1990s, but
Figure 4 Arterial thrombolysis. Patient presented with grade IIa
its temporary withdrawal from the market in 1998 because of
ischemia, and duplex ultrasonography showed evidence of an
manufacturing problems allowed physicians to become more occluded femoropopliteal reverse saphenous vein bypass graft.
comfortable working with t-PA. At present, recombinant t-PA (rt- Angiogram taken from the ipsilateral external iliac artery demon-
PA) (e.g., alteplase) is the lytic agent most commonly used in the strating a patent but diseased CFA and a patent PF. The SFA is
United States. Reteplase is a newer recombinant agent that is sim- occluded. The stump of the occluded arterial bypass graft is visi-
ilar to rt-PA but has a longer half-life and a less specific affinity for ble (arrow).
a b c
Figure 5 Arterial thrombolysis. Follow-up imaging of the patient in Figure 4 illustrates the use of a
thrombolytic infusion catheter. (a) Shown is the proximal end of the occluded CFA–popliteal artery
bypass graft. (b) The infusion catheter (black arrow) is placed. (c) The infusion wire rests in the distal
bypass graft (hollow arrow), increasing the infusion length for the thrombolytic agent.
is removed.The power pulse spray technique, with rt-PA added to Over-the-wire embolectomy is another mechanical means of
the saline (10 mg in 100 ml) and delivered by the rheolytic catheter removing clot. Newer designs of the standard Fogarty embolecto-
directly into the clot, may also be employed to help dissolve clot. In my catheter have been developed that include an inner lumen, so
this technique, the system is modified so that the outflow circuit is that the catheter can be passed over a 0.035-in. wire. Use of these
closed and the unit pulses the saline–rt-PA mixture into the clot, devices facilitates fluoroscopically guided embolectomy and en-
allowing simultaneous lysis and maceration. Once the thrombus sures that the catheter can be passed to all target vessels. Over-the-
has been treated and an additional 15-minute interval has elapsed, wire embolectomy provides an efficient percutaneous method of
conventional catheter therapy is employed to remove the clot and removing clot without any need for the constant monitoring that
the residual rt-PA.The advantage of this approach is that it permits pharmacologic thrombolysis requires.
high-dose lysis while imposing only a low systemic load.23 If more This embolectomy technique may be supplemented by intra-
than 750 ml of saline is used with the AngioJet catheter during a operative catheter-directed thrombolytic therapy when postopera-
single session, there is a significant risk of acute renal impairment tive imaging reveals residual clot or inadequate perfusion. Under
secondary to hemolytic debris. fluoroscopic guidance, an end-hole catheter or a multi–side-hole
Also used for mechanical thrombectomy are wall-contact instru- infusion catheter is guided over a wire into the target vessel or ves-
ments such as the Arrow-Trerotola device (Arrow International, sels, and a thrombolytic agent (e.g., rt-PA, 0.5 mg/kg over 30 min-
Reading, Pennsylvania). Such devices result in significant endo- utes) is directly infused with inflow occlusion. Imaging is recom-
thelial damage and distal clot embolization and thus are better mended both before and after thrombolysis. Adjunctive use of an
suited for hemodialysis grafts. Another option is the Helix Clot embolectomy catheter may also be beneficial. If, however, there is
Buster (ev3, Plymouth, Minnesota), which creates a vortex at the still no perfusion after adequate thrombolytic therapy and embo-
catheter tip that macerates the clot into microscopic fragments; it lectomy, the situation generally is not retrievable, and alternative
differs from the AngioJet in that it lacks an aspirating port.The Oasis therapies should be explored. In the clinical trials of perioperative
thrombectomy catheter (Boston Scientific, Natick, Massachusetts) thrombolytic therapy published to date, success rates ranged from
also fragments thrombus into small particles. The use of these 64% to 100%. Bleeding was the most common complication.
devices in the setting of acute arterial occlusion was addressed in
a comprehensive review published in 2001.24 All of these devices Postprocedural care After the intervention, the patient is
may be used either in place of or in addition to pharmacologic observed in a monitored unit by personnel trained in the manage-
thrombolysis. ment of thrombolytic therapy. Lower-extremity neurovascular
At present, the evidence supporting the use of mechanical examinations are carried out frequently (every 1 to 2 hours). The
thrombectomy devices in the setting of acute limb ischemia is mod- patient’s clinical status is also monitored for evidence of bleeding,
est. One retrospective study demonstrated successful recanalization including access-site hematoma, neurologic changes, and hypo-
in approximately 60% of patients.25 At our own institution, we have tension. Repeat angiograms are performed at 12-hour intervals (or
found these devices to be useful in decreasing the clot burden on sooner if clinical examination reveals significant deterioration) to
the second or third t-PA check (24 to 36 hours after commence- assess the progress of lytic therapy and to allow changes in catheter
ment of the infusion), after the clot has been softened by the initial positioning. Some physicians recommend following fibrinogen
pharmacologic lysis. It remains to be seen whether this approach levels and discontinuing the lytic agent if levels fall below 150
reduces the overall time needed for thrombolytic therapy. mg/dl. Other end points for the thrombolytic therapy are failure to
progress, complete lysis of the target thrombus, or significant crossed, the thrombolytic agent may be delivered just proximal to
bleeding complications necessitating discontinuance of lysis. the lesion for 2 to 4 hours after initiation of therapy, but the
Once lysis is discontinued, the heparin dosage should be in- chances of a good outcome with this approach are diminished.
creased to achieve therapeutic levels of anticoagulation. Any lesions Whereas it is common for clinical findings to worsen slightly (as
unmasked by thrombolytic therapy should be treated, either by a result of distal microembolization) before improving—the so-
endovascular means or with an open procedure. Whether long- called storm before the calm phenomenon—dramatic worsening
term anticoagulation is indicated depends on the patient’s cir- of the physical findings calls for urgent angiography. Possible rea-
cumstances and the specific cause of the thrombosis. sons for ischemic progression include propagation of clot (treat-
able by performing open embolectomy or thrombectomy), dis-
Troubleshooting Many of the issues raised in connection placement of the lysis catheter (treatable by repositioning the
with basic arterial access techniques arise during attempts at catheter), or distal embolization of clot resulting in obstruction of
thrombolysis. Occasionally, the interventionalist experiences signif- the principal runoff vessels (treatable by advancing the infusion
icant difficulty in accessing an occluded bypass graft.Thrombolysis catheter or wire more distally, employing a rheolytic catheter, or
of these occluded grafts can often be facilitated by employing a performing open embolectomy or thrombectomy).
double-puncture technique, in which both a retrograde and an
antegrade puncture of a bypass graft are performed under ultra- Complications General access-site complications—includ-
sonographic guidance, allowing the infusion catheters to be placed ing hematoma, pseudoaneurysm formation, ischemia to the con-
so as to cover the entire length of the graft [see Figure 6].26 With this tralateral leg from an occlusive sheath, nerve damage (which is
approach, there is no need for CFA puncture, which is often made more common with axillary or brachial puncture secondary to an
difficult by the presence of scar tissue, and the problem of finding axillary sheath hematoma), arterial dissection of the access vessel,
access to the graft takeoff is eliminated. If a lesion cannot be and distal embolization of the clot—are also seen with thrombolyt-
a c e
Diagnostic
Infusion
Catheter
Catheters
Infusion
Wire
b d
Guidewire Antegrade
Wire
Diagnostic
Catheter
Figure 6 Arterial thrombolysis. Illustrated is ultrasound-guided double puncture of an arterial

bypass graft for thrombolysis.26
Table 5 Prospective, Randomized, Controlled

Trials of Arterial Thrombolytic Therapy
Limb Salvage Rate at

Trial (Date) N Lytic Agent 1 Yr (Surgery vs. Lytic 30-Day Mortality (Surgery Bleeding Complication
Therapy) vs. Lytic Therapy) Rate with Lytic Therapy
Rochester (1994)41 114 Urokinase 82% vs. 82% (NS) 18% vs.12% (NS) 11%
STILE (1994)27 393 Urokinase/rt-PA 100% vs. 90% No difference 5.6%
TOPAS (1996)42 213 Urokinase 65% vs. 75% (NS) 5% vs. 3% (NS) 10%
NS—not significant STILE—Surgery versus Thrombolysis for Ischemia of the Lower Extremity TOPAS—Thrombolysis Or Peripheral Arterial Surgery
ic therapy. Bleeding complications have presented a significant hur- Overall success rates may exceed 95%. Complications include dis-
dle for thrombolytic therapy. Early studies that used therapeutic tal native artery thrombosis and distal embolization, which gener-
doses of heparin and higher doses of thrombolytics reported unac- ally can be treated with I.V. heparin.28
ceptable rates of intracranial hemorrhage and other bleeding com-
plications. Currently, most physicians employ rt-PA doses in the Placement of Covered Stent
range of 0.25 to 0.50 mg/hr without compromising results. Overall, Treatment of lower-extremity aneurysms with covered stents is
rates of bleeding complications with urokinase and rt-PA range currently being studied. Isolated iliac artery and SFA lesions,
from 5% to 10%, and the incidence of intracranial hemorrhage is though rare, lend themselves to endovascular repair [see Figure 7].
less than 2%.22 As with open surgical therapy, compartment syn- Initial data suggest that repair of popliteal aneurysms with covered
drome can complicate reperfusion of the ischemic limb; this com- stents is also feasible in high-risk patients.29 Newer stents are being
plication should be checked for on serial clinical examinations. developed that are better able to withstand the stresses imposed by
the repetitive motion of the knee joint.
Outcome evaluation The use of thrombolysis to treat acute
lower-extremity arterial occlusion has been extensively studied.
The results of the major prospective, randomized trials [see Table 5] Venous Procedures
showed thrombolytic therapy to be equivalent to surgery with As endovascular therapy for arterial disease continues to evolve,
respect to limb salvage and mortality and superior with respect to techniques learned in the arterial tree are increasingly being
the need for complex surgical intervention. Most of these major applied to the venous system. At present, the main venous disease
trials were performed with urokinase and t-PA. The information processes being treated with endovascular techniques are
gained from them has helped surgeons determine which patients iliofemoral deep vein thrombosis (DVT) and superficial reflux of
are good candidates for thrombolytic therapy. Factors predictive of the greater saphenous system causing symptomatic varicose veins.
successful thrombolysis include symptoms of less than 14 days’
VENOUS THROMBOLYSIS
duration, prosthetic graft occlusion, and high medical risk for open
operation. Factors predictive of a poor outcome include chronic Lower-extremity DVT can have a significant impact on
occlusion, native artery occlusion, and a lesion that cannot be patients’ quality of life. Multiple studies indicate that approxi-
crossed with a wire.27 mately 50% of patients experience postthrombophlebitic syn-
drome (PTS) and that the majority of patients with PTS report
PROCEDURES FOR LOWER-EXTREMITY ARTERIAL ANEURYSMS
that physical and emotional well-being are negatively affected.30
The goals of venous lysis are to relieve obstruction and to preserve
Ultrasound-Guided Thrombin Injection valve function.
Pseudoaneurysms of the CFA are a complication of femoral
access for therapeutic procedures and are often amenable to per- Preprocedural Evaluation
cutaneous therapy. The pseudoaneurysm is visualized with a 7.5- If DVT is less than 1 month old, a trial of lytic therapy is appro-
MHz duplex ultrasound probe. Contraindications to injection of priate. The ideal candidate for such therapy has a symptomatic
the sac are the presence of a wide mouth and no discernible neck, clot with lower-extremity swelling, is young and mobile, is not in a
the development of an arteriovenous fistula, compression of adja- hypercoagulable state, and has no contraindications to lysis.
cent structures by the pseudoaneurysm, and skin changes overly- Currently, lytic therapy is more commonly employed in active
ing the pseudoaneurysm. If infection is a possibility, the procedure patients, whose quality of life is more likely to be negatively affect-
should not be attempted. The ABI should be determined and ed by PTS. In cases of unprovoked DVT or recurrent DVT, a
duplex ultrasonography of the groin performed before injection. hypercoagulability workup is indicated.31 Venous thrombosis is
Once it is certain that the pseudoaneurysm meets the criteria discussed more fully elsewhere [see 6:6 Venous Thromboembolism].
for thrombin injection, the sac is injected in the fundus area, away
from the native artery, under direct ultrasonographic visualization Technique
and after infiltration of a local anesthetic. Usually, 1,000 units of The initial diagnostic venogram can be obtained via almost any
thrombin is injected, and injection may be repeated one or more venous access site. Our preference is to perform an ipsilateral
times. With multilobar aneurysms, serial injections into each fun- popliteal vein stick with the patient in the prone position; the pos-
dus may be required to achieve complete resolution. terior tibial vein or the contralateral femoral vein can also be used.
Factors associated with successful treatment are a long, narrow The popliteal vein is accessed with a micropuncture needle under
pseudoaneurysm neck and a sac diameter smaller than 8 cm. ultrasonographic guidance by means of a Seldinger technique.
The micropuncture sheath is then replaced with a 5 French than 50% lysis was achieved in 83% of the patients; 11% experi-
sheath over a 0.035-in. wire. The diagnostic venogram is per- enced complications, and 1% had pulmonary emboli.33 Small
formed through the sheath or with a straight multi–side-hole diag- prospective, randomized trials found that thrombolysis yielded
nostic catheter. increased patency and decreased venous reflux in comparison
As in arterial thrombolysis [see Arterial Procedures, Procedures with standard anticoagulation therapy.35 Retrospective studies
for Acute Lower-Extremity Ischemia, Arterial Thrombolysis, indicated that this improved venous patency and valve function
above], a 3 French infusion catheter is advanced over the wire and might translate into better quality of life than would be achieved
positioned within the clot. Longer lesions can be managed with a with anticoagulation alone.36
coaxial infusion catheter–wire system.The lytic infusion is started,
TREATMENT OF SAPHENOFEMORAL VENOUS REFLUX
and a low-dose intravenous heparin infusion is initiated through
the sheath. Mechanical thrombectomy and power pulse spray The application of endovascular techniques to saphenofemoral
thrombectomy can efficiently debulk thrombus and may be ben- venous reflux has significantly changed the treatment of this con-
eficial in patients with phlegmasia caerulea dolens.32 The patient dition.37 Over the past decade, two minimally invasive approach-
is kept in a monitored floor bed, and repeat venograms are per- es have been developed to replace standard high ligation and strip-
formed every 12 to 24 hours. ping of the greater saphenous vein (GSV): radiofrequency abla-
In some patients, May-Thurner syndrome (compression of the tion (RFA) and endolaser obliteration.
iliac vein by the overlying iliac artery) develops; it is treated by
placing a venous stent in the iliac vein to help reduce the effect of Preprocedural Evaluation
external compression and presumably treat the initiating factor. Initially, symptomatic varicose veins are treated conservatively,
Venous stents are larger than corresponding arterial stents in a with compression stockings. If conservative methods fail to pro-
given vascular bed. Because of the increased compliance of the vide relief, a varicose vein–related complication develops, and
venous wall, self-expanding stents are preferred for use in veins. there is evidence of significant superficial reflux on duplex ultra-
Once lysis either is complete or has been continued for 72 sonography, the patient may be considered for endovenous treat-
hours, the lytic infusion is stopped, and the heparin infusion is ment of GSV reflux.
increased to therapeutic levels. The patient is placed on warfarin
therapy and should be treated in accordance with current algo- Preprocedural Planning
rithms for DVT [see 6:6 Venous Thromboembolism]. GSV ablation procedures may be performed either in an office
or in an operating or procedure room. If an office setting is cho-
Complications sen, the patient must be able to tolerate a small amount of dis-
Reported rates of bleeding complications after venous lysis are comfort with light sedation. The interventionalist must be certi-
higher than those after arterial lysis, typically ranging from 10% to fied to deliver conscious sedation and must be laser qualified if
15%.33 Pulmonary embolism, though rare in this setting, is known providing laser therapy.The procedure room, whether in an office
to occur, presumably as a result of partially lysed clot breaking off. or a medical facility, should be equipped with a procedure table
To prevent this complication, some authors advocate prophylactic capable of a steep Trendelenburg position, a high-resolution
placement of an inferior vena cava (IVC) filter.34 Ongoing devel- duplex ultrasonography device, and the appropriate ablation
opment and wider use of retrievable IVC filters may accelerate the equipment. For more symptomatic side-branch varicosities, stab
application of this adjunctive technique. avulsions may be needed; as a rule, these are best done in the OR.
Outcome Evaluation Technique
In a large retrospective study of 312 cases of iliofemoral and RFA of GSV The development of the Closure system
femoropopliteal DVT treated with urokinase infusion, greater (VNUS Medical Technologies, Sunnyvale, California) has allowed
a b c
Figure 7 Placement of covered stent. Shown is endovascular repair of an external iliac artery aneurysm.
The patient presented with left groin pain several months after undergoing urologic surgery. (a) CT scan
demonstrates a left external iliac artery pseudoaneurysm. (b) Angiogram demonstrates the same
pseudoaneurysm. (c) Shown is the left external iliac artery after covered stent placement successfully
excluded the pseudoaneurysm.
the application of RFA to GSV reflux therapy. Before the proce- RFA is that the laser wire can be pulled back relatively quickly (up
dure, the GSV is mapped by means of ultrasonography. The to 18 mm/min).
patient is placed in the Trendelenburg position with a tourniquet
around the upper thigh. Access to the GSV is obtained at the knee Complications
with an introducer needle and a wire threaded into the vein, and The most serious complication associated with any of these
the needle is then replaced with a proprietary sheath.The Closure endovenous techniques is DVT.There have been several reports of
catheter is threaded through the sheath, and the tip is placed under DVT resulting from RFA of the GSV, with incidences as high as
ultrasonographic guidance just proximal to the takeoff of the 16%.38 As of September 2005, four instances of pulmonary
superficial epigastric vein at the saphenofemoral junction (SFJ). A embolism from these clots had been reported in the United States
mixture of normal saline (500 ml), 1% lidocaine with epinephrine Food and Drug Administration’s Manufacturer and User Facility
(50 ml), and sodium bicarbonate (5 mg) is injected under ultra- Device Experience (MAUDE) database (http://www.fda.gov/
sonographic guidance through the sheath and into the area sur- cdrh/maude.html), with at least one patient dying of a pulmonary
rounding the GSV to provide anesthesia, improve impedance, and embolism after the procedure.
protect the overlying tissues from exposure to the heat (so-called Lower-extremity DVT has also been reported after endovenous
tumescent anesthesia). laser therapy. Other problems include saphenous nerve paresthe-
The Closure device is then connected to the RFA delivery sys- sias along the course of the GSV, bruising, skin burns, and super-
tem, deployed, and pulled back at a controlled rate (initially, 1 cm ficial phlebitis. If endovenous laser therapy fails to obliterate the
every 30 seconds), with both impedance and temperature GSV, the problem can be remedied by prompt high ligation at the
checked periodically. Manual compression, particularly in the time of ablation. Clot in the common femoral vein can be treated
upper thigh, may help in obtaining optimal numeric values on the with standard anticoagulation. Clot abutting the common femoral
RFA unit, as well as increase the efficiency of ablation. After the vein can be treated with clopidogrel, 75 mg/day orally for 1 month;
catheter has been withdrawn into the sheath, it is removed, and serial ultrasonograms should be obtained to confirm that the clot
ultrasonography is performed to confirm that the GSV has been is not propagating.
obliterated.
Outcome Evaluation
Endovenous laser treatment of GSV Access to the GSV is Overall, good results are obtained with endovenous treatment
obtained as in RFA (see above), and a wire is advanced under of GSV reflux. In one study of patients who underwent RFA of the
ultrasonographic guidance to a point above the SFJ. A 600 µm GSV, 85% of patients had complete occlusion of the GSV at 2
laser fiber is placed over the wire and positioned just distal to the years, and 90% of all patients were free of GSV reflux at that
SFJ in the GSV. A tumescent anesthetic solution is injected. Laser time.39 In a study of patients who underwent endolaser oblitera-
energy is delivered (e.g., with an 810 nm diode laser) as the laser tion, similar results were obtained: ultrasonographic surveillance
fiber is pulled back. One advantage endolaser obliteration has over documented a 93% rate of complete GSV closure at 2 years.40
References
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2. Spinosa D, Kaufmann JA, Hartwell GD: taneous angioplasty and stenting of the superficial 19. Working Party on Thrombolysis in the Management
Gadolinium chelates in angiography and interven- femoral artery. J Vasc Surg 41:269, 2005 of Limb Ischemia:Thrombolysis in the management
tional radiology: a useful alternative to iodinated 11. Murphy TP, Khwaja AA, Webb MS: Aortoiliac of lower limb peripheral arterial occlusion—a con-
contrast media for angiography. Radiology stent placement in patients treated for intermit- sensus document. Am J Cardiol 81:207, 1998
223:319, 2002 tent claudication. J Vasc Interv Radiol 9:421, 1998 20. Davies MG, Lee DE, Green RM: Current Spec-
3. Fava M, Loyola S, Polydorou A, et al: Cryoplasty 12. Karch LA, Mattos MA, Henretta JP, et al: Clinical trum of Thrombolysis, 3rd ed. WB Saunders Co,
for femoropopliteal arterial disease: late angio- failure after percutaneous transluminal angioplas- Philadelphia, 2001
graphic results of inital human experience. J Vasc ty of the SFA and popliteal arteries. J Vasc Surg 21. Ouriel K: A history of thrombolytic therapy. J
Interv Radiol 15:1239, 2004 31:880, 2000 Endovasc Ther 11:128, 2004
4. Kasirajan K, Schneider PA: Early outcome of 13. Becquemin JP, Allaire E, Qvarfordt P, et al: Surg- 22. Ouriel K, Kandarpa K: Safety of thrombolytic
“cutting” balloon angioplasty for infrainguinal ical transluminal iliac angioplasty with selective therapy with urokinase or recombinant tissue plas-
vein graft stenosis. J Vasc Surg 39:702, 2004 stenting: long term results assessed by means of minogen activator for peripheral arterial occlu-
5. Zeller T, Rastan A, Schwarzwalder U, et al: Percuta- duplex scanning. J Vasc Surg 29:422, 1999 sion: a comprehensive compilation of published
neous peripheral atherectomy of femoropopliteal 14. Cejna M, Schoder M, Lammer J: PTA versus stent work. J Endovasc Ther 11:436, 2004
stenosis using a new-generation device: six-month in femoropopliteal obstruction. Radiologie 39:144, 23. Allie DE, Herbert CJ, Lirtzman MD, et al: Novel
results from a single-center experience. J Endovasc 1999 simultaneous combination chemical thromboly-
Ther 11:676, 2004 sis/rheolytic thrombectomy therapy for acute crit-
15. Vroegindeweij D, Vos LD, Buth J, et al: Balloon
6. Duda SH, Bosiers M, Lammer J, et al: The angioplasty combined with primary stenting versus ical limb ischemia: the power-pulse spray tech-
SIROCCO II trial: sirolimus-eluting versus bare balloon angioplasty alone in femoropopliteal ob- nique. Catheter Cardiovasc Interv 63:512, 2004
nitinol stent for obstructive superficial femoral structions: a comparative randomized study. Car- 24. Kasirajan K, Gray B, Beavers FP, et al: Rheolytic
artery disease. J Vasc Interv Radiol 16:331, 2005 diovasc Interv Radiol 20:420, 1997 thrombectomy in the management of acute and
7. Nikolsky E, Mehran R, Halkin A, et al: Vascular 16. Zdanowski Z, Albrechtsson U, Lundin A, et al: subacute limb-threatening ischemia. J Vasc Interv
complications associated with arteriotomy closure Percutaneous transluminal angioplasty with or with- Radiol 12:413, 2001
devices in patients undergoing percutaneous coro- out stenting for femoropopliteal occlusions? A ran- 25. Kasirajan K, Haskal ZJ, Ouriel K: The use of
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Cardiol 44:1200, 2004 ment of acute peripheral arterial occlusive disease.
17. TASC Working Group: Management of peripher-
8. Davies MG, Waldman DL, Pearson TA: Compre- al arterial disease (PAD): Transatlantic Inter-So- J Vasc Interv Radiol 12:405, 2001
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Surg 201:275, 2005 18. Soeder HK, Manninen HI, Jaakkola P, et al: nique for thrombolysis of peripheral bypass grafts.
9. Schurmann K, Mahnken A, Meyer J, et al: Prospective trial of infrapopliteal artery balloon J Vasc Interv Radiol 11:445, 2000
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28. Powell A, Benenati JF, Becker GJ, et al: deep venous thrombosis: report of a national multi-
Percutaneous ultrasound-guided thrombin injec- center registry. Radiology 211:39, 1999 39. Merchant RF, DePalma RG, Kabnick LS: Endovas-
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Surg 41:561, 2005 bolysis vs. anticoagulation in iliofemoral venous 41. Ouriel K, Veith FJ, Sasahara AA: Thrombolysis or
30. Kahn SR, Hirsch A, Shrier I: Effect of postthrom- thrombosis: a randomized clinical trial. Eur J Vasc peripheral arterial surgery: phase I results. TOPAS
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162:1144, 2002 Catheter-directed thrombolysis for iliofemoral ison of thrombolytic therapy with operative revas-
31. Weitz JI, Middeldorp S, Geerts W, et al: Thrombo- deep venous thrombosis improves health-related cularization in the initial treatment of acute periph-
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matic lower extremity deep venous thrombosis: safe- 2002 Figures 1a, 2b, and 6 Tom Moore.
6 VASCULAR SYSTEM 24 RAYNAUD PHENOMENON — 1
24 RAYNAUD PHENOMENON
Tina R. Desai, M.D., F.A.C.S., and Ryan Headley, M.D.
Raynaud phenomenon is an episodic, exaggerated vascular Pathophysiology of Raynaud Phenomenon], but an attack may
response to cold or emotional stimuli, typically involving the fin- also be elicited by generalized cooling of the entire body. In addi-
gers.The classic triphasic color change, first described by Maurice tion, attacks may be precipitated by any stimulation of the sympa-
Raynaud in 1862, consists of initial pallor (secondary to vaso- thetic nervous system, especially at times of emotional stress.
spasm), followed first by cyanosis (from deoxygenation of the sta- As a rule, Raynaud phenomenon is more likely to affect the
tic blood) and then by rubor (as blood flow to the digits is restored hands than the feet. It is characterized by the sudden occurrence
and reactive hyperemia ensues).1 This classic manifestation of of cold digits in association with sharply demarcated pale skin—
Raynaud phenomenon occurs in as many as two thirds of affect- the so-called ischemic phase. Eventually, the skin may become
ed patients; however, less common variants of the phenomenon cyanotic. Subsequently, rapid restoration of blood flow to the dig-
(e.g., pallor followed by cyanosis alone and pallor followed by its results in reactive hyperemia—the reperfusion phase. Attacks
rubor alone) also exist. typically start in a single digit and spread symmetrically to other
Raynaud phenomenon occurs throughout the world. Overall, it digits, eventually involving both hands. Other sites may be involved
tends to be more common in colder climates. In warmer areas of as well—notably, the ears, the nose, the nipples, the face, and the
the United States and Spain, the prevalence ranges from 3% to knees. Ischemic attacks may be accompanied by mottling of the
5%, whereas in cooler areas, the prevalence ranges from 15% to
20%.2-4 In a study of the African-American population, the preva-
lence was 3%.5 Table 1 Conditions Associated with
Raynaud Phenomenon20
Classification Systemic sclerosis syndrome (scleroderma)
Raynaud phenomenon is generally classified as either primary or Systemic lupus erythematosus
Dermatomyositis or polymyositis
secondary. Primary Raynaud phenomenon occurs as an isolated
Rheumatoid arthritis
finding in an otherwise healthy individual; secondary Raynaud Rheumatologic diseases Takayasu arteritis
phenomenon is caused by an associated disease (in most cases, an Giant cell arteritis
autoimmune disease) or by identifiable environmental or chemical Thromboangiitis obliterans
exposure [see Table 1].6 The two types are distinguished from each Primary biliary cirrhosis
other on the basis of clinical criteria, and the distinction has signif-
Vibration (hand/arm vibration syndrome)
icant prognostic implications. Mechanical injury
Frostbite
With primary Raynaud phenomenon, the typical age of onset is
15 to 30 years, symptoms are generally symmetrical and less severe, Recurrent trauma or injury Crutch pressure
to large vessels Thoracic outlet syndrome
patients are more likely to be female, and multiple family members
may be affected.7 With secondary Raynaud phenomenon, the typ- Arterial diseases Brachiocephalic atherosclerosis
ical age of onset is greater, symptoms are usually more severe, and
Migraine or vascular headache
a systemic inflammatory disorder is commonly involved. In fact, Vasospastic disorders
Prinzmetal angina
Raynaud phenomenon is a prominent component of many
autoimmune disorders, occurring in 90% of patients with sclero- Carcinoid syndrome
derma, 10% to 45% of patients with systemic lupus erythematosus Endocrine disorders Pheochromocytoma
(SLE), one third of patients with Sjögren syndrome, 20% of pa- Hypothyroidism
tients with dermatomyositis or polymyositis, and 10% to 20% of Ovarian cancer
Malignant diseases
patients with rheumatoid arthritis.8 In 0% to 13% of patients who Angiocentric lymphoma
present with primary Raynaud phenomenon, an identifiable con-
Cryoglobulins
nective tissue disorder develops within a few years after presenta- Cold agglutinins
tion.9,10 The best predictors of transition to such a disorder are (1) Abnormal blood elements
Paraproteinemia
serologic findings that are positive for autoantibody and (2) sugges- Polycythemia
tive physical findings (e.g., abnormal nailfold capillary patterns,
Parvovirus B19
cutaneous telangectasias, puffy fingers, and sclerodactyly).6,10 Infections
Helicobacter pylori
Bleomycin, vinblastine
Clinical Evaluation and Investigative Studies Polyvinyl chloride
Chemicals or drugs Beta blockers
CHARACTERISTIC FINDINGS Ergots (e.g., methysergide)
Interferon alfa, beta
Exacerbation of Raynaud phenomenon typically occurs after Tegafur
direct exposure of an extremity to cold temperatures [see Sidebar
skin on the arms and legs. During the ischemic phase, patients
may complain of paresthesias and clumsiness in the involved
extremities. In the most severe cases of secondary Raynaud phe- Pathophysiology of Raynaud Phenomenon
nomenon, critical ischemia may cause painful digital ulceration.
Raynaud phenomenon should be differentiated from simple Blood flow to the skin is regulated by a complex interaction between
the endothelium, vascular smooth muscle, circulating hormones, and
“cold hands” (a more common and benign condition). In patients
neural plexus. Patients with Raynaud phenomenon demonstrate an
with Raynaud phenomenon, cold hands occur in conjunction exaggerated vasomotor response to otherwise benign stimuli, no-
with clearly distinguished skin-color changes. Moreover, recovery tably cold exposure. Normally, on exposure to cold, blood flow to the
takes longer than it does in patients who merely have cold hands. skin is reduced in an effort to preserve core temperature. This natural
The guidelines for diagnosing Raynaud phenomenon are based response is mediated primarily by the sympathetic nervous system
on a history of color change on exposure to cold or other stimuli. via the neurotransmitter norepinephrine, which causes contraction of
vascular smooth muscle in the cutaneous arterial beds. This cold-
A history of repeated episodes of biphasic skin-color change on
induced vasoconstriction of cutaneous vascular smooth muscle
exposure to cold is indicative of Raynaud phenomenon. A histo- appears to be mediated specifically by the alpha2 receptor.40
ry of uniphasic skin-color change with paresthesias on exposure It has been suggested that the cold-induced vasoconstriction
to cold is suggestive. In the absence of any skin-color change, seen in primary Raynaud phenomenon is the result of exaggerated
Raynaud phenomenon is ruled out.11 Generally, additional diag- activity of the alpha2 receptors. This suggestion was supported by
nostic tests are unnecessary; however, both evaluation of digital the results of experiments that blocked the cold-induced vasocon-
pressure response to cooling and laser Doppler assessment of skin striction in primary Raynaud phenomenon by delivering alpha2 re-
ceptor antagonists locally.41 The mechanism of this Raynaud-specif-
perfusion pressure have been employed in this setting. There is ic hyperactive response has not been fully elucidated, though there is
evidence to suggest that laser Doppler assessment of skin perfu- evidence to indicate that the response may, in part, be attributable to
sion pressure is capable of distinguishing between normal control increased activity in the protein tyrosine kinase signal transduction
subjects, persons with primary Raynaud phenomenon, and per- pathway.42 Endothelial derangements may also contribute to the
sons with secondary Raynaud phenomenon.12-14 pathogenesis of primary Raynaud phenomenon through increased
Raynaud phenomenon should also be differentiated from carpal plasma concentrations of endothelin and decreased levels of nitric
oxide.43,44
tunnel syndrome and other neuropathies, which may cause cold
In secondary Raynaud phenomenon, it is generally accepted
sensitivity but do not induce the skin-color changes characteristic that vascular damage from the underlying disease (especially in the
of Raynaud phenomenon. Patients who have asymmetrical, per- case of scleroderma) is responsible for the disruption of normal va-
sistent, or positional symptoms should undergo a full evaluation somotor homeostasis. Activated or damaged endothelial cells exac-
for possible large vessel occlusive disease, embolism, or thoracic out- erbate vasospasm and further damage perfusion by mediating the
let compression, any of which might lead to hand-color changes. proliferation and contraction of smooth muscle cells; enhancement
of procoagulant activity and reduction of fibrinolysis promote the for-
Raynaud phenomenon may also be a reflection of a more general-
mation of intravascular microthrombi, and the release of chemotactic
ized vasospastic disorder (e.g., migraine headache or Prinzmetal and adhesion factors activates local inflammatory processes.20
angina).15,16
Once a diagnosis of Raynaud phenomenon has been estab-

lished—or, at least, strongly suspected—a thorough history and “hairpin” capillary loops. However, the pattern seen in patients
physical examination can help distinguish between primary and with Raynaud phenomenon secondary to an underlying cause
secondary forms of the condition.The presence of specific symp- (e.g., scleroderma, dermatomyositis, or undifferentiated connec-
toms of connective tissue disease (particularly arthralgia, myalgia, tive tissue disease) often includes enlarged capillary loops , with
and dry mucous membranes), extended exposure to vibrating evidence of angiogenesis, architectural derangements, and areas
machinery, or antecedent use of certain medications is suggestive of decreased vascularity.19 Serologic markers provide additional
of secondary Raynaud phenomenon. The earliest specific diag- support for the diagnosis of secondary Raynaud phenomenon:
nostic criteria for primary Raynaud phenomenon were described the anti-Smith antibody is specific for SLE, and the anti-topoiso-
by Allen and Brown in 1932.17 More current criteria take advan- merase and anti–RNA polymerase antibodies are highly specific
tage of modern diagnostic tools and serologic testing. Primary for scleroderma-spectrum disorders. Among experts, there is lit-
Raynaud phenomenon is suspected when attacks are symmetrical tle doubt that patients with Raynaud phenomenon who test pos-
and episodic, when the history and the physical examination itive for autoantibodies are at higher risk for the eventual devel-
reveal no evidence of tissue gangrene or a possible underlying opment of a connective tissue disease.20
causative condition, when antinuclear antibody titers and eryth-
rocyte sedimentation rates are normal, and when nailfold capil-
Management
lary examination yields unremarkable results.18
Management of Raynaud phenomenon generally consists of
TESTING FOR SUSPECTED SECONDARY RAYNAUD lifestyle modification and medical treatment, with surgical
PHENOMENON options limited to severe or refractory cases. Nonpharmacologic
If secondary Raynaud phenomenon is suspected on the basis treatment generally suffices for primary Raynaud phenomenon,
of the history and the physical examination, more specific testing but it is often inadequate for management of secondary Raynaud
is appropriate. A particularly helpful test is nailfold capillaroscopy. phenomenon, which is usually more severe. Mild forms of Raynaud
The bases of the fingernails of the fourth and fifth digits are phenomenon are managed with lifestyle modification, including
examined with a handheld ophthalmoscope set to 10 to 40 maintenance of total body warmth (as well as warmth of hands
diopters after a drop of immersion oil is placed on each nailfold. and fingers), avoidance of cold and emotional stress, cessation of
The normal vascular pattern, seen in healthy control subjects and smoking, discontinuance of the use of vibrating tools, and avoid-
patients with primary Raynaud phenomenon, consists of delicate ance of vasoconstricting substances (e.g., caffeine, cocaine, beta
blockers, and decongestants). Biofeedback training has also been plasminogen activator and with low-molecular-weight heparin;
shown to be of some utility in reducing symptoms of Raynaud however, these agents were found to carry significant bleeding
phenomenon, though several studies have questioned its value, risks and thus have not been widely accepted for treatment of
especially in comparison to that of medical management.21,22 Raynaud phenomenon.28,33
Calcium channel blockers are the vasodilators most commonly For refractory, severe Raynaud phenomenon, surgical manage-
used to treat Raynaud phenomenon. Nifedipine, diltiazem, felodi- ment, most often involving some form of sympathectomy, is rec-
pine, and amlodipine are all effective, though they tend to be more ommended. Both central and distal sympathectomy have been
effective in patients with the primary form of the condition than in employed for this purpose; initial success rates are good, but there
those with the secondary form. One meta-analysis found short-act- is a high incidence of recurrent symptoms.
ing nifedipine, 10 to 20 mg three or four times a day, to be moder- For many years, open cervicothoracic sympathectomy was
ately effective at reducing symptoms in patients with Raynaud phe- commonly performed for symptomatic treatment of Raynaud
nomenon and scleroderma.23 A large clinical study found sustained- phenomenon (which was thought to result from an overactive
release nifedipine to be useful as well.22 Despite some variability in sympathetic response), but the results were mixed.34,35 The open
the published reports, calcium channel blockers remain the first form of the procedure was associated with substantial morbidity
choice for medical treatment after failure of nonmedical treatment. and frequent recurrence of symptoms, and as a result, it has now
Other vasodilators have also been shown to be effective. In one been largely abandoned. Some surgeons have advocated perform-
study, losartan, an angiotensin receptor blocker, proved to be more ing thoracoscopic sympathectomy [see 4:7 Video-Assisted Thoracic
effective than nifedipine in reducing the frequency and severity of Surgery] to treat severe Raynaud phenomenon that is refractory
episodes of both primary and secondary Raynaud phenomenon.24 to medical management, but the benefits and durability of this
Topical nitrates provide a degree of benefit as well.20 Because sero- approach have not been established. In this procedure, the ipsilat-
tonin may be partially involved in the pathogenesis of Raynaud eral pleural space is approached thoracoscopically, with the patient
phenomenon, a number of studies have focused on the use of sero- under general anesthesia. The sympathetic chain is identified as it
tonin reuptake inhibitors and serotonin receptor antagonists.25 In a courses down the ribs near the costovertebral junction, and the
small open-label trial that included both patients with primary second through fourth thoracic sympathetic ganglia lying be-
Raynaud phenomenon and patients with the secondary form of the tween the ribs are cauterized. Bilateral sympathectomy may be
condition, fluoxetine was more effective than nifedipine in reduc- performed in a sequential fashion during the same operation. Ap-
ing the severity and frequency of attacks over a 6-week period; the proximately 90% of patients experience immediate relief of symp-
effect was most pronounced in female patients and in patients with toms after thoracoscopic sympathectomy, but the majority also
primary Raynaud phenomenon.26 In another study, ketanserin, a experience recurrence of symptoms.36,37 Proponents of this proce-
selective serotonin receptor antagonist that is no longer available in dure argue that these recurrent symptoms are not as severe as the
the United States, significantly reduced the number of attacks over original preoperative symptoms and that patients who undergo the
a 3-month period.27 Intravenous prostaglandins have also been operation as treatment of ulceration exhibit continued long-term
used with success. In one report, iloprost, given as a 5-day infusion, healing. Nonetheless, in our view, it is advisable to reserve thora-
was beneficial in severe cases of Raynaud phenomenon, mitigating coscopic sympathectomy for selected cases of Raynaud phenome-
symptoms and enhancing the healing of ischemic ulcers28; unfor- non that are refractory to medical management.
tunately, iloprost is also unavailable in the United States. Of the I.V. At present, localized digital sympathectomy using microsurgical
prostaglandins currently available in the United States, alprostadil techniques is generally preferred to proximal sympathectomy for
(prostaglandin E1 [PGE1]) and epoprostenol (PGI2) have achieved, treatment of nonhealing ulcerations in patients with severe, refrac-
at best, mixed results,29,30 whereas prazosin has been employed tory Raynaud phenomenon.38 This procedure involves stripping the
with some success against primary and secondary Raynaud phe- adventitia, along with digital sympathetic fibers, from the involved
nomenon (though its effectiveness seems to be limited in patients digital arteries, with the patient under either regional or general
with scleroderma).31 anesthesia. In one small study of seven patients, it was suggested
Some authors have advocated low-dose aspirin therapy for that this digital sympathectomy could be extended to include the
Raynaud phenomenon, but to date, trials of antiplatelet therapy palmar arch, the radial and ulnar arteries proximal to the wrist,
have yielded disappointing results.28 In a placebo-controlled, ran- and the nerve of Henle, which is responsible for the sympathetic
domized trial published in 2003, cilostazol increased blood vessel innervation of the distal ulnar artery.39 The investigators found
diameter in patients with primary and secondary Raynaud phe- that by 1.5 years after adventitial stripping of the proximal radial
nomenon but did not bring about any improvement in symp- and ulnar arteries with resection of the nerve of Henle, all ischemic
toms.32 In smaller studies, some success was achieved with tissue ulcerations had resolved.
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non, or scleroderma spectrum disorders. J Rheu- roderma: clinical and biochemical findings in a doscopic thoracic sympathicotomy for Raynaud’s
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13. Jennings JR, Maricq HR, Canner J, et al: A ther- trolled trial. Arthritis Rheum 42:2646, 1999 37. Adams DCR, Wood SJ, Tulloh BR, et al: Endo-
mal vascular test for distinguishing between pa- 25. Seibold JR: Serotonin and Raynaud’s phenome- scopic transthoracic sympathectomy: experience
tients with Raynaud’s phenomenon and healthy non. J Cardiovasc Pharmacol 7(suppl 7):S95, in the southwest of England. Eur J Vasc Surg
controls. Raynaud’s Treatment Study Investiga- 1985 6:558, 1992
tors. Health Psychol 18:421, 1999 38. O’Brien BM, Kumar PA, Mellow CG, et al:
26. Coleiro B, Marshall SE, Denton CP, et al:
14. Kanetaka T, Komiyama T, Onozuka A, et al: Treatment of Raynaud’s phenomenon with the Radical microarteriolysis in the treatment of
Laser Doppler skin perfusion pressure in the selective serotonin reuptake inhibitor fluoxetine. vasospastic disorders of the hand, especially scle-
assessment of Raynaud’s phenomenon. Eur J Rheumatology (Oxford) 40:1038, 2001 roderma. J Hand Surg [Br] 17:447, 1992
Vasc Endovasc Surg 27:414, 2004 39. Balogh B, Mayer W, Vesely M, et al: Adventitial
27. Coffman JD, Clement DL, Creager MA, et al:
15. Miller D, Waters DD, Warnica W, et al: Is variant International study of ketanserin in Raynaud’s stripping of the radial and ulnar arteries in
angina the coronary manifestation of a general- phenomenon. Am J Med 87:264, 1989 Raynaud’s disease. J Hand Surg [Am] 27:1073,
ized vasospastic disorder? N Engl J Med 2002
304:763, 1981 28. Hummers LK, Wigley FM: Management of
Raynaud’s phenomenon and digital ischemic 40. Ekenvall L, Lindblad LE, Norbeck O, et al:
16. O’Keeffe ST, Tsapatsaris NP, Beetham WP Jr: lesions in scleroderma. Rheum Dis Clin North alpha-Adrenoceptors and cold-induced vasocon-
Increased prevalence of migraine and chest pain Am 29:293, 2003 striction in human finger skin. Am J Physiol
in patients with primary Raynaud disease. Ann 255:H1000, 1988
Intern Med 116:985, 1992 29. Mohrland JS, Porter JM, Smith EA, et al: A mul-
ticlinic, placebo-controlled, double-blind study 41. Freedman RR, Baer RP, Mayes MD: Blockade of
17. Allen E, Brown G: Raynaud’s disease: a critical of prostaglandin E1 in Raynaud’s syndrome. Ann vasospastic attacks by α2-adrenergic but not α1-
review of the minimal requisites for diagnosis. Rheum Dis 44:754, 1985 adrenergic antagonists in idiopathic Raynaud’s
Am J Med Sci 183:187, 1932 disease. Circulation 92:1448, 1995
30. Badesch DB, Tapson VF, McGoon MD, et al:
18. LeRoy EC, Medsger TA Jr: Raynaud’s phenom- Continuous intravenous epoprostenol for pul- 42. Furspan PB, Chatterjee S, Freedman RR:
enon: a proposal for classification. Clin Exp monary hypertension due to the scleroderma Increased tyrosine phosphorylation mediates the
Rheumatol 10:485, 1992 spectrum of disease: a randomized, controlled cooling-induced contraction and increased vas-
19. Cutolo M, Grassi W, Matucci Cerinic M: Ray- trial. Ann Intern Med 132:425, 2000 cular reactivity of Raynaud’s disease. Arthritis
naud’s phenomenon and the role of capillaros- 31. Russell IJ, Lessard JA: Prazosin treatment of Rheum 50:1578, 2004
copy. Arthritis Rheum 48:3023, 2003 Raynaud’s phenomenon: a double blind single 43. Turton EP, Kent PJ, Kester RC: The aetiology of
20. Block JA, Sequeira W: Raynaud’s phenomenon. crossover study. J Rheumatol 12:94, 1985 Raynaud’s phenomenon. Cardiovasc Surg 6:431,
Lancet 357:2042, 2001 32. Rajagopalan S, Pfenninger D, Somers E, et al: 1998
21. Freedman RR, Ianni P, Wenig P: Behavioral Effects of cilostazol in patients with Raynaud’s 44. Zamora MR, O’Brien RF, Rutherford RB, et al:
treatment of Raynaud’s disease: long-term fol- syndrome. Am J Cardiol 92:1310, 2003 Serum endothelin-1 concentrations and cold pro-
low-up. J Consult Clin Psychol 53:136, 1985 33. Hart DA, Fritzler MJ: Regulation of plasmino- vocation in primary Raynaud’s phenomenon.
22. Raynaud’s Treatment Study Investigators. Com- gen activators and their inhibitors in rheumatic Lancet 336:1144, 1990
6 VASCULAR SYSTEM 25 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 1
25 UPPER-EXTREMITY
REVASCULARIZATION PROCEDURES
John Byrne, M.CH., F.R.C.S.I.(Gen), Philip S. K. Paty, M.D., F.A.C.S., and R. Clement Darling III, M.D., F.A.C.S.
Vascular surgeons are commonly called on to treat patients with years).6 Usually, there is an underlying embolic source (e.g., car-
acute arm ischemia. Elective arm revascularization is an infre- diac dysrhythmia). Most arm emboli (75%) are of cardiac origin.
quently performed procedure, one that usually prompts surgeons The brachial artery is the most common site of emboli (60% of
to resort to reference texts. Even in busier centers, elective arm cases), followed by the axillary artery (26%). In situ thrombosis
reconstructions currently account for only 3.2% of elective limb accounts for 5% of episodes of arm ischemia.7
revascularizations. Balloon angioplasty has largely replaced surgi-
cal bypass in the treatment of subclavian occlusions; however, the Selection of patients All patients with acute-onset arm
very growth of endoluminal approaches to arm revascularization ischemia are candidates for embolectomy. Conservative manage-
has led to a paradoxical increase in the need for so-called prophy- ment should be considered only for patients who are terminally ill
lactic carotid-subclavian bypass in patients with thoracic aneurysms. or unfit for surgical intervention.
In addition, the rising incidence of diabetes and the longer survival
times reported in patients with renal impairment have led to Alternative therapy Some authors have achieved good re-
increased use of distal bypass procedures in the arm (analogous to sults by using thrombolysis to treat acute occlusion of the axillary
pedal bypass procedures in the leg [see 6:18 Infrainguinal Arterial artery or the brachial artery.8 However, in a 2001 series that in-
Procedures]). Finally, the growing number of dialysis access proce- cluded 38 patients with 40 occlusions treated with thrombolysis,
dures performed has led to an increased incidence of arm ische- the success rate of this approach was only 55%, and eight patients
mia resulting from these operations. had to undergo surgical thrombectomy after thrombolysis failed.9
In this chapter, we describe the technical aspects of the proce- Excellent outcomes have also been reported for the treatment of
dures employed for emergency and elective arm revascularization. acute arm ischemia with rotational thrombectomy devices (e.g.,
We also touch on pharmacologic alternatives to elective revascu- Rotarex; Straub Medical, Wangs, Switzerland). To date, however,
larization and briefly consider the potential role of minimally inva- no large published studies have evaluated these devices, and clini-
sive techniques (e.g., thoracoscopic sympathectomy). cal experience with them is currently limited to case reports.10
Operative Planning
Procedures for Acute Arm Ischemia In most patients with acute arm ischemia, diagnosis is straight-
Acute arm ischemia accounts for one fifth of all episodes of forward and surgical treatment relatively easy. Some instances of
acute limb ischemia. It occurs twice as often in females as in males. acute arm ischemia, however, are caused by an inflow lesion in the
Brachial embolectomy is the most common treatment. After suc- subclavian artery (SA) (e.g., from ulcerated plaques, a throm-
cessful brachial embolectomy, 95% of patients are symptom free1; bosed SA aneurysm, or an arterial thoracic outlet syndrome). In
however, the operative mortality may be as high as 12%.2 Most re- such situations, even a technically perfect embolectomy will fail to
ports that address acute arm ischemia include only those patients restore normal hand perfusion.
who are treated surgically. In fact, between 9% and 30% of The majority of brachial embolectomies are performed with
patients who present to vascular surgeons with acute arm ischemia local anesthesia, with or without monitored conscious sedation.
are managed conservatively, either because they are unfit for sur-
Operative Technique
gery or because they have minimal symptoms.These conservatively
managed patients are probably underrepresented in the literature. The origins of the ulnar and radial arteries are exposed by means
In the few reported series, assessment of symptoms and disability of a so-called lazy S incision [see Figure 1a], which prevents the
has been largely inconsistent. However, in a 1964 series that in- elbow contracture that can occur with a vertical incision. The skin
cluded 95 patients, 32% of those who were managed conservative- and the subcutaneous tissues are divided. Care is taken to preserve
ly were left with abnormal function in the arm after treatment.3 In the superficial veins, especially the median antecubital vein, which
a 1977 report, 75% of the conservatively managed patients had may be needed to patch the brachial artery. The bicipital fascia is
poor functional outcomes.4 In a 1985 study, 50% of the conser- incised, and the brachial artery is found between the tendon of the
vatively managed patients had persistent forearm claudication.5 biceps laterally and the median nerve medially [see Figure 1b].
The conclusion to be drawn is that although conservative manage- Dissection is continued distally until the ulnar and radial arteries
ment is appropriate for some patients with acute arm ischemia, are encountered.The radial artery is a continuation of the brachial
every effort should be made to restore blood flow in patients who artery; the ulnar artery comes off the brachial artery medially and,
have a reasonable life expectancy. within 2 to 3 cm of its origin, dives beneath the pronator and
epitrochlear muscles. It is important to expose the origins of both
BRACHIAL EMBOLECTOMY
forearm arteries because the embolectomy catheter must be passed
down each vessel. If the catheter is blindly passed down the brachial
artery, it will probably travel down the radial artery.
Patients with acute arm ischemia tend to be slightly older at pre- An arteriotomy (usually vertical) is made in the brachial artery.
sentation than patients with leg ischemia (74 years versus 70 Clot may be encountered at the bifurcation; if so, it is readily
a tained a further embolic episode, and all had ongoing atrial fibril-
lation.6 Patients are routinely followed up by means of noninvasive
studies 4 to 6 weeks after operation.
FOREARM FASCIOTOMY
b Unlike calf fasciotomies, which are commonly necessary for leg
ischemia, forearm fasciotomies are rarely required for acute arm
ischemia.They are more commonly required for traumatic injuries
to the arm (e.g., crush injuries or supracondylar fractures of the
Musculocutaneous
Nerve
humerus) or for iatrogenic injuries (e.g., inadvertent infusion of
fluid into the muscle compartments of the forearm). Forearm fas-
Radial ciotomies are immediately effective when they are performed, and
Nerve the incisions, though extensive, usually heal quickly.
The forearm muscles are typically tense and tender, though the
diagnosis can be difficult to make. One option for assessment is to
test compartment pressures with a needle and a transducer; if the
intracompartmental pressure is higher than 30 mm Hg, fascioto-
Radial Artery my may be indicated. Another option is insonation of the radial
and ulnar arteries; if the signal is absent or severely obstructed,
fasciotomy may be indicated. Neither of these techniques, howev-
er, is reliable. As with lower-extremity ischemia, even the finding
Median
Nerve
of a pulse does not eliminate the need for fasciotomy.The decision
whether to perform the procedure is made on clinical grounds.11
The relevant dictum is “If one is thinking about a fasciotomy, it is
probably indicated.”
Brachial
Artery Selection of patients Awareness of the diagnosis is crucial.
Bicipital Any patient with the traumatic or iatrogenic conditions previous-
Aponeurosis ly mentioned (see above) should be considered to be at risk for
compartment syndrome.
Ulnar Artery
Alternative therapy There is no alternative to fasciotomy.
Failure to recognize the problem or undue delay in performing
adequate fasciotomies will lead to forearm muscle ischemia and a
Volkmann’s ischemia contracture, resulting in a useless hand.
Figure 1 Brachial embolectomy. Shown are (a) a lazy S skin inci-
sion and (b) the main nerves and vessels exposed. Operative Planning
Because this procedure is rarely performed, the surgeon may
find it useful to mark the incisions on the skin with an indelible
removed. In some cases, the brachial artery is pulseless, which indi- pen before operation. The operation is generally performed with
cates that the embolus is lodged more proximally. Once inflow is general anesthesia, but if the patient is profoundly ill, it may be
established, a size 2 or 3 embolectomy catheter is passed distally performed with local anesthesia instead.
down each forearm artery. The arteriotomy is then closed either
primarily or with a vein patch. A segment of vein may be harvest- Operative Technique
ed from the antecubital fossa. Adequate flow in the radial and ulnar Both a volar and a dorsal incision are required [see Figure 2];
arteries is confirmed by means of an intraoperative Doppler probe. there is no single-incision option, as there is for leg fasciotomy. On
Occasionally, the hand continues to appear ischemic even after the volar aspect of the arm, a curvilinear incision is made to allow
an adequate embolectomy. This persistent ischemia is caused decompression of the flexor compartment. Because this compart-
either by an unrecognized inflow lesion or by embolization to the ment is supplied by a single vessel (the interosseous artery) and
digital arteries that has been occurring over an extended period. lacks any collateral circulation, it is particularly susceptible to
In these patients, an arch aortogram with selective views of the ischemia. On the dorsal aspect, a vertical incision is made to
affected arm should be performed immediately after operation. release the dorsal compartment. Because of its deep location in the
Any lesion in the SA or the innominate artery can be treated with forearm, the median nerve is especially susceptible to compart-
angioplasty and stenting. ment syndrome. At the level of the elbow, the bicipital aponeuro-
sis is divided so that it can be decompressed. At the wrist, the flex-
Postoperative Care
or retinaculum is divided in much the same way as in a carpal tun-
The mainstay of postoperative management is adequate antico- nel decompression. In severe cases, the deep intramuscular fascia
agulation. Embolization recurs after successful embolectomy in enveloping the flexor digitorum superficialis, the flexor digitorum
one third of patients if systemic anticoagulation is not instituted. profundus, and the flexor pollicis longus may be opened as well.
It may recur even in the face of oral anticoagulation: in a 1989 As a rule, the skin incisions are loosely approximated to facilitate
study, 11% of patients given warfarin after embolectomy sus- later closure. In any case, the incisions usually heal very well.
Postoperative Care
reasons, may not be candidates for endovascular procedures
Regular dressings are applied to the area. Often, delayed prima- (e.g., those with an occluded stent and those in whom the anato-
ry closure of the fasciotomy sites may be performed once the mus- my is unsuitable). In patients for whom it is indicated, innomi-
cle edema has resolved. Further pressure measurements may be nate artery bypass has durable beneficial effects and thus is an
performed to confirm that all muscle compartments have been option worth considering, despite its potential for significant
released. morbidity.
Procedures for Chronic Arm Ischemia Arm ischemia is the typical presentation for patients with
The etiology of chronic arm ischemia is diverse. Although ath- innominate artery occlusion. Cerebrovascular symptoms related
erosclerosis is still the major cause, other potential causes (includ- to the vertebral or carotid arteries are the second most common
ing thoracic outlet syndrome and iatrogenic injury, as well as rarer presentation.
causes such as Takayasu arteritis, giant cell arthritis, and radiation- In many patients, noninvasive imaging yields the first indication
induced injury) must also be considered. Initial assessment is car- of innominate artery stenosis. It is difficult, however, to distinguish
ried out by means of noninvasive studies (e.g., pulse-volume between an occlusion in the proximal SA and one in the innomi-
nate artery on a duplex ultrasonogram. Contrast angiography is
recordings [PVRs] and duplex ultrasonography), followed by
the gold standard for making this distinction. As with all major
magnetic resonance angiography (MRA) or computed tomo-
vascular procedures, standard cardiac investigations and clearance
graphic angiography (CTA). Confirmation of the findings
are mandatory.
obtained from these studies may be obtained by means of arch
and arm angiography. As a rule, any occlusive lesions found will be Selection of patients Innominate artery bypass is the oper-
in the innominate, subclavian, axillary, or forearm arteries. Each ative standard for selected patients with upper-extremity ischemia.
location calls for a different treatment stratagem. In patients who are at particularly high risk, however, extrathoracic
AORTOSUBCLAVIAN BYPASS AND EXTRATHORACIC options (e.g., carotid-carotid bypass or, rarely, axilloaxillary
OPTIONS FOR INNOMINATE ARTERY OCCLUSION crossover grafting) should be considered.We prefer carotid-carotid
crossover for higher-risk patients. Cerebrovascular considerations
Innominate artery reconstruction is a major surgical proce- (e.g., asymptomatic high-grade lesions [i.e., > 70% occlusion] or
dure. In one major series, the reported operative mortality was ulcerated plaques with greater than 50% luminal narrowing) may
5.4%.12 Currently, innominate artery bypass is rarely performed, also warrant intervention.
having been largely supplanted by balloon angioplasty and stent-
ing. Nevertheless, there are still some patients who, for technical Alternative therapy Indirect or extra-anatomic approaches
to innominate artery reconstruction include axilloaxillary
crossover grafting, carotid-carotid crossover, and femoroaxillary
bypass. In general, these approaches are reserved for higher-risk
patients in whom endovascular therapy is not an option.
Operative Planning
Operative planning must take into account relevant anatomic
details. It is important to keep in mind that the anatomy of the aor-
Areas of Maximum tic arch is not invariable: in 30% of patients, there are variations in
Compression of
the arch anatomy that may make innominate artery bypass more
Median Nerve
difficult.The most common variation is an innominate artery that
branches into a right common carotid artery (CCA) and a right
SA, with the right CCA and the right SA coming directly off the
arch. In 16% of patients, however, the innominate artery and the
right CCA may have a common ostium. In 8% of patients, the left
CCA comes off the innominate artery, leaving the left SA as the
only other artery coming off the arch. In 6% of patients, the left
vertebral artery comes off the arch between the left CCA and the
left SA. In fewer than 1% of patients, the right SA comes off the
descending aorta as the last arch branch, then travels behind the
esophagus (as the retroesophageal right SA) to reach the right
supraclavicular fossa.13
Operative Technique
The innominate artery is approached via a median sternoto-
my.14 A sternal retractor is placed and opened. The thymus is
divided along its midline with the electrocautery, and the inferior
thymic vein is ligated and divided. The brachiocephalic vein is
identified as it crosses the innominate artery, then mobilized and
Volar Incision Dorsal Incision
placed in a vessel sling. The pericardium is opened from the ven-
Figure 2 Forearm fasciotomy. Shown are (a) a volar incision tricular surface to a point just below the origin of the innominate
and (b) a dorsal incision in the forearm. artery. It is held away from the operative field with stay sutures.
Right Common Left recovery, patients are followed by means of noninvasive graft
Carotid Artery Brachiocephalic surveillance.
Vein Left Common
Carotid Artery CAROTID-SUBCLAVIAN BYPASS OR TRANSPOSITION
Most patients with SA stenosis or occlusion require no treat-

Right ment. In many cases, overt symptoms are absent, and the diagno-
Subclavian
Artery
sis is made serendipitously when a reduced pulse pressure is
encountered in one arm. For patients with symptomatic lesions,
balloon angioplasty with stent insertion is currently the treatment
of choice, having been shown to be a durable and effective thera-
py.15,16 Elective bypass is typically reserved for lesions that are not
amenable to balloon angioplasty. As stenting of thoracic aortic
aneurysms becomes more common, however, stents are increasing-
ly being applied across the origin of the left SA to facilitate proxi-
mal fixation, which means that a carotid-subclavian transposition
or bypass is required to maintain flow.Thus, the growth of endovas-
cular surgical treatment of thoracic aortic aneurysms has, paradox-
ically, created a growing population of patients who require a
carotid-subclavian bypass. It is important, therefore, that this pro-
Aortic Arch cedure remain part of the armamentarium of all vascular surgeons.
A healthy CCA is an excellent inflow source for an SA bypass
procedure. Before operation, the CCA should be evaluated with
duplex ultrasonography, supplemented by arteriography. Aortic
arch anomalies (e.g., the presence of a bovine aortic arch) should
be identified. In patients with contrast allergies or renal impair-
ment, MRA may be employed. In the future, CTA may prove to
be the modality of choice.
Figure 3 Innominate artery bypass. One end of the graft is sewn
to the aorta in an end-to-side fashion, and the other is sewn to the Selection of patients It is important to confirm that arm
common ostium of the right SA and the right CCA in an end-to- symptoms are in fact caused by subclavian disease. In young
end fashion. patients, the possibility of thoracic outlet syndrome should be con-
sidered. In older patients, the differential may include cervical disc
problems or osteoarthritis. In patients with thoracic aortic
The ascending aorta is then exposed. Fat and visceral pericardium aneurysms, our threshold for treatment is a diameter of 5 cm.
are cleared from the anterior and lateral walls of the aorta to allow Given the complexity of the anatomy and the potential for nerve
placement of a partial exclusion clamp. injury, some surgeons are reluctant to perform carotid-subclavian
The brachiocephalic vein is retracted downwards, and dissec- bypass or transposition, instead favoring axilloaxillary crossover
tion is continued distally along the innominate artery toward the grafting. However, axilloaxillary crossover has a lower patency rate
origins of the right SA and the right CCA. Care must be taken to than carotid-subclavian bypass or transposition, and its subcuta-
keep from injuring any major nerves, particularly the right recur- neous placement and prominence make it less acceptable to most
rent laryngeal nerve. patients. In addition, instances of erosion through the skin have
Some authors have employed a partial median sternotomy been reported.
approach to the innominate artery, which is useful when access to
the distal half of the innominate artery is required and access to Alternative therapy Subclavian artery balloon angioplasty
the ascending aorta is not required. The advantage of this is less invasive than surgical bypass and is a durably effective pro-
approach is that it preserves the lower sternum, thereby enhancing cedure that is well tolerated by most patients.17 However, patients
the stability of the chest and reducing postoperative pain.The inci- who have recurrent stenosis or whose lesions are too close to the
sion extends only to the fourth intercostal space. vertebral arteries may not be candidates for angioplasty. For such
After heparinization, a partial exclusion clamp is placed on the patients, prosthetic bypass or reimplantation of the subclavian
ascending aorta, and an arteriotomy is made. An 8 mm graft is artery is an ideal option. The temptation to perform a lesser pro-
sutured to the aorta in an end-to-side fashion with 3-0 or 4-0 cedure (e.g., axilloaxillary bypass) should be resisted.
polypropylene. If the innominate artery is occluded, the right
Operative Planning
CCA and the right SA are clamped, and the innominate artery is
divided and oversewn. The graft is then sewn to the common The two key considerations in the planning of the operation are
ostium of the SA and the CCA in an end-to-end fashion [see (1) whether to perform a bypass or a transposition and (2), if a
Figure 3]. Flow is confirmed with a Doppler probe, as with all the bypass is chosen, whether to use autologous vein or synthetic
reconstructions we describe in this chapter. material as the conduit. For a bypass, prosthetic grafts, being short
and of large caliber, are generally considered preferable to autolo-
Postoperative Care
gous vein grafts18,19: they are less likely to become kinked or give
After the operation, patients are observed in the intensive rise to intrinsic disease, and the long-term patency of prosthetic
care unit. In general, anticoagulation is not indicated. After reconstructions is excellent.
Transposition of the SA is an excellent alternative to carotid- constructed. The CCA is mobilized so that once two straight vas-
subclavian bypass, with long-term patency rates approaching cular clamps are placed and rotated anteriorly, the graft-CCA
100%.20 Preoperative consent should include acknowledgment of anastomosis may be performed more easily. Once the bypass has
the potential for injury to the phrenic nerve or the brachial plexus. been completed, flow is restored—first to the arm, then to the
proximal SA, and finally to the distal CCA, so as to minimize the
Operative Technique
carriage of embolic debris to the brain. Flow should then be
The patient is placed in the supine position, with a towel roll assessed with a pencil Doppler probe.
placed between the scapulae. The neck is tilted toward the con- After completion of the bypass, the scalene fat pad is tacked to
tralateral shoulder. A transverse incision is made 1 cm superior to its former medial and inferior attachments; failure to do so may
the clavicle.The underlying platysma and the lateral portion of the leave a visible defect in this area. The wound is drained with a
sternocleidomastoid muscle are divided in the line of the incision. closed suction apparatus. An upright chest x-ray is obtained to rule
The underlying omohyoid muscle and the external jugular veins out pneumothorax or hemidiaphragmatic elevation secondary to
are divided, and the scalene fat pad is mobilized and retracted lat- phrenic nerve injury. Postoperative evaluation of bypass patency is
erally and cephalad. Minor lymphatic vessels are identified and li- accomplished by physical examination with palpation of pulses at
gated. The internal jugular vein is visible medially in the carotid the wrist. Further objective documentation of patency is obtained
sheath, and the carotid artery is usually situated posteriorly. Every by means of PVRs, duplex ultrasonography, or both.
effort should be made to keep from injuring the vagus nerve and Postoperative Care
the thoracic duct on the left; the risk of thoracic duct injury may
be minimized by not dividing the lymphatic tissue lying between The major postoperative complication is phrenic nerve injury
the phrenic nerve and the lateral border of the internal jugular and resulting paralysis of the hemidiaphragm [see 4:3 Paralyzed
vein. The anterior scalene muscle is divided as far caudad as pos- Diaphragm]. Another significant complication is lymphatic leakage,
sible to reveal the SA; care must be taken to avoid the overlying which may occur as a result of either minor or major duct injury.
phrenic nerve, which courses diagonally in a lateral-to-medial Adequate wound drainage and prompt recognition of the lymphat-
direction along the anterior surface of the muscle. ic leak are the keys to management. Minor leaks usually seal with
A bypass from the CCA to the SA is then performed in an end- adequate drainage. If drainage is excessive, the patient will have to
to-side fashion with a 6 mm or 8 mm prosthetic graft [see Figure be maintained on parenteral nutrition with a formula that includes
medium-chain triglycerides. On occasion, thoracic duct ligation via
4]. The graft is usually tunneled under the internal jugular vein.
thoracotomy or thoracoscopy may be necessary. Other complica-
Often, the graft-SA anastomosis is constructed first. A clamp is
tions include pneumothorax, brachial plexus injury, and stroke.
placed on the proximal graft, and the anastomosis to the CCA is
Patients are followed with serial PVRs of the arm and duplex
ultrosonography of the grafts.
Vertebral Inferior Superficial
Thyroid Cervical AXILLOBRACHIAL BYPASS
Artery Phrenic
Artery Artery
Left Nerve Axillobrachial bypass may be performed to treat severe occlu-
Common sive disease in the axillary or proximal brachial arteries. It is infre-
Carotid Artery Suprascapular
Artery
quently performed for chronic ischemia and more frequently per-
formed for shoulder trauma. In the latter setting, it is often associ-
ated with brachial plexus injuries.
Axillobrachial bypass is not commonly performed on an elec-
tive basis. The axillary and proximal brachial arteries seem to be
remarkably impervious to the effects of systemic atherosclerosis. In
those rare cases in which this procedure is indicated, preoperative
evaluation of the affected arm with selective angiography is appro-
priate.Vein mapping should be performed. It is important to con-
firm that the patient’s symptoms derive from arm ischemia and
not from other conditions (e.g., neuropathy).
Alternative therapy If arm ischemia is truly symptomatic at

this level, sympathectomy may be considered [see Alternative
Therapies for Chronic Arm Ischemia, below]. Angioplasty may be
an option for axillary artery lesions, but it is infrequently per-
formed in this setting, and data on its effectiveness and durability
are relatively sparse.
Left Subclavian Artery Operative Planning
Autogenous vein is the conduit of choice for axillobrachial bypass.
Left Subclavian Vein Prosthetic bypasses have lower patency rates than venous bypasses
Figure 4 Carotid-subclavian bypass. One end of the graft is sewn in this setting and should therefore be avoided.The greater saphe-
to the left SA in an end-to-side fashion, and the other is sewn to nous vein is the preferred source of the venous conduit, though the
the left CCA in an end-to-side fashion. use of the cephalic vein in situ has also been described.
Axillary Vein
Axillary Artery
Saphenous Vein Graft
Brachial Artery
Pectoralis
Major
Figure 5 Axillobrachial bypass. Shown is the
completed bypass, with the greater saphenous
vein tunneled subcutaneously.
Operative Technique
within the sheath. It is gently mobilized and retracted to afford
The patient is placed in the supine position, and the arm is access to the brachial artery. Any venous branches that cross the
draped circumferentially. A previously mapped leg is draped in artery should be divided carefully, and every effort should be
preparation for vein harvesting. The axillary artery is approached made to keep from injuring the posteriorly located ulnar nerve.
via a transverse incision placed 2 cm below the middle third of the In contrast, the distal third of the brachial artery and its bifur-
clavicle. The underlying pectoralis major is divided in the line of cation are exposed in the antecubital fossa. A lazy S or sigmoid
the decussation between its sternocostal and clavicular portions. incision [see Figure 1a] is made to expose the brachial artery while
Despite the assurances of most operative texts, the decussation is avoiding wound contracture. The bicipital aponeurosis is then
not always readily apparent. Division of the pectoralis major incised to expose the brachial artery, which is sandwiched
exposes the clavipectoral fascia, which is then divided.The axillary between the biceps tendon laterally and the median nerve medi-
artery is identified cephalad to the axillary vein and is carefully dis- ally. Further dissection exposes the origins of the ulnar and radi-
sected, with care taken not to injure the surrounding branches of al arteries.
the brachial plexus. The second part of the axillary artery is After systemic heparinization, the venous conduit is harvested,
exposed by dividing the pectoralis minor. and its side branches are ligated with fine polypropylene suture lig-
If necessary, the distal third of the axillary artery may be exposed. atures or silk ties.The vein is distended with a solution containing
An oblique incision is made along the lateral margin of the pec- dextrose 70 (500 ml I.V.), heparin (1,000 U), and papaverine (120
toralis major with the arm abducted 90° relative to the thorax. Once mg).The excised conduit may be employed in either a reversed or
the subcutaneous tissue is divided, the axillary sheath is located near an orthograde (nonreversed) orientation, depending on the taper
the posteroinferior border of the coracobrachialis. Care should be of the conduit. If the orthograde orientation is used, the proximal
taken to keep from injuring the medial and lateral cords of the anastomosis is performed, the conduit is distended, and the valves
brachial plexus medially and the median and ulnar nerves laterally. are lysed with a retrograde Mills valvulotome. In either case, the
By preference, bypasses originating from the axillary artery are conduit is tunneled anatomically wherever possible; in this way, it
tunneled anatomically along the axis of the axillary and brachial will be less prone to movement, distraction, or distortion. After
arteries. Alternatively, they may be positioned subcutaneously; tunneling, the distal anastomosis is constructed [see Figure 5].
however, subcutaneous bypasses are more susceptible to distrac- Immediately upon completion of the bypass, patency and aug-
tion injuries caused by forcible abduction of the shoulder. Accord- mentation of flow are assessed with a pencil Doppler probe.
ingly, some degree of redundancy should be built into a subcuta- Major potential complications include injuries to the brachial
neous bypass. plexus, the median nerve, or the ulnar nerve. Such injuries usual-
The middle or the distal portion of the brachial artery is ly are caused by traction and may be minimized by careful dissec-
exposed as necessary.The proximal or the middle third of the ves- tion during operative exposure.The median and ulnar nerves and
sel is exposed by making a medial incision over the bicipital the brachial plexus are also vulnerable to direct thermal injury;
groove, with care taken to keep from injuring the basilic vein and accordingly, dissection with the electrocautery should be avoided.
the cutaneous nerves located within the subcutaneous tissue. Postoperative Care
Traction on or transection of the median antebrachial cutaneous
nerve may lead to hyperesthesia or anesthesia along the medial Postoperatively, the patency of the bypass is documented by
dorsal surface of the forearm; these problems occasionally occur surveillance with noninvasive studies. In general, duplex ultra-
after dialysis access procedures (e.g., basilic vein transposition) sonography is valuable for determining the patency of the recon-
and can be highly debilitating, sometimes even rendering the fis- struction and for detecting any early flow abnormalities in the
tula unusable. The brachial sheath is then incised longitudinally. venous conduit. Graft infection should be watched for and appro-
The median nerve is the most superficial structure encountered priately treated if found.
DISTAL REVASCULARIZATION–INTERVAL LIGATION

AND REVISION USING DISTAL INFLOW
smaller distal artery as the inflow source, RUDI lengthens the fis-
tula and preserves antegrade flow in the brachial artery.
The rising incidence of diabetes in the United States has led to Of the two options, DRIL is better established and more wide-
a corresponding rise in the number of patients in whom vascular ly used at present. It is our preferred option and thus is the prima-
access is required for hemodialysis.21,22 As reconstructions become ry focus of the ensuing description. Nevertheless, there are aspects
more complex, these patients are increasingly coming under the of the DRIL procedure that many vascular surgeons find counter-
care of vascular surgeons. An unfortunate consequence of the intuitive—namely, the ligation of a healthy artery and the bypass-
growing number of upper-arm fistulas is that the incidence of dial- ing of a normal arterial segment with a venous conduit.There does
ysis-associated steal syndrome (DASS) is increasing as well. DASS seem to be a good argument in favor of RUDI. Long-term evalu-
is rare after Cimino or radiocephalic fistula procedures,23 but it ation of this procedure is awaited.
occurs in 6% to 8% of patients who undergo upper-arm brachial
artery–based fistula or graft procedures.24,25 DASS may present in
either an acute form (characterized by severe rest pain and obvi- Preoperative evaluation for DRIL should follow the same pat-
ous ischemia developing within 24 to 48 hours after operation) or tern as that for any elective procedure performed to treat arm or
a chronic form (characterized by symptoms and signs developing leg ischemia. Preoperative angiography is performed with vein
several weeks or even months after the original operation), each of mapping to identify an adequate source of a venous conduit.
which is managed in its own distinct fashion. Cardiac clearance is obtained.
In cases of acute ischemia that develops within 24 to 48 hours
after an upper-arm fistula procedure, the fistula should be ligated Selection of patients DRIL is generally reserved for patients
to restore flow down the native arteries. In cases of chronic with chronic arm ischemia in whom a fistula has been established
ischemia, however, the aim is to preserve the fistula and avoid li- that must be preserved. If the option of creating a new fistula in
gation.To this end, there are two main surgical options that should the other arm is available, DRIL is probably a less appropriate
be considered. The first option is distal revascularization–interval choice than simply ligating the original fistula.
ligation (DRIL), which involves the creation of a venous bypass
from the proximal portion of the brachial artery to the distal por- Alternative therapy Besides simple ligation of the offending
tion of the vessel [see Figure 6].The brachial artery distal to the ori- fistula, which is an option that should always at least be considered
gin of the fistula is ligated, flow to the distal arm is restored, and in these patients, there are two techniques that deserve mention as
the fistula is preserved.26 The second option is revision using dis- alternatives to DRIL. The first technique is aimed at preventing
tal inflow (RUDI), which involves ligation of the fistula at its ori- steal from an upper-arm fistula (always a laudable aim). In this
gin, followed by reestablishment of the fistula by means of a technique, the fistula is formed by extending the cephalic vein or
venous bypass from the radial or the ulnar artery.27 By using a the basilic vein down the arm and anastomosing it to the proximal
ulnar artery or the radial artery just below the brachial bifurcation
so as to preserve part of the blood supply to the hand. The medi-
Brachial
a b Artery
an cubital vein may also be used.28
Brachial
The second technique is RUDI [see Figure 7]. This procedure
Artery
differs from DRIL in that it is the fistula, not the native arterial
Vein supply, that is placed at risk by the surgical revision, so that in
Saphenous the event of graft failure, the fistula is lost but the arm is not
Vein Graft endangered.
Operative Planning
Fistula
We do not use prosthetic grafts for this procedure; we prefer to
Cephalic or
use autogenous vein for the graft, usually a segment of the greater
Basilic Vein saphenous vein from the leg. As a rule, the operation is performed
with the patient under general anesthesia.
Ulnar Ulnar Operative Technique
Artery Artery
Radial A vertical incision is made in the upper arm at the level of the
Artery proximal brachial artery. The skin and the subcutaneous fat are
Radial
divided, and the proximal brachial artery is sharply dissected free.
Artery
The portion of the brachial artery distal to the origin of the fistu-
la is also dissected free. An adequately long segment of vein is
obtained and prepared. Anticoagulation is initiated, and a proxi-
mal end-to-side anastomosis is fashioned with 6-0 polypropylene.
The vein graft is tunneled subcutaneously, and a distal end-to-end
Pre-DRIL Post-DRIL anastomosis to the distal brachial artery is created. Some surgeons
prefer an end-to-side distal anastomosis with ligation of the
Figure 6 Distal revascularization–interval ligation (DRIL). In
brachial artery proximal to the anastomosis. Adequate flow is con-
patients with a brachial artery–based fistula (a), chronic ischemia
may develop weeks or months after the procedure. The best estab-
firmed by means of intraoperative Doppler ultrasonography.
lished surgical treatment option is DRIL (b), which preserves the Postoperative Care
fistula by creating a venous bypass between the proximal brachial
artery (above the origin of the fistula) and the distal brachial Postoperative anticoagulation is generally not warranted; how-
artery. ever, a postoperative graft surveillance protocol is initiated. If the
a b consideration. Vascular reconstruction offers a chance to gain

Brachial
both. The alternative to attempted arm salvage is amputation.
Brachial Artery
Artery
Selection of patients At our institution (Albany Medical
Oversewn
Center), all patients with rest pain, digital necrosis, or nonheal-
Cephalic or or Ligated ing ulcers are evaluated for possible palmar artery reconstruc-
Basilic Vein Fistula tion, provided that they are surgical candidates. Reconstruction
is feasible in approximately half of the patients who have renal
disease or diabetes.
Fistula
Cephalic or Alternative therapy Sympathectomy, in various incarna-
Basilic Vein tions, has been employed in the treatment of hand ischemia.
Ulnar
Artery Isolated reports of success notwithstanding, the experience of
most vascular surgeons with sympathectomy in this setting has not
Radial been favorable.
Artery Ulnar
Artery Operative Planning
Fortunately, exposure of the palmar vessels beyond the wrist is
Saphenous not as difficult as might be imagined [see Operative Technique,
Vein Graft
below]. Nevertheless, because hand bypass procedures are relative-
ly new territory for many vascular surgeons, operative planning
may benefit from a brief review of the normal anatomy.The hand
Radial
Artery
is supplied with blood by the superficial and deep palmar arches.
The superficial palmar arch is supplied by a branch of the radial
Pre-RUDI Post-RUDI
artery and by the ulnar artery. The deep palmar arch is supplied
Figure 7 Revision using distal inflow (RUDI). Another option by the radial artery itself and by a deep branch of the ulnar artery.
for patients with a brachial artery–based fistula (a) is RUDI (b), Venous grafts are preferred to prosthetic grafts for hand by-
which involves ligating the fistula at its origin, lengthening the
passes. All venous grafts are tunneled anatomically. In a radial
original venous graft with an additional vein segment, and
artery reconstruction, the graft is tunneled over the anatomic
reestablishing the fistula by anastomosing the lengthened graft to
the radial artery (as shown) or the ulnar artery. snuff box onto the dorsum of the hand, between the thumb and
the index finger, to join the deep palmar arch. In an ulnar artery
reconstruction, the venous graft takes a less circuitous course,
venous graft becomes occluded, the fistula is ligated.This step fre- passing superficial to the flexor retinaculum at the wrist to join
quently leads to resolution of the symptoms of arm ischemia. the superficial palmar arch.
HAND REVASCULARIZATION Operative Technique
Patients with rest pain in the hands and digital ulcers often have The donor limb that will provide the venous graft is prepared.
significant comorbid conditions (e.g., collagen vascular or The brachial artery is exposed as described previously [see Pro-
rheumatologic disorders, end-stage renal disease, or hypercoagu- cedures for Acute Arm Ischemia, Brachial Embolectomy, Oper-
lable states). In addition, patients who have received organ trans- ative Technique, above].
plants and are taking immunosuppressive medications may expe- The course of the radial artery in the forearm follows an oblique
rience severe occlusion of forearm or palmar arteries. Younger line from the brachial artery pulse medial to the biceps tendon to
patients with hand ischemia are often manual laborers who have the styloid process of the radius. In the midforearm, the radial
hypothenar hammer syndrome. Patients with established signs artery is medial to the brachioradialis and lateral to the flexor carpi
and symptoms of hand ischemia have little to lose by undergoing radialis. A lateral longitudinal incision is made, and the muscles
revascularization: there are few viable therapeutic alternatives. are separated to reveal the radial artery. At the wrist, the radial
Aggressive treatment of hand ischemia is worthwhile, in that it artery is exposed by making a longitudinal incision between the
achieves rapid relief of symptoms and offers the opportunity for tendon of the flexor carpi radialis and the tendon of the brachio-
hand and limb salvage. The techniques resemble those employed radialis.This is the site of the radial artery pulse in normal persons.
for distal bypass in the leg [see 6:18 Infrainguinal Arterial Proce- Here, the artery is superficial, and exposure is relatively straight-
dures]. Early results from several centers indicate that hand bypass forward. Care must, however, be taken not to injure the superficial
procedures can be performed with low morbidity and good long- branch of the radial nerve, which is often located near the lateral
term patency.29,30 Postoperative life expectancy, however, is often aspect of the artery. Injury to this nerve branch can result in trou-
limited by the comorbid conditions present. blesome paresthesia along the lateral aspect of the thumb.
The course of the ulnar artery runs from the medial epicondyle
of the humerus to the pisiform bone. In the midforearm, the ulnar
Preoperative evaluation for hand bypass should follow the same artery lies beneath the deep fascia between the belly of the flexor
protocol as that for any elective revascularization: preoperative digitorum laterally and the belly of the flexor carpi ulnaris medial-
angiography to delineate anatomy with vein mapping to identify a ly.The ulnar nerve joins the artery on its lateral aspect for the dis-
venous conduit. tal two thirds of the vessel’s length; this nerve may be injured if not
Many patients with hand ischemia have intractable pain from carefully identified and preserved. At the wrist, the ulnar artery is
ulcerative lesions, gangrene, or both. Their main requirement is lateral to the tendon of the flexor carpi ulnaris. It is exposed by
adequate relief of pain; improved hand function is a secondary locating this tendon (which is the most medial tendon palpable at
a
First Dorsal
Interosseous
Muscle
Radial
Artery
Figure 8 Hand revascularization. (a) Shown is exposure of the distal

radial artery. (b) The deep palmar arch is exposed via an incision made
across the medial border of the thenar eminence.
the wrist) and making a vertical skin incision lateral to it. Although the hand and division of the oblique head of the adductor pollicis
the ulnar artery lies deeper than the radial artery at the wrist, it is are then required to provide access to the origin of the deep pal-
just as easily exposed. Superficial to the ulnar artery, palmar cuta- mar arch.
neous branches of the ulnar nerve may be identified; these should
also be preserved. Exposure of ulnar artery and superficial palmar arch
Grafts originating from the brachial artery are tunneled in the Like exposure of the radial artery, exposure of the ulnar artery and
subcutaneous plane. Subcutaneous tunneling facilitates physical the superficial palmar arch is fairly straightforward. In reality, these
examination to determine the patency of the bypass, as well as sur- vessels are no smaller than the tibial and pedal vessels in the leg. A
veillance of the bypass with duplex ultrasonography. Alternatively, curved incision is made along the lateral border of the hypothenar
if good-quality basilic or cephalic veins are present, an in situ eminence [see Figure 9a].The aponeurotic layer is divided, and the
bypass may be performed. artery is exposed in the upper part of the palm at the origin of the
superficial palmar arch. There are no major nerves in the vicinity,
Exposure of radial artery and deep palmar arch Ex- and it usually is not difficult to expose a reasonable length of artery
posure of the radial artery is relatively straightforward. Generally, for an arterial anastomosis [see Figure 9b]. Alternatively, the super-
it may be accomplished as previously described (see above). ficial palmar arch may be exposed in the palm by making an inci-
Alternatively, it may be accomplished by making a vertical incision sion along one of the larger vertical or oblique skin creases.
over the anatomic snuff box (which lies between the extensor pol-
Postoperative Care
licis longus tendon posteriorly and the tendons of the extensor
pollicis brevis and the abductor pollicis longus anteriorly). This As with all venous grafts, postoperative graft surveillance is
incision is then deepened through the subcutaneous tissues to essential. Routine postoperative anticoagulation generally is not
expose the radial artery in the floor of the snuff box [see Figure 8a]. warranted.
This area contains no significant nerves and thus is often chosen
as a site for hemodialysis access.
The deep palmar arch is much less accessible than the radial Alternative Therapies for Chronic Arm Ischemia
artery. Consequently, exposure of this vascular structure is consid-
THORACOSCOPIC SYMPATHECTOMY AND DIGITAL
erably more difficult than exposure of the radial artery. The deep
SYMPATHECTOMY
palmar arch extends across the palm, level with the proximal bor-
der of the outstretched thumb. To expose it, an incision is made Our experience with sympathectomy in the treatment of
along the medial border of the thenar eminence [see Figure 8b]. patients with critical hand ischemia or digital ulceration has been,
Extensive dissection of the superficial and deep flexor tendons of frankly, disappointing. When we do perform sympathectomy, we
a b
Digital
Arteries
Ulnar
Figure 9 Hand revasculariza- Nerve
tion. (a) The distal ulnar artery
and the superficial palmar arch
are exposed via a curving incision Ulnar Superficial
made along the lateral border of Artery Palmar Arch
the hypothenar eminence. (b)
Shown is exposure of the distal
ulnar artery and the superficial Median
palmar arch, along with the ulnar Nerve
and median nerves.
prefer the thoracoscopic approach to the traditional cervical route. Phenomenon],35 the results in patients with peripheral ischemia are
Either way, however, the results have been discouraging; any less encouraging. At present, iloprost is mainly used to treat
improvements noted prove to be only temporary. Sympathectomy patients with digital ulcers caused by systemic sclerosis, systemic
may help alleviate pain in these patients, but even in this regard, lupus erythematosus, mixed connective tissue disease, or cuta-
the results are, at best, unpredictable. A review of the literature neous polyarteritis nodosa. There are no good data on its use to
seems to support this conclusion. Admittedly, the available data on treat patients with digital ulcers caused by diabetes mellitus, ath-
thoracoscopic sympathectomy for digital ischemia are sparse: to erosclerosis, or renal impairment; however, a study of iloprost
date, only three reports encompassing 21 patients have been pub- therapy for arterial leg ulcers found that the success rate was lower
lished.31-33 In contrast, there is a wealth of data on thoracoscopic than 50%.36
sympathectomy for hyperhidrosis.
GUANETHIDINE BLOCKS
An alternative technique has been devised in which a very dis-
tal sympathectomy is performed at the level of the origin of the Transvenous regional guanethidine blocks have also been
proper digital arteries. The sympathectomy site is exposed via a employed to treat critical digital ischemia. Patients receive a sin-
palmar approach, and a 3 to 4 mm length of the adventitia is gle block, with 5 mg of guanethidine in 60 ml of normal saline
removed from the proper digital arteries distal to the junction of injected into a superficial vein of the affected hand under 30
the distal perforating artery with the common digital artery. This minutes of arterial arrest. In successful cases, hyperemia is
procedure appears to be well tolerated, and data from small series induced in the treated upper limb, and blood flow to the fingers
attest to its value in selected patients with digital ulcers.34 improves. The effects of these blocks are said to persist for up to
1 month. Patients who have finger ulcers, however, appear to be
PROSTACYCLINS
less responsive than those whose only symptom is pain. The
The prostacyclin analogue iloprost has been used in Europe to advantages of this treatment approach are that it is free of side
treat patients with hand ischemia. Although iloprost therapy effects and that it can be repeated for as long as necessary37; the
appears to be reasonably effective in patients with vasospastic dis- disadvantage is that it must be repeated at monthly intervals for
orders, such as Raynaud syndrome [see 6:24 Raynaud as long as necessary.
References
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386:261, 2001 sive disease: a single center’s experience. Cardiovasc 28. Ehsan O, Bhattacharya D, Darwish A, et al:
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160:905, 1964 18. Law MM, Colburn MD, Moore WS, et al: Carotid- extremity bypass grafting for limb salvage in end-
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32. De Giacomo T, Rendina EA, Venuta F, et al:
76:515, 1989 20. Cina CS, Safar HA, Lagana A, et al: Subclavian Thoracoscopic sympathectomy for symptomatic
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8. Widlus DM, Venbrux AC, Benenati JF, et al: 33. Ishibashi H, Hayakawa N, Yamamoto H, et al:
Fibrinolytic therapy for upper-extremity arterial 21. National Diabetes Surveillance System: State-specif- Thoracoscopic sympathectomy for Buerger’s dis-
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http://www.cdc.gov/diabetes/statistics/prev/state/Met
10. Zeller T, Frank U, Burgelin K, et al: Treatment of hods.htm, accessed April 2006 35. Rademaker M, Cooke ED, Almond NE, et al:
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21:326, 1995 Outcome for arterio-venous fistula at the elbow for of transvenous regional guanethidine block in the
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Endovascular therapy of symptomatic innominate- Ischemic steal syndrome: a case series and review of Figures 1 through 9 Alice Y. Chen.
6 VASCULAR SYSTEM 26 RENOVASCULAR HYPERTENSION AND STENOSIS — 1
26 RENOVASCULAR HYPERTENSION
AND STENOSIS
Michael T.Watkins, M.D., F.A.C.S., and Marvin D. Atkins, M.D.
Approach to Suspected Renovascular Disease

Vascular disease that affects the renal arteries is an increasingly imaging, renal artery stenosis (RAS) is frequently diagnosed in
common clinical scenario encountered by general and vascular hypertensive patients. However, the precise contribution RAS
surgeons. As a result of heightened clinical awareness and makes to hypertension and renal dysfunction is not always clear,
advances in vascular imaging, more patients than ever before are and therefore, the patient’s response to treatment may not be read-
being identified as having some degree of atherosclerotic or fibro- ily predictable.
muscular renovascular disease. The vast majority of these lesions The natural history of RAS consists of continued narrowing of
cause no symptoms, are hemodynamically insignificant, or both. the renal artery. Studies in which duplex ultrasonography (DUS)
Some, however, are severe enough to alter renal perfusion pres- was employed to follow untreated patients with greater than 60%
sure, leading to changes in blood pressure regulation and renal renal artery stenosis documented a 20% progression of disease per
function. Symptomatic renovascular disease can have a variety of year, with 11% of patients progressing to renal occlusion within 2
manifestations, ranging from mild renovascular hypertension to years.3 RAS is associated with loss of renal mass, which is a surro-
congestive heart failure and ischemic nephropathy. gate marker for renal function. Occlusion of a renal artery is asso-
Our purpose in this chapter is to outline an approach to the ciated with substantial loss of renal size and function. Historical
diagnosis and management of renovascular disease that is based studies of the clinical course of RAS suggested that chronic renal
on an understanding of the relevant pathophysiology [see Discus- failure developed within 6 years in as many as 27% of patients
sion, Pathophysiology of Renovascular Hypertension, below]. The with RAS.4
procedures employed for surgical and endovascular treatment of The two main conditions associated with RAS are atherosclero-
renovascular disease are described in greater depth in other chap- sis and fibromuscular dysplasia. The former accounts for the vast
ters [see 6:22 Open Procedures for Renovascular Disease and 6:23 majority of renovascular lesions. Atherosclerotic RAS is typically
Endovascular Procedures for Renovascular Disease]. located at the aortic orifice or the proximal renal artery and prob-
ably represents spillover of aortic atherosclerotic disease [see Figure
1]. It is most commonly found in patients older than 50 years who
Incidence and Risk have signs of atherosclerosis in other vascular beds. RAS associat-
Factors
In the United States,
hypertension affects approx- Table 1—Screening Tests for Secondary Causes
imately 24% of the entire of Hypertension
population and 50% of per-
sons over the age of 60 years.1 It is an independent risk factor for
increased cardiovascular morbidity and mortality: cardiovascular Diagnosis Diagnostic Study
risk doubles for every 20/10 mm Hg increase in blood pressure.2
In fact, it is the number-one modifiable risk factor associated with Chronic renal disease and salt
Serum creatinine, GFR
retention
increased cardiovascular morbidity and mortality. Data from the
National Health and Nutrition Examination Survey (NHANES) Renal artery stenosis DUS, MRA, CTA
revealed that 30% of hypertensive persons in the United States
Primary hyperaldosteronism 24-hr urinary aldosterone
were unaware that they had hypertension, that more than 40% of
hypertensive persons were not being treated for their condition, Pheochromocytoma
24-hr urinary metanephrine,
and that in two thirds of hypertensive patients who were being normetanephrine
treated, blood pressure was not maintained below the recom- Cushing syndrome or chronic History, cortisol, dexamethasone
mended target level of 140/90 mm Hg. steroid use suppression test
An estimated 90% to 95% of cases of hypertension are classi- Thyroid or parathyroid disease TSH, calcium, serum PTH
fied as essential or idiopathic, with the remaining 5% to 10% con-
sidered to be secondary to another cause. Secondary hypertension Coarctation of aorta CTA
is sometimes refractory to usual medical treatment, the reason Sleep apnea Sleep study with oxygen saturation
being that the underlying pathophysiologic state must be identi-
fied and treated in addition to the hypertension itself. There are Effect of medication History, drug screen
many possible causes of secondary hypertension [see Table 1], and CTA—computed tomographic angiography DUS—duplex ultrasonography GFR—
it can be difficult to determine which one is operative in a given glomerular filtration rate MRA—magnetic resonance angiography PTH—parathyroid
clinical situation. As a result of the increasing use of diagnostic hormone TSH—thyroid-stimulating hormone
1
Renal artery stenosis is suspected on clinical grounds
No limitations on the performance of duplex

ultrasonography exist
Perform renal artery DUS (RADUS).
RADUS is positive for RAS RADUS is negative for RAS
Treat stenosis, either medically or If study is technically accurate and results

surgically. Consider percutaneous are reliable, no further workup is required.
angioplasty and stenting. If accuracy of study is in doubt and index
of suspicion for RAS is high, perform CTA,
conventional angiography, or MRA.
CTA is positive for RAS
Treat stenosis, either medically

or surgically. Consider
percutaneous angioplasty
and stenting.
Approach to Suspected Renovascular Disease
Patient is obese, or institution lacks sufficient

ultrasonographic expertise and experience
Examination of aorta for other pathologic Patient has renal insufficiency or failure
conditions (e.g., aneurysm) is desired, or
quality of MRA is poor Perform magnetic resonance angiography.
Perform computed tomographic angiography.
MRA is positive for RAS MRA is negative for RAS
CTA is negative for RAS Treat stenosis, either medically or surgically. If study is technically accurate and
Consider percutaneous angioplasty and results are reliable, no further workup
If study is technically accurate and stenting. is required.
results are reliable, no further workup If accuracy of study is in doubt and
is required. index of suspicion for RAS is high,
If accuracy of study is in doubt and perform conventional angiography.
index of suspicion for RAS is high,
perform conventional angiography.
of RAS. These studies make the points that cardiovascular risk is

high in RAS patients and that blood pressure control may be a
poor surrogate for clinical outcome. At present, it is not known
whether the higher cardiovascular morbidity and mortality associ-
ated with RAS are attributable to the effects of renal ischemia or
to the systemic effects of activation of the renin-angiotensin-aldos-
terone system (RAAS) [see Discussion, Pathophysiology of
Renovascular Hypertension, below] or whether RAS is simply a
marker of more advanced atherosclerotic disease.
Ischemic nephropathy may be defined as a progressive decline
in renal function secondary to global renal ischemia. It is estimat-
ed that for 5% to 15% of the patients in whom end-stage renal dis-
ease necessitating dialysis develops each year, ischemic nephro-
pathy is the underlying cause of the decline in renal function.8,9
Investigative Screening Studies
Figure 1 Shown is severe bilateral RAS with poststenotic dilation Screening for suspected RAS is performed to identify those
in a severely diseased aorta. patients who are most likely to benefit from renal artery interven-
tions aimed at managing hypertension or renal insufficiency. The
decision regarding which screening test or tests to perform is not,
ed with fibromuscular dysplasia is usually seen in patients younger however, a simple and obvious one. All of the noninvasive studies
than 40 years and usually affects the middle and distal segments currently in use have their strengths and weaknesses, many of
of the renal artery. These lesions have a characteristic “string of which are institution dependent. Constant improvements in tech-
beads” appearance. nology and institutional variations in reporting standards, tech-
Population-based studies indicate that hemodynamically signif- niques, and published results have further complicated the process
icant atherosclerotic RAS is present in approximately 6% of per- of determining the optimal first-line screening method. A variety
sons older than 65 years, with a somewhat higher incidence in of physiologic tests have been employed to screen for RAS and
men (9.1%) than in women (5.5%). Incidental RAS is seen in assess the contribution of RAS to hypertension or ischemic
approximately 20% of patients undergoing coronary angiography nephropathy. Peripheral plasma renin assays, rapid-sequence
and in 35% to 50% of patients undergoing peripheral vascular intravenous pyelography (for indirect assessment of differences in
angiography for occlusive disease of the aorta and the lower renal filtration), and isotope renography have all proved insuffi-
extremity. The prevalence of renovascular disease corresponds to ciently sensitive to be useful for screening purposes. Catheter-
the overall atherosclerotic burden. In the vast majority of patients, based angiography has been widely used to screen for RAS, but
no direct causal relation between significant RAS and hyperten- technical improvements in DUS, computed tomographic angiog-
sion or ischemic nephropathy can be identified. Efforts to define raphy (CTA), and magnetic resonance angiography (MRA) have
such a relation are confounded by the fact that the same popula- caused many physicians to prefer one or another of these imaging
tion in which renovascular disease is prevalent is also at risk for modalities for this purpose. A thorough understanding of the
essential hypertension, diabetes, and baseline renal insufficiency. strengths and limitations of all of the screening tests, as well as an
Other risk factors associated with renovascular disease include informed awareness of specific institutional limitations, is required
smoking, increased age, and hyperlipidemia. to define the place of each test in one’s preferred diagnostic
RAS is believed to be the cause of hypertension in only 3% to approach.
5% of the 90 million hypertensive persons in the United States. In
IMAGING
those with mild hypertension (the vast majority), it plays only a
negligible role; however, it plays a significantly larger role in those
Contrast Arteriography
with severe systemic hypertension. (The severity of a case of
hypertension is related to the patient’s blood pressure without Of the several noninva-
medication, not necessarily to the difficulty or ease with which sive or functional studies
blood pressure can be controlled medically.) At the extremes of that are used to diagnose
age (i.e., in the very young and the elderly), severe hypertension is RAS and renovascular hypertension, none has displaced catheter-
substantially more likely to be renovascular than essential in origin based contrast arteriography from its role as the diagnostic gold
[see Table 2]. standard. In many institutions, however, CTA is now considered
Patients with RAS are at higher risk for cardiovascular morbid- preferable to formal catheter-based arteriography as an easily
ity and mortality than similar patients without RAS are. One reproducible screening test for RAS. The obvious drawback of
series, in which patients underwent renal angiography after coro- CTA, as compared with the other imaging modalities, is the neces-
nary angiography, found that 4-year survival was significantly sity of administering iodinated contrast material and the conse-
decreased in patients with incidentally discovered RAS.5 Several quent risk of contrast-induced nephropathy (CIN). We frequently
series have suggested that the risk of adverse cardiovascular events use CTA for the diagnosis of RAS in cases where concomitant aor-
is high in this population and exceeds the risk that might have toiliac aneurysmal or occlusive disease is suspected [see Figure 2].
been expected on the basis of the severity of hypertension.6,7 Blood
pressure control—measured by the number of antihypertensive “Drive-by” renal arteriography In a 1992 study of
medications used, as well as by systolic and diastolic pressures—is screening renal angiography (the largest such study published to
the most commonly used end point in series examining treatment date), 1,235 consecutive patients underwent renal arteriography at
B mode with a Doppler angle of less than 60°.The ratios between

Table 2 Clinical Clues to Diagnosis of Renal the velocities in the renal artery and those in the aorta are deter-
Artery Stenosis mined, and the Doppler spectral waveform is recorded [see Figure
3]. The normal Doppler spectral waveform of the low-resistance
Onset of hypertension at extremes of age (< 30 or > 60 yr) renal vascular bed shows continuous diastolic flow.
Severe hypertension at > 55 yr
Accelerated, resistant, or malignant hypertension
Unexplained renal insufficiency or failure
Renal dysfunction associated with initiation of ACE inhibitor or ARB
therapy
Unexplained congestive failure, pulmonary edema, or both
Unexplained atrophic kidney or size discrepancy between kidneys
Abdominal bruit
the conclusion of coronary angiography.10 Approximately 30% of

these patients were found to have evidence of RAS, and 15% had
greater than 50% stenosis. A 2001 study confirmed that RAS is
associated with an increased risk of myocardial infarction, stroke,
and death and that its presence in patients with coronary disease
doubles the risk of mortality even when coronary revascularization
is performed.5 This same study found that the severity of RAS was
also predictive of mortality: 4-year survival was significantly lower
(47%) in patients with bilateral RAS than in those with unilateral
RAS (59%). The addition of nonselective renal arteriography in
cases where the patient’s serum creatinine concentration was lower
than 2.0 mg/dl was associated with minimal additional cost and
no clinically significant deterioration in renal function.
In 2006, on the basis of the findings from these studies, the
American Heart Association (AHA) published a science advisory
that made recommendations concerning routine renal arteriogra-
phy in patients undergoing coronary angiography.11 The AHA
concluded that screening renal arteriography can reasonably be
performed at the time of cardiac catheterization in patients at
increased risk for RAS who are candidates for revascularization;
however, it made no recommendation regarding concomitant
treatment of RAS discovered during cardiac catheterization. In
most cases, such a combined intervention is not feasible, whether
because of the lack of preprocedural informed consent about renal
artery endovascular intervention, the risk of CIN, or both.
Duplex Ultrasonography
In many institutions,
including our own, renal
artery duplex ultrasonogra-
phy (RADUS) is currently
used as the first-line screen-
ing test for RAS. Compared with other imaging modalities,
RADUS has several unique advantages. In B mode, it provides
direct images of the renal arteries, as well as a clear picture of con-
tralateral kidney size (see below). It allows ongoing surveillance of
lesions and interventions. It also achieves excellent imaging
through renal stents, which on MRA appear only as flow voids.
Finally, unlike CTA or even gadolinium-enhanced MRA,
RADUS carries no risk of CIN.
Before RADUS is performed, the patient should fast overnight,
should be given simethicone (to minimize interference on the images
caused by bowel gas), or both. The study is done from both the
anterior approach and the oblique flank approach; the latter is
particularly helpful in obese patients, whose body habitus may
severely limit the accuracy of the study.The renal arteries are imaged Figure 2 CTA in a woman with a 7 cm infrarenal abdominal aor-
at their aortic origin and in their middle and distal segments.The tic aneurysm and chronic renal insufficiency shows severe bilater-
peak systolic and end-diastolic arterial velocities are measured in al stenosis of the renal artery origins and small, atrophic kidneys.
Figure 3 DUS focused on the proximal left renal artery reveals severe stenosis with markedly
elevated peak systolic velocity (PSV) and end-diastolic velocity (EDV).
The size of the contralateral kidney is a useful surrogate mark- enhanced MRA is the technique of choice, in that the presumably
er for kidney function. A significant discrepancy in size and mass less nephrotoxic gadolinium enhances visualization of the renal
between the two kidneys should prompt the ultrasonographer to arteries. Multiplanar reconstruction (MPR) and maximum-inten-
search for significant RAS or an occluded renal artery. sity projection (MIP) techniques provide three-dimensional
Doppler examination of the renal parenchyma is also employed anatomic detail that is superior to what can be obtained with con-
as a means of indirectly evaluating RAS. This technique, per- trast arteriography [see Figure 4]. On a two-dimensional arteri-
formed via a flank approach, is very useful with obese patients and ogram, vessel overlap can cause the examiner to miss a severe
with cases in which examination is hindered by the presence of stenosis; this problem rarely arises with three-dimensional images.
bowel gas.The acceleration time (the interval from the onset of the We find renal MRA to be especially helpful in evaluating patients
upstroke of the arterial waveform to the systolic peak), the accel- with RAS and ischemic nephropathy necessitating endovascular
eration index (the slope of the acceleration curve), and the resis- intervention.
tive index (a measure of the resistance within the renal circulation) Before the intervention is carried out, we review the axial MRA
are determined. There is evidence to suggest that a normal resis- images of the aorta and the origins of the renal vessels. Working
tive index (< 80) before renal revascularization (whether endovas- from these images, we rotate the image intensifier camera so as to
cular or surgical) predicts improvement with respect to blood obtain a perpendicular view of the renal orifice [see Figure 5].This
pressure, renal function, and freedom from dialysis.12 The resistive step allows us to use smaller quantities of contrast material and
index itself, however, is not useful in predicting the degree of cannulate the renal orifice more quickly during endovascular
stenosis, because it may already be elevated in elderly patients and intervention. It must be kept in mind that MPR and MIP postpro-
those with renal parenchymal disease. cessing techniques are well known to exaggerate or even create the
One disadvantage of RADUS is that the diagnostic value of the appearance of a stenosis and that the original source axial images
images can be limited by the patient’s body habitus or the pres- must therefore be evaluated.The three-dimensional data set is dig-
ence of overlying bowel gas. In addition, RADUS can be time con- itally subtracted from the precontrast source images to create the
suming to perform (requiring 30 to 60 minutes), and its accuracy contrast MRA images. Other signs of significant RAS include
is highly dependent on the experience of the ultrasonographer. poststenotic dilation, loss of cortical medullary differentiation, and
Finally, polar or accessory renal arteries can easily be missed on delayed renal enhancement or asymmetric filling of the collecting
RADUS, potentially leading to a false negative study result. system during contrast injection.
The utility of MRA can be limited by several factors that are
Magnetic Resonance capable of degrading the acquired data. The presence of nearby
Angiography metal (e.g., clips or stents) and air-tissue interfaces can lead to
Many practitioners pre- focal signal drop-out and simulate stenosis or obstruction. Move-
fer MRA as the initial ment by the patient during the scan (or even bowel peristalsis) can
screening test for RAS. One result in degraded, blurred images. The timing of the contrast
advantage of renal MRA in bolus must be right to ensure adequate visualization of the arteri-
this setting is that the quality of the results is less dependent on al vessels. A contrast bolus that is delivered too late will not opaci-
operator technique than is the case with RADUS. Gadolinium- fy the vessels and will appear as a stenosis, whereas a bolus that is
delivered too early will opacify the veins, resulting in so-called

venous contamination of the images. We have found that the
image quality attained with MRA is highly dependent on the insti-
tution where it is performed.
MRA is contraindicated in patients with pacemakers, automat-
ic implantable cardioverter defibrillators (AICDs), brain aneurysm
clips, cochlear implants, or metal fragments in the eyes. It is not
contraindicated in patients with vascular stents, coils, or inferior
vena cava filters, nor is it contraindicated in those with metal
orthopedic devices, heart valves, or dental devices and materials.
Captopril Renal Scintigraphy
Radionuclide imaging is a noninvasive and safe means of eval-
Figure 5 For optimal viewing of the right renal artery during
uating renal blood flow and excretory function.The addition of an endovascular intervention, the C arm should be set to a 30° left
angiotensin-converting enzyme (ACE) inhibitor, such as capto- anterior oblique position. Evaluation of axial MRA images before
pril, to isotope renography improves the sensitivity and specificity the procedure is begun facilitates cannulation and limits the
of the test. In the presence of unilateral RAS, administration of amount of contrast material used.
captopril is associated with a 30% reduction of the glomerular fil-
tration rate (GFR) in the affected kidney.The contralateral kidney
shows a rise in the GFR, an increase in urine flow, and enhanced function at baseline (serum creatinine concentration greater than
salt excretion, leading to marked retention of the isotope in the 2.0 mg/dl), bilateral RAS, or both adversely affects the sensitivity
cortex of the affected kidney.The presence of significant renal dys- and specificity of captopril renal scintigraphy, thereby limiting its
utility as a screening test. In addition, the necessity of discontinu-
a ing ACE inhibitors and angiotensin-receptor blockers (ARBs)
before the study may preclude the use of this test in patients with
severe hypertension. Improvements in DUS, CTA, and MRA
have now relegated captopril renal scintigraphy to secondary sta-
tus as a screening modality.
Contrast-Induced Nephrotoxicity
The increasing use of diagnostic imaging studies (e.g., CTA
and MRA) and catheter-based interventions in patients with sig-
nificant RAS has made treatment and prevention of CIN impor-
tant issues in this patient population. Current strategies for pre-
venting CIN have generally involved one of three approaches: (1)
providing hydration, (2) using low-osmolar or iso-osmolar iodi-
nated contrast agents, and (3) administering the free radical scav-
enger N-acetylcysteine.
Intravascular volume depletion is an important risk factor for the
development of CIN. Although to date, no randomized, controlled
trials comparing hydration with placebo have been published, it has
been standard practice for some time to institute hydration (usual-
ly intravenous) before administering a contrast agent. A small ran-
domized, controlled trial from 2003 that compared I.V. hydration
(0.9% saline, 1 ml/kg, starting 12 hours before infusion of contrast
material) with unlimited oral fluid intake found I.V. hydration to be
far superior for preventing CIN.13 In a subsequent study, 119
patients at a single center were randomly assigned to receive a 154
mEq/L infusion of either sodium chloride or sodium bicarbonate
b both before and after administration of contrast material (starting
with a 3 ml/kg bolus 1 hour before contrast administration and con-
tinued at a rate of 1 ml/kg/hr for 6 hours afterward).14 Sodium
bicarbonate hydration was found to reduce the incidence of CIN
from 13.6% to 1.7%. Although this study is probably underpow-
ered from a statistical perspective, the findings are suggestive.
Sodium bicarbonate hydration is inexpensive and well tolerated
and has become standard practice at most institutions.
The optimal choice of contrast media for preventing CIN has
also been a subject of debate.There is evidence that the use of iso-
Figure 4 (a) Gadolinium-enhanced MRA reveals signal dropout osmolar nonionic contrast agents (e.g., iodixanol [Visipaque; GE
(flow void) at the origin of the left renal artery, signifying severe Healthcare, Princeton, New Jersey]) yields significantly lower
stenosis. (b) Axial MRA image reveals severe right renal artery rates of CIN than the use of low-osmolar contrast agents (e.g.,
stenosis. iohexol [Omnipaque; GE Healthcare, Princeton, New Jersey]) in
patients with diabetes or baseline renal insufficiency who undergo that appropriate cardiovascular risk factor modification measures are
cardiac or vascular angiography.15 being undertaken. After consultation with the patient’s primary care
N-acetylcysteine, a thiol-containing antioxidant, is believed to provider, we routinely provide prescriptions for a cholesterol-lower-
act as a free-radical scavenger to prevent toxic effects on the renal ing medication (e.g., a 3-hydroxy-3-methylglutaryl coenzyme A
tubular epithelium. Multiple clinical studies have examined the [HMG-CoA] reductase inhibitor) and an antiplatelet drug (e.g.,
question of whether administration of N-acetylcysteine is benefi- acetylsalicylic acid [ASA]) if the patient has not already been taking
cial in preventing CIN, but the results have been mixed. Although these agents.
pooled meta-analyses have recommended giving N-acetylcysteine It is worth remembering that although medical treatment may
to patients who are at high risk, the overall effect of this measure lead to significant reductions in cardiovascular morbidity and
is small in comparison with that of simple hydration. Never- mortality, no medical therapy has yet been shown to prevent the
theless, N-acetylcysteine is inexpensive and generally well tolerat- progression of ischemic nephropathy and renal failure. For
ed, and its use in those at high risk for CIN may reasonably be patients with these latter conditions, renal revascularization is like-
recommended. ly to be preferable to medical therapy.
On the basis of the existing evidence regarding prevention of
CIN, we routinely preadmit patients with baseline serum creati- Antihypertensive Agents
nine concentrations higher than 2.5 mg/dl for overnight hydration, Both ACE inhibitors and ARBs have proved to be safe and ef-
usually with saline; we then switch to sodium bicarbonate hydra- fective for the treatment of hypertension in the setting of renovas-
tion (see above) before administering the contrast agent. We also cular disease. In addition to their effects on the RAAS, these
use N-acetylcysteine (600 orally twice daily on the day before, the agents have been shown to reduce proteinuria and glomerular
day of, and the 2 days after contrast administration) in this high- scarring in patients with a variety of renal diseases. Close clinical
risk patient subset. Patients with serum creatinine concentrations supervision is necessary when ACE inhibitors or ARBs are given
between 1.5 and 2.5 mg/dl receive sodium bicarbonate hydration to patients with renal insufficiency or failure. In this population,
on the day of the procedure.We try to limit the amount of contrast serum creatinine and potassium levels should be obtained weekly
material given during the procedure, and we currently favor iodix- for 2 to 3 weeks after antihypertensive therapy with an ACE inhi-
anol over iohexol in patients with baseline serum creatinine con- bitor or an ARB is started. These patients are at increased risk for
centrations higher than 1.5 mg/dl or other risk factors for CIN acute renal failure (ARF); if ARF develops, the medications
(e.g., diabetes or a solitary kidney). Because of its substantial cost, should be promptly discontinued. Patients with significant RAS
we do not routinely use iodixanol in all patients. Well-hydrated who take ACE inhibitors or ARBs are also at risk for ARF when
persons with normal renal function receive I.V. saline before and severely dehydrated; accordingly, they should be instructed to
after the procedure. In such patients, we routinely use iohexol, refrain from taking these agents when affected by severe vomiting,
without other adjuncts. diarrhea, or dehydration. As a rule, ARF that occurs in this latter
setting responds rapidly to fluid rehydration and temporary sus-
LABORATORY TESTS
pension of the ACE inhibitor or ARB. Once renal function has re-
turned to baseline, the medications can usually be safely restarted.
Renal-Vein Renin Assay It is important to be aware that some antihypertensive drugs
When hemodynamically significant RAS is found, functional may be associated with lack of energy (e.g., beta blockers and cal-
studies may be indicated to determine the physiologic significance cium channel blockers) or chronic cough (ACE inhibitors), either
of the lesion. One such study involves measuring the renin concen- of which may have substantial effects on patient compliance.
tration in blood samples from the two renal veins to determine Several studies have shown that as many as 50% of such medica-
whether unilateral renin hypersecretion is occurring. If the ratio of tions are changed or discontinued within 6 months. Proponents of
the renin concentration in the affected side to that in the unaffect- renovascular revascularization have cited such studies as evidence
ed side is greater than 1.5, the assay is considered to have yielded favoring aggressive use of open or endovascular treatment of RAS
a positive result. The sensitivity and specificity of this test are over reliance on medical therapy alone.
diminished by the presence of bilateral RAS or RAS of a solitary
kidney. Other factors that may reduce the reliability of the results Lipid-Lowering Agents
include the inherent limitations of the renin assay itself and the Lipid-lowering therapy with HMG-CoA reductase inhibitors
potential for sampling errors. Because of the invasive nature of the (also referred to as statins) effectively reduces total and low-densi-
selective renin assay and the concerns about its accuracy, we do ty lipoprotein (LDL) cholesterol levels while increasing high-den-
not routinely use this test in RAS patients. sity lipoprotein (HDL) cholesterol levels.There is compelling level
1 evidence that this reduction of total and LDL cholesterol levels
markedly lowers the incidence of secondary cardiovascular events
Management and mortality.There is, however, no direct evidence that lipid con-
trol has an effect on the progression of renal artery disease, though
MEDICAL THERAPY
one might reasonably suspect that it would.
Given the known associa- Statins generally are well tolerated, but on occasion, they may
tion between RAS and sys- be associated with hepatic toxicity (0.5% to 3% of cases) or myosi-
temic cardiovascular disease, medical treatment aimed at preventing tis. Accordingly, liver function tests should be performed at base-
or retarding further progression of systemic atherosclerosis is clearly line and again 3 months after the start of therapy. If a threefold or
a paramount concern in the management of RAS patients. Measures greater increase in aminotransferase levels is noted, the statin
for modifying cardiovascular risk factors include effective blood pres- should be discontinued, and alternative therapy with another
sure control, weight reduction, smoking cessation, lipid-lowering lipid-lowering medication (e.g., a fibrate, a bile acid sequestrant, a
therapy, and antiplatelet therapy. It is the responsibility of the sur- cholesterol absorption inhibitor, or nicotinic acid) should be start-
geon evaluating a patient with RAS to use this opportunity to ensure ed in conjunction with diet modification.
Muscle injury is uncommon with statin therapy alone: myalgias were unable to demonstrate any beneficial effect on blood pressure.16-
occur in 2% to 11% of patients, myositis in 0.5%, and rhabdomy- 18 Proponents of renal artery intervention have argued that these
olysis in fewer than 0.1%. Myositis associated with statin therapy three trials were flawed by their failure to include stenting and by the
is treated by switching to another HMG-CoA reductase inhibitor. fact that blood pressure control may be a poor surrogate clinical end
Routine measurement of serum creatine kinase levels in not rec- point.These studies were plagued by several other weaknesses as well,
ommended, but patients taking statins should be warned about including high rates of crossover to angioplasty and marked variations
the risk of myositis and weakness and instructed to stop statin in the medical therapy provided.The inclusion of stenting as a com-
therapy if such side effects occur. ponent of endovascular treatment of RAS is now considered the stan-
dard of care by many, in that it significantly improves technical suc-
Antiplatelet Agents cess rates and lowers the incidence of restenosis.
Antiplatelet therapy has been shown to reduce the risk of sec- Revascularization of RAS with stenting treats the root cause of
ondary events in patients with coronary artery disease and carotid the neurohormonal activation that leads to end-organ heart and
stenosis. The data currently available do not conclusively demon- kidney damage; best medical therapy, when adequately carried
strate that antiplatelet therapy has a beneficial effect on RAS, but out, yields substantial reductions in cardiovascular morbidity and
given that RAS is a manifestation of systemic atherosclerosis, mortality in and of itself. Consequently, it is difficult to detect sig-
antiplatelet therapy appears warranted on the same grounds that nificant differences between best medical therapy alone and best
statin therapy would be. After endovascular intervention to treat medical therapy plus renal artery stenting. Until sufficient evi-
RAS, we typically place patients on ASA, 81 mg/day, and clopido- dence (from adequately powered, well-designed, and unbiased tri-
grel, 75 mg/day, for 4 to 6 weeks while the stent is undergoing als) has been accumulated to confirm or rule out such differences,
endothelialization. After this period, patients are switched to ASA, the debate regarding the benefits of percutaneous renal artery
325 mg/day. Admittedly, there is no direct evidence supporting revascularization will continue.
this practice in patients with RAS who undergo endovascular To date, no trials comparing best medical therapy with best
intervention; however, data extracted from the coronary stenting medical therapy plus angioplasty and stenting have been complet-
literature suggest that such an approach may be reasonable. ed. Currently, however, patients are being recruited into a clinical
trial sponsored by the National Heart, Lung, and Blood Institute,
ENDOVASCULAR AND OPEN SURGICAL THERAPY
which is likely to answer several important questions about the
Despite the relatively high prevalence of RAS, especially in per- management of RAS that have not been answered by previous
sons who have atherosclerosis in other vascular beds, there is cur- studies. This study, known as the Cardiovascular Outcomes in
rently no consensus on diagnosis, therapy, or follow-up. In the Renal Atherosclerotic Lesions (CORAL) trial, is expected to yield
absence of well-designed, evidence-based studies, many practition- important information about which groups of RAS patients bene-
ers have adopted a “find it and fix it” approach to managing RAS. fit from endovascular intervention. A total of 1,080 patients will be
The endovascular and surgical interventions employed to treat enrolled in the trial and will be randomly assigned to receive either
RAS are described more fully elsewhere [see 6:22 Open Procedures best medical therapy or best medical therapy with angioplasty and
for Renovascular Disease and 6:23 Endovascular Procedures for Reno- stenting.The primary outcome evaluated will be adverse cardiovas-
vascular Disease]. We ourselves generally take an aggressive stance cular and renal events. Best medical therapy will be provided on
toward the application of renal artery stenting, especially in patients the basis of current evidence-based guidelines, which include tight
with evidence of ischemic nephropathy (who presumably would be control of blood pressure (< 140/90 mm Hg; <130/80 mm Hg in
the patients most likely to benefit from renal revascularization). patients with diabetes or proteinuria), treatment of hypercholes-
It must be admitted, however, that the current evidence for terolemia (LDL concentration < 100 mg/dl) and diabetes (glyco-
renal artery percutaneous intervention is circumstantial at best. sylated hemoglobin [HbA1c] level < 7 mg/dl), smoking cessation,
Clearly, there are three possible outcomes associated with renal and antiplatelet therapy (with ASA, clopidogrel, or ticlopidine). All
revascularization. Some patients derive tremendous benefit from patients will receive an ARB as the first-line antihypertensive agent,
the procedure, showing substantial improvements in blood pres- and a specific stepwise algorithm will be implemented for patients
sure and renal function. Others (a very small subset) experience a requiring combination antihypertensive therapy. All patients will
rapid decline in renal function, probably resulting from either undergo diagnostic angiography to assess the severity of their
atheroembolization or CIN associated with the procedure itself. lesions. Patients will be followed for as long as 5 years with an eye
Still others exhibit no changes in renal function, number of anti- to both primary end points (e.g., death, stroke, myocardial infarc-
hypertensive medications used, or blood pressure control. tion, ARF, and dialysis) and secondary end points (e.g., hyperten-
Unfortunately, there are, at present, no good methods of reliably sion, medication use, quality of life, and cost). It is expected that
predicting which patients will benefit from renal revascularization. enrollment in the CORAL trial will conclude in 2009, though
Several uncontrolled reports suggested that hypertension and renal interim data will probably be reported earlier.This important study
function may improve after successful renal artery stenting. However, should make a major contribution to determining the appropriate
three small trials evaluating angioplasty alone (i.e., without stenting) role of endovascular stenting in the management of RAS.
Discussion
Pathophysiology of Renovascular Hypertension ical role in this process. The RAAS maintains vascular tone, water
The seminal studies performed by Goldblatt and associates in the and salt balance, and cardiac function. It works through the sympa-
1930s demonstrated that reduction of renal perfusion can result in thetic nervous system and the actions of several hormones to main-
sustained elevation of arterial pressures.19 Later work revealed that tain hemodynamic stability.The RAAS is activated through several
the renin-angiotensin-aldosterone system plays an intricate and crit- mechanisms, including hypotension and decreased intravascular
volume.These mechanisms cause decreased renal perfusion and the Ischemic injury to the affected kidney, hypertensive nephro-
secretion of renin from the juxtaglomerular apparatus within the sclerosis of the contralateral kidney, and smooth muscle hypertro-
kidneys. Renin cleaves angiotensinogen in the liver to form angio- phy in the peripheral blood vessels may all contribute to sustained
tensin I; ACE then transforms angiotensin I into angiotensin II in hypertension independently of RAAS activity. In addition, both
the lung. Angiotensin II is a potent vasoconstrictor (considerably the sympathetic nervous system and the central nervous system
more potent than epinephrine) and is implicated in end-organ dam- contribute to hypertension associated with RAS.22 Several neu-
age to the heart and the kidney.20,21 Angiotensin II promotes the roendocrine systems activated by RAS have also been shown to
release of aldosterone from the adrenal cortex, and this release of have deleterious cardiovascular effects. Besides increasing periph-
aldosterone leads to the reabsorption of sodium in the distal convo- eral resistance, angiotensin II is thought to cause smooth muscle
luted tubules of the kidney, resulting in increased intravascular volume. hypertrophy (both in peripheral arteries and in cardiac myo-
In patients who have unilateral RAS with a normal contralater- cytes), plaque rupture, endothelial dysfunction, and inhibition of
al kidney, the elevation of blood pressure is renin dependent and fibrinolysis.23-25 An elevated angiotensin II level is believed to cause
is characterized by increased peripheral vascular resistance. Such left ventricular hypertrophy (LVH) on occasion, even in cases
patients are considered to have volume-independent hyperten- where blood pressure is well controlled.26 Angiotensin II also in-
sion, in that the normal contralateral kidney compensates for the teracts with tumor growth factor–β, platelet-derived growth fac-
unilateral RAS by increasing its excretion of fluid. In patients who tor, and endothelin, each of which has been implicated in the
have bilateral RAS or unilateral RAS with no contralateral kidney, development of vascular muscle hypertrophy, cardiac myocyte
intravascular volume increases and renin secretion decreases over hypertrophy, and renal parenchymal damage. Clearly, RAS and
time. Such patients are considered to have volume-dependent or activation of the RAAS have systemic effects that go beyond sim-
Goldblatt hypertension. ply causing hypertension.
References
1. Burt VL, Whelton P, Roccella EJ, et al: Prevalence risk factors in patients undergoing routine cardiac 18. Webster J, Marshall F, Abdalla M, et al:
of hypertension in the US adult population. catheterization. J Am Soc Nephrol 2:1608, 1992 Randomised comparison of percutaneous angio-
Results from the Third National Health and 11. White CJ, Jaff MR, Haskal ZJ, et al: Indications for plasty vs continued medical therapy for hyperten-
Nutrition Examination Survey, 1988–1991. renal arteriography at the time of coronary arteri- sive patients with atheromatous renal artery steno-
Hypertension 25:305, 1995 ography: a science advisory from the American sis. Scottish and Newcastle Renal Artery Stenosis
Heart Association Committee on Diagnostic and Collaborative Group. J Hum Hypertens 12:329,
2. Lewington S, Clarke R, Qizilbash N, et al: Age-
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sonography. J Vasc Surg 19:250, 1994 of therapy for renal-artery stenosis. N Engl J Med angiotensin-converting enzyme inhibitors in car-
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J Cardiol 21:60, 1968 prospective trial to assess the role of saline hydra- 21. Meyrier A: [Vascular mechanisms of renal fibrosis.
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5. Conlon PJ, Little MA, Pieper K, et al: Severity of Bull Acad Natl Med 183:33, 1999
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renal vascular disease predicts mortality in patients
undergoing coronary angiography. Kidney Int 14. Merten GJ, Burgess WP, Gray LV, et al: Prevention 22. Mathias CJ, Kooner JS, Peart S. Neurogenic com-
60:1490, 2001 of contrast-induced nephropathy with sodium ponents of hypertension in human renal artery
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7 TRAUMA AND THERMAL INJURY 1 INITIAL MANAGEMENT OF LIFE-THREATENING TRAUMA — 1
1 INITIAL MANAGEMENT OF LIFE-

THREATENING TRAUMA
Frederick A. Moore, M.D., F.A.C.S., and Ernest E. Moore, M.D., F.A.C.S.
Initial Approach to the Critically Injured Patient

Salvage of the critically injured patient is optimized by a coordi- all injured patients. When it is geographically and logistically fea-
nated team effort in an organized trauma system. Management of sible, critically injured patients should be taken directly to a des-
life-threatening trauma must be prioritized according to physio- ignated level I trauma center or to a level II trauma center if a
logic necessity for survival—that is, active efforts to support air- level I trauma center is more than 30 minutes away.The current-
way, breathing, and circulation (the ABCs) are usually initiated ly available field trauma scores, however, are not entirely reliable
before specific diagnoses are made. In this chapter, we outline a for identifying critically injured patients8: to capture a sizable
systematic approach to severely injured patients within the so- majority of patients with life-threatening injuries, a 50% over-
called golden hour.The discussion is divided into prehospital care triage is probably necessary. Advance transmission of key patient
and emergency department management; the ED component is information to the receiving trauma center facilitates the organi-
further divided into (1) primary survey with initial resuscitation, zation of the trauma team and ensures the availability of ancillary
(2) evaluation and continued resuscitation, and (3) secondary sur- services.9
vey with definitive diagnosis and triage.
DECLARATION OF DEATH AT SCENE
The determination that care is futile during prehospital evalu-

Prehospital Care ation is best made on the basis of the cardiac rhythm. Asystole jus-
tifies declaration of death at the scene, and recent profound
INTERVENTION AT
bradycardia (heart rate < 40 beats/min) has been shown to signal
INJURY SITE
an unsalvageable situation.10-12
Resuscitation and eval-
uation of the trauma pa-
tient begins at the injury Emergency Department
site. The goal is to get the Management
right patient to the right hos-
ARRIVAL AT HOSPITAL
pital at the right time for definitive care. First responders (typical-
UNDER ACTIVE
ly, firefighters and police) provide rapid basic trauma life support
CARDIOPULMONARY
(BTLS) and are followed by paramedics and flight nurses with
RESUSCITATION
advanced trauma life support (ATLS) skills. Medical control is
ensured by preestablished field protocols, radio communication Prehospital pulseless
with a physician at the base hospital, and subsequent trip audits. electrical activity (PEA)
Management priorities of BTLS on the scene are (1) to assess in injured patients has a dismal prognosis, and it has been pro-
and control the scene for the safety of the patient and the prehos- posed that such patients should be declared dead in the field.13
pital care providers, (2) to tamponade external hemorrhage with Unfortunately, most first responders do not use the cardiac
direct pressure, (3) to protect the spine after blunt trauma, (4) to rhythm to decide whether to initiate CPR.When a patient arrives
clear the airway of obstruction and provide supplemental inspired in the ED after prehospital CPR has been initiated, the critical
oxygen, (5) to extricate the patient, and (6) to stabilize long-bone question is whether to perform a resuscitative thoracotomy. The
fractures.Whereas the benefits of BTLS are undisputed, the mer- prognosis for blunt trauma patients is poor because the major
its of the more advanced interventions remain controversial.1,2 causes of cardiopulmonary arrest after blunt trauma (e.g., mas-
Airway access, once considered a major asset of the care provided sive brain injury, high spinal cord injury, and exsanguination
by paramedics and flight nurses, has now been questioned, not from multiple injuries) are difficult to reverse. In contrast, pa-
only because missed tracheal intubation is a concern but also tients with stab wounds to the heart are frequently salvageable if
because unintentional hyperventilation (hypocarbia) is detrimen- cardiac arrest occurs because of cardiac tamponade. In most
tal in the setting of traumatic brain injury (TBI) and during car- cases, the heart can be resuscitated by simply decompressing the
diopulmonary resuscitation (CPR).3-5 Moreover, the value of I.V. pericardium, given that blood volume is usually maintained.
fluid administration remains controversial.6,7 Guidelines for terminating resuscitation are based on the mech-
anism of injury, the duration of CPR, the presence of signs of life
FIELD TRIAGE
(e.g., pupillary response, respiratory effort, or motor activity),
Prehospital trauma scores have been devised to identify criti- and the presence of asystole documented by cardiac monitoring
cally injured trauma victims, who represent about 10% to 15% of [see Table 1].14
Communicate with base hospital
Field triage: Level I, II, or III facility

Assemble trauma team:
• Trauma surgeon • Radiology technicians
• ED physician • Nurses
Initial Approach to the • Surgical specialist • Respiratory technicians
Ensure ancillary services:
Critically Injured Patient • OR • Blood bank
• CT scanning • Interventional radiology
Hemodynamic stability is restored
Cardiogenic shock
Tension Myocardial contusion Pericardial Air embolism

pneumothorax tamponade
Chest trauma
Monitor with ECG. Prevent
Place chest tube. hypoxia. Provide pharmacologic
cardiac support.
Arrest is not Impending

Hemodynamic stability is restored imminent cardiac arrest
Perform
pericardiocentesis.
Secondary survey (perform systematic assessment) Arrest is not

imminent
Question EMT/flight nurse. Obtain medical history. Conduct Place chest tube.
rapid, systematic physical exam. Assess potential sites of Criteria for operation:
ongoing blood loss by means of abdominal Patient Shock persists • Continued shock
ultrasonography, chest x-ray, and pelvic x-ray. Initiate flow stabilizes • Continued bleeding
sheet and treatment: (250 ml/hr for 3 hr)
• Ensure adequate ventilation.
• Insert NG tube and Foley catheter. • Monitor core T° .
• Give tetanus prophylaxis. • Splint long bone fractures.
• Give systemic antibiotics for specific indications only.
• Obtain CBC, urinalysis, and ECG. • Type and crossmatch. Perform ED thoracotomy.
• Measure arterial blood gases for significant chest injuries and
evidence of occult shock.
Obtain radiologic studies as needed to assess occult

injuries and clarify indications for operation. Transport to SICU.
Initiate resuscitation and evaluation of trauma patients at the injury scene; communicate with base hospital
Management priorities of basic trauma life support are the following:

• Assess and control the accident scene • Protect the spine after blunt trauma • Supplement inspired O2
• Tamponade external hemorrhage with direct pressure • Extricate the patient • Stabilize long bone fractures
Advanced trauma life support may include the following:
• Active airway support • I.V. fluid administration • Decompression of thorax for suspected pneumothorax
< 3 Minutes
Primary survey (evaluate and initiate management of airway, breathing, and circulation)
Listen to prehospital report. Airway: Clear airway and establish patency; obtain cervical spine x-ray. Breathing: Assist ventilation; vent
suspected hemopneumothoraces with chest tubes. Circulation: Establish I.V. access; infuse fluid (crystalloid); draw blood samples.
Assess chest and abdomen with ultrasonography.

Blunt trauma: obtain x-rays of cervical spine, chest, and pelvis.
< 5 Minutes
Evaluate response to initial resuscitation
Assess response to crystalloid infusion (i.e., BP, heart rate, respiratory rate, mental status). Identify easily reversible causes of shock.
Shock persists
Secondary survey:
Reassess physical signs. Monitor CVP. Unstable patients: 5 minutes
Repeat ultrasonography; consider DPL if ultrasonography is equivocal. (Stable patients: up to 30 minutes)
Hypovolemic shock Neurogenic shock
[See 7:3 Shock.]
Abdominal trauma Pelvic fracture
Compress with sheet or C-clamp;

administer blood.
Impending Multisystem Isolated injury

cardiac arrest trauma
Hemodynamic stability Shock persists
is restored
Perform ultrasonography
Consider pelvic fixation or open DPL.
(consult orthopedic surgeon).
Abdominal Abdominal
ultrasonography ultrasonography
is positive is equivocal
Perform DPL.
Ultrasonogram or DPL is positive by red
DPL is grossly cell count or negative
positive
DPL is DPL is
Perform ED thoracotomy. positive Perform angiography and
negative
percutaneous embolization,
depending on fracture
geography. If DPL was
negative, transport to ICU.
If DPL was positive,
evalute by CT scan.
Transport to OR. < 30 Minutes
Table 1 Guidelines for Declaring Patients must be considered before correct definitive triage is possible.The
Dead on Arrival clinician must rapidly formulate a differential diagnosis and then
sequentially initiate the appropriate diagnostic tests.
Prehospital CPR for > 15 min with no signs of life
Penetrating trauma Airway and Breathing
Asystole without wound that could cause pericar-
dial tamponade After blunt trauma, airway control should proceed on the
Prehospital CPR for > 5 min with no signs of life assumption that an unstable cervical spine fracture exists; thus,
Blunt trauma Asystole hyperextension of the neck must be avoided. Airway management
in the seriously injured victim can usually be accomplished with
simple techniques, but it is occasionally challenging. Evaluation
PRIMARY SURVEY AND INITIAL RESUSCITATION
begins by asking the patient a question such as “How are you?” A
During initial assessment, an empirical sequence of lifesaving response given in a normal voice indicates that the airway is not
therapeutic and diagnostic procedures is pursued. The ultimate in immediate jeopardy; a breathless, hoarse response or no
goal is to establish adequate oxygen delivery to the vital organs. response at all indicates that the airway may be compromised.
This is accomplished by first progressing through the ABCs: air- Airway obstruction and hypoventilation are the most likely
way control with cervical spine precautions, assisted breathing causes of respiratory failure.The critical decision is whether active
with ventilation, and empirical tube thoracostomy to relieve a airway intervention is needed. The first maneuver is to clear the
pneumothorax if indicated. These maneuvers are carried out to airway of debris and to suction secretions. In the obtunded
maximize oxygen delivery to the alveoli. Support of the circulation patient, this procedure is followed by elevation of the angle of the
(tamponade of external bleeding and fluid administration) is insti- mandible to alleviate pharyngeal obstruction and placement of an
tuted to restore effective blood volume, thereby enhancing oropharyngeal or nasopharyngeal tube to maintain airway paten-
myocardial performance and thus oxygen delivery to the tissues. cy. Supplemental oxygen is given via a nasal cannula (6 L/min) or
Unstable patients fall into two categories: those who respond to a nonrebreathing oxygen mask (12 L/min). Airway patency, how-
initial intervention and those who do not. Early nonresponders ever, does not ensure adequate ventilation, nor does a normal
are challenging because they require an immediate lifesaving arterial oxygen saturation (SaO2) on pulse oximetry. Clinical evi-
intervention.The challenge is to perform the correct intervention dence of hypoventilation includes poor air exchange at the nose
before the patient dies. Patients who respond to initial interven- and mouth, diminished breath sounds, and decreased chest wall
tions can be equally challenging because a subset of them have excursion; the most likely causes are head injury, spinal cord tran-
only a finite time window before shock recurs. Multiple diagnoses section, hemopneumothorax, flail chest, and profound shock.
Figure 1 Technique for cricothyrotomy is illustrated here. The larynx is stabilized with one hand, and a 2
cm vertical incision is made over the cricothyroid space. The cricothyroid membrane is palpated and incised
horizontally. A Trousseau dilator is inserted and spread vertically for visualization of the subglottic space
(left). A tracheal hook is used to retract the inferior border of the thyroid cartilage as a tracheostomy tube
with a 6 mm internal diameter is inserted into the trachea (right).
diameter) cuffed endotracheal tube is inserted to a distance of 23

Table 2 10 Steps in Rapid-Sequence cm from the incisors. In children, tube size is gauged to equal the
diameter of the little finger. The proper depth (in centimeters) to
Intubation which the tube should be inserted can be estimated by multiply-
1. Preparation of equipment and supplies
ing the tube’s internal diameter (in millimeters) by 3. A chest x-
2. Preoxygenation
ray should be obtained as soon as possible to rule out the possi-
3. Sedation to decrease anxiety
bility of right mainstem intubation.
4. Premedication to mitigate adverse effects: vecuronium bromide
Intubated patients should be placed on a high fraction of
(1 mg) to prevent defasciculations, lidocaine (1.5 mg/kg) to prevent inspired oxygen (FIO2), and their SaO2 should be monitored by
increased ICP with TBI means of pulse oximetry. Generally, a low SaO2 is easily treated by
5. Cricoid pressure increasing the FIO2. Patients who do not respond when the FIO2 is
6. Administration of paralytic agent: succinylcholine (1.0–1.5 mg/kg), increased to 100% should be treated with low levels of positive
vecuronium bromide (0.6–1.2 mg/kg) if succinylcholine contraindicated end-expiratory pressure (PEEP) once adequate volume status is
7. Intubation assured. Positive-pressure ventilation impedes return of blood to
8. Confirmation of tube position by auscultation and capnography the heart; as a result, emergency intubation of a hypovolemic
9. Securing of airway patient can adversely affect cardiac output. Hyperventilation
10. Chest x-ray should be avoided. An ABG analysis should be obtained to assess
pH and arterial carbon dioxide tension (PaCO2).
ICP—intracranial pressure TBI—traumatic brain injury
Circulation
Once alveolar ventilation is ensured, the next priority is to opti-
Suspected hemopneumothoraces should be vented with large- mize oxygen delivery by maximizing cardiovascular performance.
bore chest tubes inserted via the midlateral thorax. External hemorrhage is controlled by means of manual compres-
Cervical spine protection is integral to airway management but sion, and empirical volume loading for presumed hypovolemia via
should not be allowed to delay necessary intervention.The major- large-bore I.V. cannulas is initiated.The size, number, and sites of
ity of significant spinal injuries in adults arriving alive at the ED are I.V. catheters depend on the degree of shock present and on esti-
at the C5 to C7 levels. In children 8 years old or younger, the most mates of injury severity. If the patient arrives in shock or has obvi-
frequent site of spinal injury is between the occiput and the C3 ous multiple injuries, a short 14 French catheter should be placed
level. Significant spinal cord injury without radiographic abnor- in each antecubital vein. When vascular collapse precludes
malities (i.e., the SCIWORA syndrome) is a relatively rare event peripheral percutaneous access in an adult, the alternative is can-
(0.5% of patients undergoing radiography), and the data on its rel- nulation of the femoral or the subclavian vein by means of the
ative frequency in children and in adults are conflicting.15,16 A frac- Seldinger technique. We have found the supraclavicular subcla-
tured cervical spine is usually tender to direct palpation in alert vian approach to be useful in the ED.23 Venous access should be
patients, but pain may be masked by distracting injuries.17,18 Even avoided in regions with potential penetrating vascular injuries
good-quality cross-table lateral cervical spine films may not detect (e.g., lower neck, upper chest, pelvis, or groin).
15% of unstable fractures. Accordingly, in high-risk patients, a cer- Intraosseous infusion through a cannula placed in the
vical collar is left in place until the cervical spine has been radio- medullary cavity of a long bone is a safe and efficacious method
logically evaluated for bony and ligamentous integrity.19 for emergency vascular access in infants and children younger
Bag-mask ventilation is an effective temporizing measure, but it than 6 years. This procedure is typically performed in the antero-
consumes the attention of a skilled trauma team member, it may medial aspect of the tibial plateau in an uninjured extremity; the
insufflate air into the stomach, and it can be resisted by sponta- distal femur, the distal tibia, and the sternum are other potential
neously breathing patients. It is also ineffective in the presence of sites. Intraosseous infusion generally allows administration of suf-
severe maxillofacial trauma.The decision for urgent airway control ficient fluid to facilitate subsequent cannulation of the venous cir-
is made on clinical grounds; there often is no time to obtain a con- culation.24 If access remains problematic in children, greater
firmatory arterial blood gas (ABG) analysis.20 Persistent airway saphenous vein cutdown at the groin is the preferred route
obstruction or signs of inadequate ventilation mandate prompt because inadvertent femoral artery injury with the percutaneous
intervention. Patients with expanding neck hematomas, deterio- approach may result in limb-threatening vasospasm.
rating vital signs, or severe head trauma are also best managed With establishment of the first I.V. line, blood should be drawn
with an aggressive airway approach. On the other hand, in equiv- for hematocrit, white blood cell (WBC) count, electrolyte con-
ocal situations, an ABG analysis may be decisive. centrations, blood-group typing, coagulation profile, and toxicol-
The best method of airway control depends on (1) the presence ogy screen as indicated.
of maxillofacial trauma, (2) possible cervical spine injury, (3) Isotonic crystalloid is used for initial resuscitation in the
overall patient condition, and (4) the experience of the physician. ED.25,26 Lactated Ringer solution (LR) is preferred to normal
Patients in respiratory distress with severe maxillofacial trauma saline (NS) unless the patient has an obvious brain injury.
warrant operative intervention. Cricothyrotomy is the preferred Excessive early administration of crystalloids has been identified
approach in adults and has virtually replaced tracheostomy in the as a risk factor for adverse outcomes; accordingly, the amount
ED [see Figure 1]; the rare exceptions are in patients with major infused should be closely monitored.27 If the patient does not
laryngeal trauma or extensive tracheal disruption. Percutaneous respond to crystalloid infusion at levels exceeding 30 ml/kg, blood
transtracheal ventilation may be safer than both of these surgical should be administered. LR and banked blood should not be
procedures for temporary airway management, particularly in infused through the same I.V. line.
children. In all other patients, the current standard approach is Early empirical blood transfusions are indicated in patients who
rapid sequence intubation (RSI) of the trachea orally with inline arrive in severe shock or who have injuries associated with signifi-
immobilization [see Table 2].21,22 In adults, a large (8 mm internal cant bleeding (e.g., a vertical shear pelvic fracture or bilateral
femur fractures), especially if the patients are elderly. Type-specif-

ic blood should be available within 20 minutes. If type-specific
blood is not available, reconstituted O-negative packed red blood
cells (RBCs) may be used. Micropore filters are not used in blood
infusion lines in hemodynamically unstable patients, because they
impede infusion capabilities.28 In the future, hemoglobin-based
oxygen carriers may become available, obviating crossmatching.
Protocols for massive transfusions should be established with the
blood bank to ensure prompt availability of blood products for
patients arriving with life-threatening bleeding.29,30
EVALUATION AND CON-
TINUED RESUSCITATION
Identification of
Hemodynamic
Instability
Recognizing the pres-
ence of shock and assess-
ing its severity [see 8:3
Shock] are key factors in early decision making. During the initial
ABCs, palpation for the presence of pulses can be used to gener-
ate an estimate of systolic blood pressure (SBP). In general, a radi-
al pulse is detected when SBP is higher than 80 mm Hg, a femoral
pulse when SBP is above 70 mm Hg, and a carotid pulse when
SBP exceeds 60 mm Hg.The initial blood pressure measurement
should be made with a manual cuff; automatic cuff BP measure-
ment machines may overestimate SBP in hypovolemic trauma
patients.31 An SBP lower than 90 mm Hg (or an age-adjusted
decrease in SBP that exceeds 30 mm Hg) in conjunction with a
heart rate higher than 120 beats/min is generally considered
indicative of shock. Most patients, however, especially young
ones, can compensate for hypovolemia and maintain a normal BP
even in the face of significant ongoing hemorrhage. It should be
kept in mind that because acute massive blood loss may paradox-
ically trigger a vagal-mediated bradycardia, the traditional inverse
correlation between increased HR and reduced effective blood
volume may not hold in the early resuscitation period.32 The ini-
tial hemoglobin level is notoriously misleading, whether because
the patient has not yet been volume loaded or because there has
not been sufficient time for influx of interstitial fluid into the
intravascular space. It may therefore be helpful to measure the
hemoglobin level again after initial volume loading for purposes of
comparison; a decrease greater than 2 g/dl should be grounds for
concern.
The size of the base deficit can be a useful measure of the depth
of hemorrhagic shock.33 Whether the base deficit is persisting or
declining is more important than its absolute value, but generally
a base deficit smaller than –8 mEq/L is indicative of severe shock.
Figure 2 In acute trauma, a tube thoracostomy is performed

through the fourth or fifth interspace at the midaxillary line, well
above the diaphragm (a). A short subcutaneous tunnel is fash-
ioned over the superior edge of the rib, and the overlying fascia
and intercostal muscle are divided sharply. The pleural space is
entered by incising the intercostal muscle and the pleura with a
heavy scissors (b). A gloved finger is then inserted to confirm
penetration of the thoracic cavity and to free up intrapleural
adhesions (c). A large-bore tube (36 French) is directed posterior-
ly toward the pleural apex; the proximal port must be well inside
the chest (d). The tube is then secured to the chest wall with No. 5
braided polyethylene suture and connected to a standard collec-
tion apparatus.
Measurement of central venous pressure (CVP) is helpful in iden-

tifying severe hypovolemia, and serial CVP measurements can be
used to assess response to volume loading. Although arterial lines
are of limited value in initial ED management, they become
increasingly useful as time passes. The end points of initial resus-
citation during the time of critical diagnostic testing and triage are
as follows: (1) SBP higher than 90 mm Hg, (2) HR lower than
120 beats/min, (3) hemoglobin concentration equal to or greater
than 10 g/dl, and (4) CVP equal to or greater than 10 cm H2O.
Management of
Nonresponsive Unstable
Patients
Shock that persists
despite initial volume
loading may derive from
severe hypovolemia, car-
diogenic causes, or neuro-
genic causes. Given that
neurogenic shock is fairly well tolerated, the key concern at this
point is to quickly distinguish hypovolemic shock from cardio-
genic shock because cardiogenic shock may necessitate immedi-
ate ED intervention. This distinction can reasonably be made by
measuring CVP. In hypovolemic shock, CVP is generally less than
5 mm Hg, whereas in clinically significant cardiogenic shock,
CVP usually exceeds 20 mm Hg.
The differential diagnosis of traumatic cardiogenic shock
depends on the mechanism of injury and may include (1) tension
pneumothorax, (2) pericardial tamponade, (3) myocardial contu-
sion, and (4) air embolism. Except in refractory shock, telltale
physical signs are frequently hard to discern in a noisy ED, espe-
cially when compounded by persistent hypovolemia.Timely diag-
nosis requires a high index of suspicion. Tension pneumothorax,
the most common cause of cardiogenic shock in both blunt and
penetrating trauma, is often first confirmed with emergency chest
tube placement [see Figure 2].
In traumatic pericardial tamponade, the classic components of
Beck’s triad (hypotension, muffled heart sounds, and jugular
venous distention) are frequently absent, and pulsus paradoxus is
rarely detectable. ED ultrasonography is the first test employed by
trauma surgeons in patients with high-risk penetrating wounds.34
CVP measurements and pericardiocentesis [see Figure 3] are help-
ful confirmative tests. Occasionally, a blunt trauma patient can be
salvaged through timely diagnosis of a blunt atrial tear. Figure 3 For pericardiocentesis, an 18-gauge spinal needle is
Myocardial contusion should be suspected in any blunt trauma inserted at the left xiphoid-costal junction and inserted toward
patient with unexplained cardiogenic shock or persistent arrhyth- the inferior tip of the left scapula (angled 45° to the patient’s
mia. Electrocardiographic changes are usually nonspecific.35,36 right and 45° from the chest wall). The needle is advanced until
blood or air is encountered; a “pop” may be appreciated as the
Fundamental measures include correction of acidosis, hypoxia,
needle tip traverses the pericardium. If air is withdrawn, the
and electrolyte abnormalities; judicious administration of fluid;
needle tip should be directed more toward the patient’s midline.
and pharmacologic suppression of life-threatening arrhythmias. If blood is withdrawn, 50 ml should be aspirated and injected
Bronchovenous air embolism into the left atrium from a pul- onto a sheet so that it can be inspected for clots. As a rule, intra-
monary laceration typically occurs after penetrating trauma and ventricular blood will clot, whereas defibrinated pericardial
probably is more common than is generally recognized.37 blood will not clot.
Hemodynamic instability develops after positive pressure ventila-
tion is initiated, as air is forced from the pulmonary bronchioles nent cardiac arrest [see Figure 4].38 The physiologic rationale is to
into the adjacent open pulmonary veins and, ultimately, into the minimize the duration of profound shock. ED thoracotomy per-
coronary arteries. ED thoracotomy is essential for pulmonary mits (1) release of pericardial tamponade, (2) control of intratho-
hilar cross-clamping, air aspiration from the left ventricle, and car- racic blood loss, (3) internal cardiac massage, and (4) cross-
diac massage.The patient is then transferred to the OR for defin- clamping of the descending thoracic aorta to enhance coronary
itive management of the pulmonary lesion before the hilar clamp and cerebral perfusion and to reduce subdiaphragmatic bleeding.
is released. Internal cardiac massage should be done bimanually; otherwise, a
ED thoracotomy is an integral part of the initial management forceful thumb may rupture the relatively thin right ventricle as it
of the patient who arrives in extremis and deteriorates to immi- becomes distended.Ventricular lacerations are repaired with pled-
geted horizontal mattress sutures, whereas atrial injuries are con- ry shock with a central abdominal gunshot wound, for example,
trolled with a partially occluding vascular clamp and repaired with clearly should be transported to the OR in a matter of minutes,
a continuous suture [see Figure 5]. Small left ventricular wounds but the management of a previously unstable victim of a motor
can be closed without pledgets. For large left ventricular wounds, vehicle crash who has a positive ultrasonogram combined with
skin staples are an alternative means of rapid closure. altered mental status, a widened mediastinum on chest x-ray, and
an unstable pelvic fracture requires a far more complex decision.
SECONDARY SURVEY
In general, however, when priorities conflict, the safest arena for
WITH DEFINITIVE DIAG-
managing critically injured patients is the OR.
NOSIS AND TRIAGE DECI-
SIONS Penetrating Trauma
Fortunately, most acute- Systematic assessment The secondary survey is more
ly injured patients arriving focused in cases of penetrating trauma than in cases of blunt trau-
in shock can be rendered ma. The priorities are (1) to identify all of the wounds, (2) to
hemodynamically stable decide whether an urgent operation is indicated, and (3) to deter-
enough to undergo a sec- mine whether additional testing is needed to assist with intraop-
ondary survey. Diagnosis and treatment proceed simultaneously. erative management. The decision-making process is driven by
Prioritization is imperative and is governed by the severity of shock hemodynamic stability and the location of the wounds. Efforts
and its rate of progression. Easily correctable life-threatening should focus not on resuscitating the patient until vital signs are
injuries should be addressed first before a search is made for normal but, rather, on obtaining adequate I.V. access, ensuring
occult trauma. Prioritization is also guided by the mechanism of that blood products are available, and notifying the OR. He-
injury. Penetrating trauma typically results in a localized injury, modynamically unstable patients should be rapidly sent to the OR
whereas blunt trauma frequently results in multiple injuries involv- with minimal or no testing.
ing several body regions.When hemodynamic instability recurs, its
cause must be identified and corrected promptly. Neck Patients who have an obvious life-threatening injury
The length of time spent in the ED, the decision for urgent (e.g., a gurgling wound, pulsatile bleeding, or a compromised air-
operation, and the ordering of special radiologic studies are criti- way) or are in severe shock should undergo operation promptly.
cal decisions that must take into account the mechanism of injury, ED management should be limited to airway control, external
the response to resuscitation, and the availability of a staffed oper- compression to control bleeding, I.V. access, and chest x-ray. A
ating room or interventional radiology suite. A patient in refracto- neurologic examination should be performed and documented.
a b
Figure 4 (a) A left anterolateral thoracotomy is performed through

the fifth intercostal space. (b) The lung is reflected superiorly for
placement of a Satinsky vascular clamp on the descending thoracic
aorta. A pericardiotomy is performed with scissors anterior to the
phrenic nerve. (c) A so-called butterfly extension across the sternum
creates a bilateral anterolateral thoracotomy, providing access to
both thoracic cavities and to the pulmonary hila, the heart, and the
proximal great vessels.
Figure 5 (a) A Satinsky vascular clamp is used to control arterial and major vessel injuries while they are closed
with a running suture. (b) For wounds close to coronary arteries, horizontal mattress sutures should be used to
spare the arteries. (c) Small wounds to the thick left ventricle can be closed with interrupted simple sutures. (d )
Larger wounds should be closed using pledgets; staple closure may be preferred for larger ventricular wounds.
Management of hemodynamically stable patients without obvi- graphically documented hemopericardium, and persistent tachy-
ous injury is selective.39 Patients with zone I wounds should cardia should undergo pericardiocentesis to relieve any ongoing
undergo CT scanning or angiography to rule out occult vascular subendocardial ischemia even if SBP is normal [see Figure 3].
injuries. Alert patients with zone II injuries but without significant Patients who exhibit persistent signs of pericardial tamponade
hematoma, crepitance, dysphonia, or dysphagia may be managed despite negative results from ultrasonography or pericardiocente-
expectantly. A missed esophageal injury is associated with signif- sis should be transported to the OR for creation of a subxiphoid
icant morbidity. If there is reason to suspect such an injury, both pericardial window. In approximately 15% of cases, the results of
esophagoscopy and esophagography should be performed. pericardial aspiration for acute hemopericardium are falsely neg-
Although individually these tests have false negative rates ranging ative because the blood in the pericardial sac is clotted and can-
from 10% to 15%, their combined sensitivity approaches 100%.40 not be aspirated.
Asymptomatic patients with zone III injuries should undergo CT If the patient is in extremis, ED thoracotomy should be per-
scanning or angiography if there is any suspicion of an occult vas- formed promptly [see Figure 4]. Most patients experiencing
cular injury. intrathoracic bleeding without pericardial tamponade stabilize
after tube thoracostomy and modest volume loading. Urgent tho-
Chest In unstable patients with thoracic injuries, a chest tube racotomy is indicated for (1) so-called caked hemothorax [see
should be placed into the wounded hemithorax, followed by a Figure 6], (2) an initial chest tube output higher than 20 ml/kg, (3)
chest x-ray to confirm tube placement, lung expansion, hemotho- a persistent output higher than 3 ml/kg/hr for 2 consecutive hours,
rax evacuation, and the presence of foreign bodies. If a cardiac or (4) a 12-hour output exceeding 30 ml/kg. Patients with an ini-
wound is suspected, ED ultrasonography should be performed.34 tial chest tube output higher than 10 ml/kg should be closely
Persistent instability without evidence of intrathoracic bleeding or observed for hemodynamic instability in the ICU. Abrupt cessa-
pericardial tamponade should raise the suspicion of intra-abdom- tion of chest tube output may be deceptive; if hypotension persists
inal bleeding. Occasionally, a high spinal cord injury contributes or recurs, a second chest tube should be inserted and another
to hemodynamic instability. chest x-ray obtained.
The challenge in this setting is to quickly identify those patients Patients with large air leaks, massive subcutaneous emphysema,
who require an urgent operation. Patients who have wounds close or a persistent pneumothorax should undergo bronchoscopy to
to the heart (i.e., in the so-called mediastinal box), ultrasono- exclude a tracheobronchial injury. Patients with transmediastinal
100,000/mm3 mandates laparotomy. Furthermore, an elevated

WBC count, amylase level, alkaline phosphatase level, or bilirubin
concentration in the lavage fluid may identify hollow viscus injury
(HVI); however, threshold values for these measurements have
not been established.45,46
Flank, back, and pelvis Unstable patients with injuries to

the flank, the back, or the pelvis should undergo immediate
laparotomy. Stable patients are difficult to evaluate. With the
exception of blood on rectal examination, the findings from phys-
ical examination are unreliable. Gross hematuria is indicative of
bladder or kidney injury. Triple-contrast CT scanning may be
helpful in patients with high-risk wounds.44,47 Most retroperi-
toneal HVIs are identified on the basis of extraluminal gas or fluid
rather than of contrast extravasation. Sigmoidoscopy should be
performed if a rectal injury is suspected. High-risk wounds should
be explored to ensure that retroperitoneal HVIs are not missed;
delayed diagnosis is associated with significant morbidity.
Extremities Unstable patients with isolated penetrating

injuries to the extremities should be managed with external com-
pression to control bleeding (not with tourniquets or direct vessel
Figure 6 ED chest x-ray shows a massive hemothorax. If the clamping), I.V. access with modest volume loading, and prompt
chest tube fails to evacuate the blood, this is a so-called caked triage to the OR for exploration and definitive treatment. Manage-
hemothorax, which is an indication for emergency thoracotomy in ment of stable patients with penetrating extremity injuries begins
the OR. with a search for “hard” signs of arterial injury (e.g., a large,
expanding, or pulsatile hematoma; absent distal pulses; a palpable
gunshot wounds (GSWs) or penetrating wounds close to the great thrill; an audible bruit; and signs of distal ischemia).48 Presence of
vessels should undergo CT angiography, formal angiography, or any of these hard signs prompts further evaluation. If signs of dis-
both.41 tal ischemia exist, the patient should be taken to the OR, where an
on-table angiogram can be performed. If knowledge of the pa-
Lower chest. Wounds located below the nipples anteriorly or tient’s specific vascular anatomy is needed and no signs of
the tips of the scapulas posteriorly may penetrate the diaphragm ischemia exist, a formal angiogram is reasonable. If “soft” signs of
and cause significant intra-abdominal or retroperitoneal injuries. vascular injury are present, distal blood pressures should be mea-
Such penetration occurs in 10% of stab wounds and 30% of sured in the injured extremity, the contralateral extremity, and,
GSWs.42 If the patient is unstable, tube thoracostomy, chest x-ray, often, the brachial artery. If either the ratio of the BP in the injured
and abdominal ultrasonography are indicated. If instability per- extremity to that in the contralateral extremity or the ratio of the
sists, the patient should be transported to the OR. If the patient BP in the injured ankle to that in the brachial artery is 0.90 or
stabilizes after tube thoracostomy, additional testing must be higher, arterial injury is excluded and no additional testing is
done to exclude associated injuries. Diagnostic peritoneal lavage needed. These ratios are not, however, reliable for excluding arte-
(DPL) is a good screening test for intra-abdominal injuries. The rial injuries in the axilla or the groin. The presence of a good
RBC threshold for abdominal exploration is lowered to Doppler signal does not exclude a vascular injury.
10,000/mm3 because isolated diaphragmatic injuries may not
bleed. An intermediate RBC count (1,000 to 10,000/mm3) war- Blunt Trauma
rants further evaluation with thoracoscopy or laparoscopy Systematic assessment The goal is to identify all potential-
because DPL may contribute this degree of RBC contamina- ly life- and limb-threatening injuries. A comprehensive assessment
tion.43 CT scanning may assist in diagnosing occult retroperi- is crucial to facilitate triage from the ED to the OR, the CT scan-
toneal injuries, but it is not reliable for excluding penetrating ning suite, the interventional radiology suite, or the ICU. The
diaphragmatic injuries.44 details of the patient’s medical history, as well as the details specif-
ically related to the injury, are critical.The prehospital emergency
Anterior abdomen Unstable patients should be transport- medical technicians are encouraged to provide a comprehensive
ed to the OR with minimal resuscitation and testing. Biplanar account of the event and a thorough patient assessment. A mini-
abdominal x-rays are often helpful in clarifying bullet trajectories; mal review of the patient’s medical history should include preex-
entrance and exit wounds should be marked with radiopaque isting medical illnesses, current medications (and when they were
objects. Intravenous pyelography (IVP) is not indicated, because most recently ingested), allergies, tetanus immunization status,
it takes too much time. Management of stable patients depends and the time of the last meal. A rapid, systematic physical exami-
on the mechanism of injury. Laparotomy is indicted for GSWs nation is done, literally from head to toe. Patients are completely
that violate the peritoneal cavity. DPL or laparoscopy is indicated disrobed and, once spinal injury is excluded, rolled from side to
for suspicious tangential GSWs. Laparotomy is indicated in side so that the back and the flanks can be inspected. A rectal
patients with overt peritonitis after a stab wound. In other examination is done to look for blood and to evaluate sphincter
patients, the stab wound should be explored. If there is no viola- tone; the perineum and the axillae are inspected; and neurologic
tion of the anterior fascia, the patient can safely be discharged. If function and peripheral pulses are assessed.
the fascia is violated, DPL is indicated; an RBC count higher than The cervical spine is rigidly immobilized, and long-bone frac-
who have been exposed to a cold environment or who require

massive volume replacement. A core temperature reading lower
than 32° C (89.6° F) should be confirmed with an esophageal
probe, and rewarming measures appropriate for the degree of
hypothermia should be initiated.50 Tetanus prophylaxis is routine.
Systemic antibiotics should be withheld until a specific indication
arises. An electrocardiogram is obtained after blunt chest trauma,
and an ABG analysis is done in select patients to confirm adequate
ventilation and metabolic balance. In any patient with evidence of
hypovolemia, a blood sample should be sent for blood-group typ-
ing and coagulation studies if urgent blood transfusion is required.
Rapid hemorrhage control Blunt trauma patients who

arrive in shock and remain hemodynamically unstable pose diffi-
cult triage decisions. Initial screening must be directed at identify-
ing life-threatening bleeding that necessitates immediate OR inter-
vention. Most hospitals do not have an interventional radiology
suite immediately available; early notification is crucial in assem-
bling the team. At our institutions, after normal working hours,
this process consumes about 1 hour.
Initial screening focuses on the chest, the abdomen, and the
pelvis. A chest x-ray is the most reliable screening test for intratho-
racic bleeding; it also confirms the location of endotracheal, naso-
gastric, and thoracostomy tubes, as well as that of the central
venous catheter. The presence of pleural fluid may be difficult to
confirm on a supine chest x-ray: 1 L of blood may produce only a
hazy appearance in a hemithorax. Hemothoraces should be
drained promptly via tube thoracostomy [see Figure 2]. Continued
bleeding must be monitored carefully by measuring chest tube
Figure 7 (a) Shown are four transducer positions in the FAST output, obtaining serial chest films to detect retained intrapleural
(focused assessment for sonographic evaluation of the trauma blood, and observing vital signs. The criteria used to decide when
patient): (1) pericardial area, (2) right upper quadrant, (3) left
thoracotomy is indicated are similar to those used in cases of pen-
upper quadrant, and (4) pelvis.
etrating trauma, but far fewer blunt trauma patients meet these
criteria, and intrathoracic bleeding is rarely a reason for immedi-
tures are splinted to minimize pain, blood loss, and soft tissue ate OR triage.51
damage. Insertion of a nasogastric tube decompresses the stom- The abdomen is notoriously difficult to evaluate and is much
ach and reduces the risk of pulmonary aspiration, but because more likely than the chest to harbor occult life-threatening bleed-
maxillofacial injury may provide a pathway into the cranial vault,49 ing. The peritoneal cavity may sequester as much as 3 L of blood
the tube should be placed orally when midfacial fractures are pres- with only minimal abdominal distention. Head injury or intoxica-
ent. Blood in the gastric aspirate may be the only sign of an oth- tion frequently alters the patient’s response to acute injury, and
erwise occult injury to the stomach or the duodenum. pain from associated fractures may overshadow peritoneal irrita-
tion secondary to bleeding. Ultrasonography [see Figures 7 and 8]
Placement of a Foley catheter empties the bladder, may disclose
is the most rapid method of identifying free blood, but it may yield
hematuria, and permits the physician to monitor urinary output.
false negative results in as many as 15% of patients on initial
The Foley catheter should not, however, be inserted until abdom-
examination.52,53 DPL [see Figure 9] remains the most reliable
inal ultrasonography is completed, and it should not be placed on
method of identifying significant intraperitoneal hemorrhage: in
an urgent basis in male patients with suspected urethral injuries
patients with life-threatening bleeding, its sensitivity approaches
(i.e., those with blood at the meatus, a perineal hematoma, 100%.54 A grossly positive aspirate (> 10 ml of blood) mandates
a high-riding prostate, or an extensively displaced anterior pelvic emergency laparotomy.
fracture). If urethral injury is suspected, a retrograde urethrogram, Assessment of bony stability by means of physical examination
followed by a cystogram (to exclude bladder injury) is obtained, and plain films of the pelvis is crucial for the early identification of
prioritized in accordance with the given setting. In females, the major pelvic fractures. Life-threatening hemorrhage occurs most
urethra is shorter and better protected and thus is rarely injured. commonly with fracture patterns involving the posterior columns
Routine x-rays performed simultaneously with the ABCs [see Figure 10].30,55 Appropriate initial management of unstable
include lateral cervical spine, anteroposterior chest, and pelvic patients who have a high-risk pelvic fracture on initial pelvic x-ray
films. Once life-threatening injuries have been addressed, thoracic includes blood volume replacement (including early blood and
and lumbar spine films should be obtained in patients who com- fresh frozen plasma [FFP]) and application of a pelvic binder;
plain of back pain, those with neurologic deficits, and those with wrapping with a sheet is also effective [see Figure 11].
high-risk mechanisms of injury in whom physical examination is The next step is to evaluate the response to initial resuscitation
unreliable. X-rays of extremities with suspected fractures (includ- and then perform ultrasonography or DPL to determine whether
ing the joint above and the joint below) should also be obtained. significant intra-abdominal bleeding is present.56,57 An unstable
Given that trauma victims are uniquely susceptible to hypo- patient with clearly positive findings from ultrasonography or
thermia, a rectal or bladder temperature probe is essential in those DPL should undergo laparotomy because of the high probability
a b
Figure 8 (a) Sagittal ultrasound image of liver, kidney, and diaphragm yields normal findings. (b) Sagittal ultrasound
image of right upper quadrant shows blood between liver and kidney and between liver and diaphragm.
Figure 9 Illustrated here is the semiopen technique for peri-

toneal lavage. A 3 to 4 cm incision is made over the infraumbilical
ring, and the linea alba is incised vertically for 1 cm. The fascial
edges are grasped with towel clips and elevated. A standard peri-
toneal dialysis catheter is introduced into the peritoneum at a 45°
angle and then advanced into the pelvis without use of the trocar.
If 10 ml of gross blood is aspirated, the study is considered to be
positive. Otherwise, 1 L of normal saline (10 ml/kg for children) is
infused. The lavage fluid is retrieved by gravity siphonage; the
empty saline bag is dropped to the floor. Ultrasonography is help-
ful for confirming intraperitoneal fluid infusion. A 50 ml sample
of the fluid is submitted for laboratory analysis.
gram depends on the patient’s hemodynamic stability. A CT scan

can be helpful in refining triage by identifying extravasation of
I.V. contrast (i.e., a blush) and in diagnosing HVIs. A blush
should prompt consideration of angiography. Early angiography
is a helpful adjunct in managing liver and kidney injuries, though
its role in managing acute splenic injuries remains to be estab-
lished.60-64 HVIs are notoriously difficult to diagnose; extravasa-
tion of oral contrast is rare.65,66 When all signs (e.g., unexplained
free fluid, bowel wall thickening, mesenteric streaking, and free
air) are considered, however, the sensitivity of CT in making the
diagnosis approaches 90%. In questionable cases of HVI in sta-
bilized patients, we advocate delayed DPL to search for eleva-
tions in WBC count, amylase level, and alkaline phosphatase
level.
Identification of traumatic brain injury Approximately

20% of blunt trauma patients who arrive in shock have a TBI.67
During initial evaluation, it is important to identify TBI patients
who might benefit from an emergency craniotomy.The neurolog-
ic examination is of utmost importance.The initial Glasgow Coma
Scale (GCS) score in the field should be confirmed with prehos-
pital personnel, and short-acting sedatives/paralytics should then
Figure 10 Pelvic angiography with selective embolization may

be an integral component in the early management of a major
pelvic crush injury with continuing hemorrhage.
of major hepatic, splenic, or mesenteric bleeding. If there is a large

pelvic hematoma at the time of laparotomy and the patient is
unstable, embolization of the internal iliac artery may be per-
formed with a slurry of autogenous clot, microfibrillar collagen,
thrombin, and calcium chloride.58 A hemodynamically unstable
patient in whom the ultrasonogram is normal and DPL yields
confirmatory negative results should undergo prompt pelvic arte-
riography for selective embolization.59
Fast track CT scanning to refine triage In unstable pa-

tients who respond to initial interventions, the priorities are as fol-
lows: (1) identify and quantitate ongoing sources of bleeding, (2)
identify TBI, especially in those patients who require immediate
craniotomy, and (3) identify any other injuries that call for urgent
intervention (e.g., thoracic aortic injury [TAI]) or special precau-
tions (e.g., spine fractures). With the widespread availability of
multidetector CT scanners, rapid whole-body imaging is now fea-
sible, permitting accurate triage for these competing priorities.
The important question is whether the patient is stable enough to
survive for the time such imaging takes. At our institutions, prepa-
ration, transport, and scanning take, in all, roughly 40 minutes.
The decision to order CT scanning is made early, while the ABCs
are being addressed and ultrasonography and initial plain x-rays
are being performed, and depends on the age of the patient, any
obvious injuries identified, and the patient’s hemodynamic stabil-
ity.The decision is less clear-cut in the common situation in which
a previously unstable patient has a positive abdominal ultrasono-
gram. The key issue here is which injuries identified by CT scan-
ning would alter the decision to perform an urgent laparotomy.
Identification of abdominal injuries The decision to per- Figure 11 Shown is the wrapping technique currently used for
form an urgent laparotomy in a patient with a positive ultrasono- support of a mechanically unstable pelvic fracture.
be given sparingly. A GCS score lower than 8 and a lateralizing cotomy.71 Currently, however, antihypertensive therapy and ICU
neurologic examination indicate a significant risk that emergency monitoring allow delayed repair in patients with significant asso-
craniotomy will be needed and, therefore, justify obtaining a CT ciated injuries.72 Delayed repair is safe but is associated with
scan of the head if hemodynamic stability permits.68,69 increased infectious complications and longer ICU stays.73
Identification of thoracic aortic injury Initial plain films Identification of limb ischemia The absence of distal
should be examined for evidence of TAI. We use the overpene- pulses in a fractured or dislocated extremity should be addressed
trated mediastinal view and specifically look for evidence of a urgently. Fractures and dislocations should be reduced, and the
mediastinal hematoma. In the multi-institutional study from the extremity should be closely examined for signs of ischemia.
American Association for the Surgery of Trauma (AAST), how- Distal SBP measurements comparing injured limbs with nonin-
ever, 7% of patients with TAI had a normal ED chest x-ray. We jured limbs (i.e., the ankle-ankle index [AAI] or the ankle-
therefore obtain a chest CT scan on the basis of the mechanism brachial index [ABI]) should be obtained. If the ABI or AAI is
of injury.70 At our institutions, CT scanning has replaced angiog- less than 0.90 after reduction, CT angiography or formal
raphy for the diagnosis of TAI. An occasional angiogram is done angiography should be performed to exclude the presence of a
to confirm the diagnosis of great vessel injury or to clarify the vas- vascular injury.74,75 A pulseless extremity is best evaluated in the
cular anatomy before thoracotomy. OR by means of on-table angiography. Delayed diagnosis as a
The management of TAI has changed markedly over the past result of waiting for formal angiography is a preventable cause of
decade. Traditionally, a diagnosis of TAI mandated urgent thora- limb amputation.
Discussion
Prehospital Care
include RSI have been instituted. This practice may, however, be
associated with worse outcomes.3 Patients intubated in the field
ADVANCED TRAUMA LIFE SUPPORT
are routinely hyperventilated, and this state has adverse physio-
The growing sophistication of emergency medical services has logic consequences. Increased intrathoracic pressure obstructs
expanded the scope of prehospital care, but the extent of prehos- venous return to the heart, impairs venous drainage from the
pital interventions remains a highly controversial issue.1,2 In trau- brain, and, in hypovolemic patients, decreases cardiac output.
ma, advocates of the so-called scoop-and-run philosophy argue Additionally, a low PaCO2 causes cerebral vasoconstriction.
that resuscitative efforts in the field unnecessarily delay provision Routine end-tidal capnometry for TBI patients undergoing field
of definitive care and have detrimental effects on physiology and intubation has been proposed as the standard of care for prevent-
survival when overzealously applied.3,5 At present, there is little ing excessive hyperventilation.4
evidence to support the use of ATLS in prehospital management
of urban trauma patients. ATLS skills may be of value in rural Prehospital Volume Resuscitation
areas where transport time exceeds 30 minutes, but unfortunate- A provocative 1994 clinical trial found that for hypotensive
ly, the limited volume of serious trauma in such areas makes it dif- patients with penetrating torso injuries, survival improved when
ficult to gain the experience necessary to maintain this expertise. fluid resuscitation was delayed until surgical intervention had
controlled the source of hemorrhage.6 A subsequent subset analy-
Airway Management sis, however, revealed that survival was improved only in patients
The goal of initial resuscitation is to restore adequate oxygen who had sustained cardiac injuries, not in patients who had sus-
delivery to vital organs. Efforts to improve tissue perfusion will be tained major vascular, abdominal solid organ, or noncardiac tho-
unproductive unless the oxygen content of the circulating blood is racic injuries.78 Although this clinical trial had some methodolog-
sufficient. Airway patency and maintenance of adequate ventilation ic flaws, it is important because it emphasizes that source control
are thus the initial priorities. However, intubation and positive of hemorrhage is an overriding priority in hemodynamically
pressure ventilation inhibit venous return to the heart and detri- unstable patients.
mentally decrease cardiac output in hypovolemic patients.76 In Whether fluid resuscitation should be withheld until control of
addition, emergency airway control after blunt trauma should be hemorrhage is achieved is doubtful; such an approach is clearly
performed with the assumption that an unstable cervical spine not the current standard of care. The point at issue is whether it
fracture exists until such injuries are excluded radiologically, but is preferable to administer fluids to restore oxygen delivery to tis-
this policy does not preclude RSI.The current recommendation— sue, thus potentially causing hemodilution and disruption of early
orotracheal intubation with in-line manual stabilization of the head hemostatic clots, or to withhold fluid resuscitation, thus prolong-
and neck—has proved safe in clinical series to date. When orotra- ing cellular shock to the point where it may be irreversible by the
cheal intubation fails, the laryngeal mask airway (LMA) is a rapid, time operative control is accomplished. At present, the rational
safe, and effective technique for maintaining temporary airway compromise between these two approaches is hypotensive resus-
control until definitive medical care becomes available.77 For citation with moderate volume loading.79,80 Whereas this
patients with extensive maxillofacial trauma that precludes oral approach is becoming the standard of care for penetrating trau-
intubation, cricothyrotomy has been the traditional alternative, but ma, its application to blunt trauma is not as clear. Some 20% of
this procedure has some risks, particularly in children. patients with major torso trauma have a serious concomitant TBI;
if they are inadequately resuscitated, reduced cerebral perfusion
Prehospital Intubation of Patients with TBI pressure may lead to devastating secondary brain injury. The
Because hypoxia has been associated with increased mortality anticipated availability of hemoglobin-based oxygen carriers may
in patients with TBI, aggressive prehospital airway protocols that further confound the hypotensive resuscitation debate.
Resuscitation with Hypertonic Saline BLOOD VOLUME RESTITUTION
Small-volume hypertonic saline (HS) has been shown to be as

Crystalloid versus Colloid
effective as large-volume crystalloid in expanding plasma volume
and enhancing cardiac output.81 Furthermore, HS increases per- Resuscitation with isotonic crystalloids has been the standard
fusion of the microcirculation, presumably by inducing selective of care in the United States since the late 1960s. A number of
arteriolar vasodilation and by reducing the swelling of RBCs and clinical trials were performed in the 1970s and 1980s that com-
endothelium82; however, this improved microcirculation could pared isotonic crystalloid resuscitation with colloid resuscita-
lead to increased bleeding. The resuscitative effectiveness of HS tion. Individually, these trials were underpowered and reported
can be further enhanced by combining it with dextran (hyper- conflicting results. When subjected to meta-analysis, they yield-
tonic saline dextran [HSD]).83 ed no consistent differences in overall outcome.91 When the
In view of the small volumes needed to achieve the desired same data were subjected to subgroup analysis, however, the use
effects, there has been great interest in employing these fluids for of isotonic crystalloids in trauma patients appeared to be associ-
field resuscitation in both military and civilian settings. A number ated with improved survival. A large clinical trial published in
of trials investigating the use of HS and HSD have been per- 2004 found no differences in outcome between crystalloid and
formed. Individually, these trials reported inconsistent results in colloid resuscitation in ICU patients, but again, subgroup analy-
terms of improved survival; however, collectively, the trials did sis demonstrated improved outcomes in trauma patients receiv-
confirm that a bolus of either HS or HSD was safe.84 Meta-analy- ing crystalloids.92 Although these subgroup analyses are not
sis of the data suggested that HS was no better than the current definitive, they are consistent with the early laboratory studies,
standard of care (isotonic crystalloid fluids) but that HSD might which indicated that survival in hemorrhagic shock is optimized
be better.83 Subgroup analysis of the data showed that the patients by administering isotonic crystalloids and blood in a 3:1 ratio.
who benefited most from HSD were those who presented with Subsequent animal studies suggested that the optimal ratio rises
shock and concomitant severe TBI. The results of this analysis to 8:1 in severe shock.93,94 However, several current reports sug-
agreed with laboratory data showing that in comparison with iso- gest that “damage control” surgery combined with aggressive
tonic crystalloid, both HS and HSD raised cerebral perfusion ICU resuscitation appears to be saving the lives of many patients
pressure, lowered intracranial pressure, and reduced brain who previously would have exsanguinated, but it also appears to
edema.85 be causing adverse edema in the brain (increased ICP), the lung
The argument in favor of HS resuscitation is even more com- (worsened pulmonary edema), and the gut (the abdominal com-
pelling with the recognition that this approach markedly reduces partment syndrome).27
the inflammatory response (specifically, neutrophil cytotoxicity)
Choice of Crystalloid
in animal models of hemorrhagic shock, ischemia and reperfu-
sion, and sepsis. However, one well-executed trial that tested HS The selection of a crystalloid engenders less controversy than
for field resuscitation of TBI patients in shock did not demon- the choice between crystalloid and colloid. Although newer form-
strate any benefits.86 ulations (e.g., Ringer’s ethyl pyruvate) are being tested clinically,95
NS and LR remain the most commonly used fluids. In theory, LR
is preferable to NS because it provides a better buffer for meta-
Emergency Department Management bolic acidosis, but to date, investigators have not documented
any important differences in outcome.96,97 One laboratory study
EMERGENCY DEPARTMENT RESUSCITATIVE THORACOTOMY found that NS and LR were equivalent in the setting of moderate
ED thoracotomy is an integral part of the initial management hemorrhagic shock but that, in the setting of massive hemorrhage,
of trauma patients who arrive in extremis.87 When blood volume NS was associated with greater physiologic derangement (e.g.,
is depleted or pericardial tamponade is present, closed-chest hyperchloremic acidosis) and higher mortality.25 Clinical experi-
compression is ineffective in maintaining systemic blood flow,88 ence confirms the adverse effects of iatrogenic hyperchloremia.98
whereas open cardiac massage maintains coronary and cerebral NS is preferred, however, when blood is being transfused simul-
perfusion for as long as half an hour. Adjunctive thoracic aorta taneously.99 There is some concern that the calcium in LR could
occlusion enhances both coronary and cerebral perfusion by exceed the chelating capabilities of the citrate in the stored blood,
maintaining aortic diastolic pressure and increasing carotid sys- resulting in the formation of clots that could enter the circulation
tolic pressure. Aortic cross-clamping also decreases subdiaphrag- and compromise the microcirculation, but at present, there is no
matic bleeding in the event of associated abdominal injury.89 hard evidence that this is a significant issue.
These benefits are obtained at the expense of increased myocar-
dial oxygen demand and poor perfusion of the lower torso. Transfusion Trigger
Clinical experience suggests that 30 minutes is the limit for pre- The optimal hemoglobin level continues to be a subject of live-
vention of splanchnic ischemic sequelae. ly debate.100 Early laboratory studies demonstrated that survival
The possibility of patient salvage is largely determined by the was improved when the hemoglobin concentration was main-
mechanism of injury, as well as by the patient’s condition at the tained in the range of 12 to 13 g/dl.101 Subsequent studies using
time of thoracotomy. Success rates approach 50% in patients arriv- isovolemic hemodilution models, however, indicated that the
ing in shock from a penetrating cardiac wound and 20% in patients optimal level for maintaining oxygen delivery was 10 g/dl, and
with penetrating wounds as a whole. On the other hand, patient until relatively recently, this value represented the recommended
outcome is dismal when ED thoracotomy is performed in the set- level for critically ill patients.102,103 Currently, there is a growing
ting of blunt trauma; it is now considered futile in patients lacking recognition that administration of stored packed RBCs can
cardiac activity. Adding laparotomy in the emergency department adversely affect outcome by modulating the inflammatory
for definitive control of abdominal hemorrhage has not improved response (amplifying early proinflammation and aggravating late
outcomes.90 immunosuppression) and by impairing tissue perfusion (limiting
access to or obstructing the microcirculation as a consequence of

Major Torso Trauma
reduced RBC deformability).104-106 A 1999 randomized trial
found that patients who received transfusions according to a
restrictive policy (i.e., transfusion when the hemoglobin concen-
tration fell below 7 g/dl) did as well as, and possibly better than, Active
patients who received transfusions on a more liberal basis (i.e., Hemorrhage
transfusion when the hemoglobin concentration fell below 10
g/dl).107 Admittedly, this study was done in a select group of eu- Progressive
Coagulopathy Iatrogenic
volemic patients; thus, it is not clear precisely how applicable the
Factors
results are to severely injured trauma patients requiring resuscita-
tion from shock. In addition, if blood transfusions are to be
restricted during acute resuscitation, it is not clear which alterna- Core Cellular
Hypothermia Shock
tive fluids should be used.
Choice of Blood Product
Metabolic Tissue
Fully crossmatched blood is rarely available for ED trauma Acidosis Injury
resuscitation. Uncrossmatched type-specific whole blood or
packed RBCs can be safely administered,108,109 and either alterna-
Contact Massive
tive is available in most hospitals within 20 minutes. If type-specif- Activation Transfusion
ic blood is unavailable, reconstituted O-negative packed RBCs
should be used. Type O-negative blood has no cellular antigens;
therefore, the risk of major hemolytic reactions caused by patient
Clotting Factor
antibodies attacking donor RBC antigens is minimal. When O- Deficiencies Preexisting
negative packed RBCs are unavailable, O-positive packed red Diseases
blood cells may be used.The patient will become sensitized to the
Rh factor, which is significant for women of childbearing age.
Figure 12 The so-called bloody vicious cycle is a syndrome that
Blood Substitutes has a multifactorial pathogenesis. The usual manifestations
include coagulopathy, hypothermia, and metabolic acidosis.118
As a consequence of the limited supply of stored blood and
the recognition that transfusions contribute to adverse patient
outcomes, there has been a resurgence of interest in blood sub- been tested extensively in phase I and phase II trials in trauma
stitutes. Hemoglobin-based oxygen carriers date back to 1933, patients and has proved to be safe and effective.113,114 A phase III
when it was shown that hemolysates could transport oxygen in prehospital trial is under way.
mammals.110 Unfortunately, when these solutions were infused
EARLY IDENTIFICATION OF NONRESPONDERS
into humans, they had excessively toxic effects (i.e., vasocon-
striction, acute renal failure, and abdominal pain), which were BP and HR are the current standard-of-care monitors of shock
attributed to stromal contamination. Although the next genera- resuscitation in the field and in the ED. Both, however, are insen-
tion of carrier solutions was stroma-free, toxic effects persisted sitive markers of early compensated shock; alternative monitors are
and were attributed to the instability of the hemoglobin badly needed for assessing the adequacy of tissue perfusion with a
tetramer, which spontaneously dissociates into dimers and view to avoiding both underresuscitation and overresuscitation.
monomers.111 Near-infrared spectroscopy (NIRS), a simple technique that mon-
One formulation of stabilized tetramer, diaspirin cross-linked itors oxygen saturation in tissue, has been shown to track oxygen
hemoglobin, was authorized for a phase III study in trauma delivery reasonably well during shock resuscitation and is being
patients.112 However, the trial was prematurely stopped because of tested as an ED monitor.115 Transcutaneous oxygen tension (PtcO2)
the unexpectedly high mortality in the treatment group (24/52 monitoring and central venous oxygen saturation (ScvO2) monitor-
[46%], compared with 8/46 [17%] in the control group). ing have also shown promising results in the ED environment.116
Although this event was judged a major setback for clinical imple- The challenge is to identify as early as possible those patients
mentation of hemoglobin-based oxygen carriers, the product used who are not responding to early interventions. Blind and aggres-
had already been shown to increase pulmonary and systemic vas- sive volume loading in the hope of normalizing BP and HR, with-
cular resistance in animals. Tetrameric hemoglobin extravasates out appropriate emphasis on control of hemorrhage, sets the stage
from the vascular space, binds nitric oxide within the vessel wall, for the so-called bloody vicious cycle or the abdominal compart-
and thereby results in unopposed vasoconstriction.This issue has ment syndrome.
been effectively addressed by polymerizing the hemoglobin
BLOODY VICIOUS CYCLE
tetramer. The additional benefit of these larger moieties is that
they exert less colloid osmotic activity, which means that a higher Among the most devastating complications of massive blood
dose can be administered. and fluid resuscitation is a bleeding diathesis. Paradoxically,
A further limitation of earlier hemoglobin-based oxygen carri- although clotting is accelerated at the capillary level because of
ers was that because of the loss of 2,3-diphosphoglycerate, oxygen shock and tissue damage, the circulating blood becomes hypoco-
affinity was greatly increased; the partial pressure of oxygen agulable.117-119 The pathogenesis of this bloody vicious cycle is
required to produce 50% saturation (P50) decreased from the nor- complex [see Figure 12]. Factors predictive of a severe coagulo-
mal 26 mm Hg to 12 mm Hg. This problem was addressed by pathic state include (1) massive rapid blood transfusion (10
pyridoxylation of the hemoglobin tetramer, which raised the P50 units/4 hr), (2) persistent cellular shock (oxygen consumption
to 29 mm Hg. One such polymerized hemoglobin solution has index < 110 ml/min/m2; lactate concentration > 5 mmol/L), (3)
progressive metabolic acidosis (pH < 7.20; base deficit > 14 lism.124 Acidosis in the trauma patient is caused primarily by a rise
mEq/L), and (4) refractory core hypothermia (< 34° C).120 in lactic acid production secondary to tissue hypoxia and usually
Stored blood is deficient in factors V and VIII and platelets but resolves when the volume deficit has been corrected. Administra-
replete with fibrin split products and vasoactive substances. tion of sodium bicarbonate may cause a leftward shift of the oxy-
Timely administration of FFP and platelets will minimize the risk hemoglobin dissociation curve, reducing tissue oxygen extraction,
of coagulopathy after massive transfusion.29,30 Presumptive factor and it may worsen intracellular acidosis caused by carbon dioxide
replacement, though not usually indicated in the early resuscita- production.119 On the other hand, adrenergic receptors may
tion phase, is appropriate in patients with massive hemorrhage become desensitized with protracted acidosis. Studies indicate that
caused by unstable pelvic fracture. vasopressin may be more effective than epinephrine as hemor-
Also germane to the initial period of massive blood transfusion rhagic shock approaches irreversibility.125,126 Bicarbonate infusion,
are the potential complications of acidosis, hypothermia, and therefore, should be limited to persons with protracted shock.
hypocalcemia. Moderate hypothermia (< 32° C) causes platelet Hypocalcemia caused by citrate binding of ionized calcium
sequestration and inhibits the release of platelet factors that are does not occur until the blood transfusion rate exceeds 100
important in the intrinsic clotting pathway. In addition, it has con- ml/min (1 U/5 min). Decreased serum levels of ionized calcium
sistently been associated with poor outcome in trauma patients.121 depress myocardial function before impairing coagulation.127,128
Core temperature often falls insidiously because of exposure at Calcium gluconate (10 mg/kg I.V.) should be reserved for cases
the scene and in the ED and because of administration of resus- in which there is ECG evidence of QT interval prolongation or,
citation fluids stored at ambient temperature. The first step is to in rare instances, for cases of unexplained hypotension during
prevent further heat loss by covering the body (including the massive transfusion.
head) and infusing warm blood and fluid. Another simple tech-
ABDOMINAL COMPARTMENT SYNDROME
nique is to heat and aerosolize ventilator gases. Active external
rewarming with heating blankets and increased room tempera- Abdominal compartment syndrome has emerged as a virtual
ture should also be employed. These techniques are not, howev- epidemic in busy trauma centers that practice damage-control
er, very effective in reversing established hypothermia. surgery and goal-oriented ICU resuscitation.129 This syndrome is
The use of bicarbonate in the treatment of systemic acidosis an early event, and its clinical trajectory can be accurately pre-
remains controversial. Moderate acidosis (pH < 7.20) impairs dicted within 3 to 6 hours after ED admission.27 At admission to
coagulation,122 myocardial contractility,123 and oxidative metabo- the ICU, high-risk patients have significant intra-abdominal
hypertension and are in persistent shock. Contrary to conven-
tional wisdom, they do not respond well to preload-directed
Prolonged Shock resuscitation.130 In fact, continued aggressive resuscitation pre-
cipitates the full-blown syndrome [see Figure 13].
Fundamental changes are needed in pre-ICU resuscitation.
Failure to recognize ongoing bleeding, indiscriminate crystalloid
Gut Ischemia-Reperfusion
infusion, and failure to prioritize definitive measures for hemor-
rhage control have been identified as key issues in the ED.131 We
share the belief that colloids may reduce the incidence of abdom-
Overwhelming of Antiedema inal compartment syndrome, but in our view, this possible bene-
Safety Factors
fit must be weighed against the potentially detrimental effects of
colloids. In severe hemorrhagic shock, the permeability of capil-
lary membranes increases, allowing the entry of colloids into the
Crystalloid Gut Edema
Filtration Secretion interstitial space, which can then exacerbate edema and impair
Resuscitation
IAP tissue oxygenation. The theory that these high-molecular-weight
agents plug capillary leaks that occur during neutrophil-mediated
Gut Dysfunction organ injury has not been proved.132,133 Furthermore, it has been
suggested that resuscitation with albumin induces renal failure
Transcapillary and impairs pulmonary function.134
Fluid Flux Similarly, hydroxyethyl starch (Hetastarch; Baxter Healthcare,
Abdominal
Compartment Deerfield, Illinois) has been shown to induce renal dysfunction in
Syndrome patients with septic shock and in recipients of kidneys from brain-
dead donors.135 Hetastarch also has a limited role in massive
Venous Compression
resuscitation because it causes coagulopathy and hyperchloremic
acidosis as a result of its high chloride content. Another hydrox-
yethyl starch preparation (Hextend; BioTime, Berkeley,
Cardiac Preload
California) has been developed that purportedly does not cause
these adverse effects, but it has not been studied in the setting of
massive resuscitation.136,137
Figure 13 Depicted is the so-called saltwater vicious cycle, which In addition, alternative crystalloid solutions are being devel-
results in the development of abdominal compartment syndrome.
oped that not only expand the intravascular space and replenish
The term filtration secretion refers to the process by which
increasing gut edema causes interstitial pressure to rise to high
the extracellular fluid but also have anti-inflammatory properties
levels, leading to disruption of the interstitial matrix. Ultimately, (e.g., Ringer’s ethyl pyruvate).95 The data currently available sug-
as a result, the villus tips spring leaks, through which interstitial gest that crystalloid administration should be restrained.
fluid passes into the gut lumen. (IAP—intra-abdominal Alternative means of enhancing tissue oxygen delivery may
pressure) involve earlier use of inotropic or vasoactive agents.
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Prospective study of blunt aortic injury: multi- 91. Choi PT-L, Yip G, Quinonez LG, et al: 113. Gould SA, Moore EE, Moore FA, et al: Clinical
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Effects of acidosis on cardiovascular function in Thorac Cardiovasc Surg 78:185, 1979 Effects of hydroxyethyl starch and gelatin on
surgical patients. Ann Surg 154:524, 1961 129. Trunkey D, Carpenter MA, Holcroft J: Calcium renal function in severe sepsis: a multicenter ran-
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dominal compartment syndrome: the cause or expander for large volume use in major surgery:
125. Douglas ME, Downs JB, Mantini EL, et al:
effect of multiple organ failure? Shock 20:483, a randomized phase III clinical trial. Anesth
Alteration of oxygen tension and oxyhemoglobin
2003 Analg 88:992, 1999
saturation: a hazard of sodium bicarbonate
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Patients with impending abdominal compart- new modified, balanced hydroxyethyl starch
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Acknowledgments
127. Morales D, Madigan J, Cullinane S, et al: 133. Conhaim RL, Watson KE, Potenza BM, et al:
Reversal by vasopressin of intractable hypoten- Pulmonary capillary sieving of Hetastarch is not Figures 1 and 3 Carol Donner, revised by Tom
sion in the late phase of hemorrhagic shock. altered by LPS-induced sepsis. J Trauma 46:800, Moore.
Circulation 100:226, 1999 1999 Figures 2, 4a, 4b, and 9 Carol Donner.
128. Stulz PM, Scheidegger D, Drop LJ, et al: 134. Lucas CE: The water of life: a century of confu- Figures 4c, 5, and 11 Tom Moore.
Ventricular pump performance during hypocal- sion. J Am Coll Surg 192:86, 2001 Figure 12 Seward Hung.
7 TRAUMA AND THERMAL INJURY 2 INJURIES TO THE CNS — 1
2 INJURIES TO THE CENTRAL

NERVOUS SYSTEM
Marike Zwienenberg-Lee, M.D., Kee D. Kim M.D., and J. Paul Muizelaar, M.D., Ph.D.
It is estimated that each year, two million patients present to physi- the understanding required for making appropriate decisions
cians with a primary or secondary diagnosis of head injury. Of these about diagnosis and treatment of injured patients [see Discus-
patients, approximately 400,000 are admitted and 70,000 die, most sion, below].
of traumatic brain injury.Thus, brain injury can be considered epi-
demic. Neurosurgeons, who number 4,000 in the United States, are
probably best trained to manage patients with severe head injuries, Head Injury
but initial resuscitation and stabilization are usually performed by
EMERGENCY DEPARTMENT MANAGEMENT
emergency department physicians, general surgeons, and trauma
surgeons. These professionals are the ones who can make a differ- Because hypoxia and hypotension interfere with cerebral oxy-
ence for patients: current understanding of the pathophysiology of genation, complete and rapid physiologic resuscitation is the high-
traumatic brain injury indicates that treatment during the first few est priority for patients with head injuries. A large study from the
hours is critical and often determines outcome. Traumatic Coma Data Bank demonstrated that a single observa-
Nonetheless, the importance of care immediately after resusci- tion of systolic blood pressure below 90 mm Hg in the field or
tation and in the ensuing days is not to be underestimated. Pa- hypoxia (arterial oxygen tension [PaO2] < 60 mm Hg) was a major
tients with multiple system injuries often receive care in surgical predictor of poor outcome.9 A multidisciplinary team should pro-
intensive care units under the supervision of a general surgeon. vide the patient with an adequate airway and ventilation (intuba-
Less than optimal management at an early stage has a greater im- tion, ventilation, and detection of hemothorax or pneumothorax)
pact overall because of the larger number of patients involved, but and restore and maintain hemodynamic stability (with adequate
less than optimal management at later stages, even in mildly in- fluid replacement and detection and treatment of any bleeding),
jured patients, has a much more dramatic impact. Initial recovery, all according to the principles developed by the Advanced Trauma
followed by relentless decline attributable to insufficient cerebral Life Support system.10 The ABCs of emergency care (Airway,
perfusion, is not an expected outcome. Although we cannot pro- Breathing, and Circulation) take precedence, irrespective of neu-
mote healing of the brain by pharmacologic means, we can pre- rologic injuries. The initial neurologic assessment, which should
vent secondary injury to the brain by ensuring adequate cerebral take no more than a few seconds, consists of rating the patient’s
circulation and oxygenation. level of consciousness on the Glasgow Coma Scale (GCS) [see
The reported incidence of spinal cord injury in the United Table 1] and assessing the width and reactivity of the pupils.
States ranges from 29 to 53 per million.1-3 About 50% of the Although the same assessment is made after resuscitation as a
injuries are related to motor vehicle accidents, 15% to 20% to guide for prognosis and therapy, it should also be made (and
falls, 15% to 20% to interpersonal violence, and the remaining recorded) before resuscitation to permit evaluation of the effect of
15% to 20% to sports and recreational activity. In general, the
group at highest risk is between 16 and 30 years of age, not unlike
the group at highest risk for head injuries. Most of those injured Table 1—Glasgow Coma Scale
are males: several studies report that the percentage is approxi-
mately 75%.4 Between 45% and 50% of patients with spinal cord Test Response Score
injury have other injuries that seriously affect their prognosis.5 Spontaneous 4
The cervical spine is most often involved in spinal cord injury. To verbal command 3
A major study of trauma outcome, conducted from 1982 to 1989, Eye opening (E)
To pain 2
revealed that the cervical spinal cord was involved in 55% of cases None 1
of acute injury, the thoracic spinal cord in 30%, and the lumbar
Obedience to verbal command 6
spinal cord in 15%.6 In an analysis of 358 patients with spinal cord
Localization of painful stimulus 5
injury, complete neurologic injury occurred in 78% of the 71 cases Flexion withdrawal response to pain 4
Best motor
of thoracic injury, 60% of the 202 cases of cervical injury, and response Abnormal flexion response to pain (decorticate 3
65% of the 85 cases of thoracolumbar injury.7 Average direct costs (arm) (M) rigidity)
of spinal cord injury (including hospitalization, rehabilitation, res- Extension response to pain (decerebrate rigidity) 2
idence modification, and long-term care) are tremendous. In None 1
1992, it was estimated that lifetime costs (in 1989 dollars) were Oriented conversation 5
$210,379 for a paraplegic and $571,854 for a quadriplegic.8 Disoriented conversation 4
Initial resuscitation and evaluation of injured patients are dis- Best verbal
Inappropriate words 3
response (V)
cussed more fully elsewhere [see 7:1 Life-ThreateningTrauma]. In this Incomprehensible sounds 2
chapter, we outline approaches to the management of severe None 1
head injury and acute spinal cord injury. In addition, we address Total (E + M + V) 3–15
the pathophysiology of such injuries to provide the reader with
resuscitative measures and differentiation between primary and Patient has head injury
secondary neurologic injury.
Early orotracheal intubation and ventilation are recommend- Resuscitate according to ATLS principles.
ed for patients with a GCS score of 8 or lower or a motor score Rate patient on Glasgow Coma Scale.
of 4 or lower. Other indications for immediate intubation are Perform emergency diagnostic or therapeutic
loss of protective laryngeal reflexes and ventilatory insufficiency, procedures as indicated.
as manifested by hypoxemia (PaO2 < 60 mm Hg), hypercarbia If GCS score ≤ 8 or motor score ≤ 4,
(arterial carbon dioxide tension [PaCO2] > 45 mm Hg), sponta- intubate and ventilate; goals should be
neous hyperventilation (causing PaCO2 < 26 mm Hg), and respi- SaO2 = 100%, PaCO2 ≈ 35 mm Hg, systolic
ratory arrhythmia. Indications for intubation before transport BP > 90 mm Hg.
are deteriorating consciousness (even if the patient is not in a Rate patient again on GCS for assessment of
coma), bilateral fractured mandible, copious bleeding into the effects of resuscitation.
mouth (as occurs with fracture of the base of the skull), and
seizures. An intubated patient must also be ventilated (PaCO2 ≈
35 mm Hg).
Herniation or deterioration Herniation and deterioration
Fluid replacement should be performed with isotonic solutions is present are absent
such as normal saline, lactated Ringer solution, or packed red
blood cells when appropriate. Glucose-based solutions should be Give mannitol, 1.4 g/kg.
avoided in the acute phase. The patient should be examined If patient is herniating,
rapidly and thoroughly for any concomitant life-threatening hyperventilate.
injuries.
Patients with spinal cord injury above T5 may have severe
hypotension as a result of vasogenic spinal shock. Aggressive treat-
ment is indicated, including volume resuscitation and administra- Obtain lateral cervical spine film or swimmer's view.
tion of alpha-adrenergic vasopressors. Intracranial hypertension Once hemodynamic stability is achieved, obtain
should be suspected if there is rapid neurologic deterioration. unenhanced CT scan of head.
Clinical evidence of intracranial hypertension, manifested by signs
of herniation, includes unilateral or bilateral dilatation of the
pupils, asymmetrical pupillary reactivity, and motor posturing.
Patient has surgical lesion Patient does not have
Intracranial hypertension should be treated aggressively. Hyper- surgical lesion
ventilation, which does not interfere with volume resuscitation Move to OR and treat operatively.
and results in rapid reduction of intracranial pressure (ICP), should
be established immediately in cases of pupillary abnormalities. It
has been demonstrated that unilateral or bilateral pupillary abnor-
malities do not result only from compression of the third cranial Admit patient to neurosurgical ICU.
nerves, as was previously thought, but also derive from compres- Monitor ICP, and perform jugular bulb oximetry.
sion of the brain stem, with resulting brain stem ischemia.11 There- Treat intracranial hypertension.
fore, administration of mannitol is effective because it not only Maintain CPP > 60 mm Hg.
decreases ICP but also increases cerebral blood flow (CBF)
through modulation of viscosity. Because mannitol is not used Figure 1 Shown is an algorithm for initial management of the
to dehydrate the body, all fluid losses through diuresis must be patient with a severe head injury.
replaced immediately or even preventively, especially in patients
suffering shock as a result of blood loss. Arterial hypertension oc-
curring after a severe head injury may reflect intracranial hyper-
tension (Cushing’s phenomenon), especially when accompanied mography of the head should be performed in all patients with
by bradycardia; it should not be treated, because it may be the sole persistent impairment of consciousness. In patients with a GCS
mechanism permitting the brain to maintain perfusion despite of 14 or 15 who have experienced transient loss of consciousness
increasing ICP. or have posttraumatic amnesia, head CT is probably necessary
In the absence of signs of herniation, sedation should be used only in the presence of certain specific signs and symptoms [see
when required for safe and efficient transport of the patient.Trans- Table 2].12
port time should be kept to a minimum because transport is often
OPERATIVE MANAGEMENT
accompanied by secondary insults (e.g., hypoxia or hypotension).
Pharmacologic paralysis, which interferes with neurologic examina- Rapid evacuation of mass lesions decreases ICP and conse-
tion, should be used only if sedation alone is inadequate for safe and quently improves cerebral perfusion pressure (CPP) and CBF;
effective transport and resuscitation.When pharmacologic paralysis reversal of ischemia soon after removal of a subdural hematoma
is used, short-acting agents are preferred. Prophylactic hyperventila- has been documented.13 In addition, ICP may be extremely high
tion, which may exacerbate early ischemia, is not recommended for in the presence of a subdural hematoma, and this pressure eleva-
these patients. Guidelines for the resuscitation and initial treatment tion can be rapidly reversed after decompression.14 Subdural
of patients with severe head injuries have been established that facil- hematomas call for emergency evacuation by a neurosurgeon;
itate management [see Figure 1]. evacuation performed within 4 hours of injury has been shown to
Minimal radiologic evaluation consists of a lateral cervical result in a better outcome.15
spine film or a swimmer’s view [see Spinal Cord Injury, below]. Af- An epidural hematoma, which is a life-threatening neurosurgi-
ter hemodynamic stability is achieved, unenhanced computed to- cal emergency, should be evacuated urgently. In cases of tempo-
ral fracture and rapid clinical deterioration, a temporal craniecto- Table 3—Jugular Desaturation* and Outcome in 116
my can be performed. If there is no temporal fracture, an unen- Patients with Severe Head Injuries22
hanced CT scan should be obtained instead of searching for a
lesion with multiple bur holes. In cases of progressive deteriora- Outcome
tion, moderate hyperventilation (PaCO2 ≈ 30 mm Hg) should be Jugular
initiated and mannitol (1.4 g/kg) given while the patient is being Desaturations Good Recovery/
Severe Disability/ Deceased
readied for surgery.16,17 (No.) Moderate Disability
Vegetative (%) (%)
(%)
Posterior fossa hematomas, which are rare, also require urgent
evacuation, because obstructive hydrocephalus and brain stem com- 0 45 39 16
pression can result in rapid neurologic deterioration. An intra- 1 26 32 42
cerebral hematoma causing a midline shift larger than 5 mm is an >1 10 20 70
indication for operative treatment, but surgery can usually be de-
*Defined as jugular venous oxygen saturation < 50% for longer than 15 min.
layed for a few hours.
ICU MANAGEMENT
older than 40 years, has a systolic BP below 90 mm Hg, and
A GCS score of 8 or lower after resuscitation is an indication for exhibits unilateral or bilateral motor posturing.21
admission to a neurosurgical ICU.The focus of ICU management
is prevention of secondary injury and maintenance of adequate Jugular bulb oximetry CBF is an important determinant of
cerebral oxygenation. To ensure optimal cerebral oxygenation, neurologic outcome, and the arterial–jugular venous oxygen dif-
CPP, hemoglobin concentration, and oxygen saturation should be ference (A-VDO2) is an important indicator of the adequacy of
optimized; vessel diameter should be maximized; and viscosity CBF. Monitoring of therapy by measuring CBF and A-VDO2
should be in the low range. Admission to an ICU does not elimi- would be ideal, but there is no practical way of doing this directly
nate the occurrence of secondary insults.18 In a series of 124 and continuously.
patients admitted to a neurosurgical ICU, more than one episode An estimate of global A-VDO2 can be obtained from simultane-
of hypotension occurred in 73% of all patients, and more than one ous monitoring of arterial oxygen saturation (SaO2) and SjvO2.
episode of hypoxia occurred in 40%.19 In another study, online Jugular venous oxygen saturation is monitored by percutaneous
monitoring of CPP, jugular venous oxygen saturation (SjvO2), local retrograde insertion of a fiberoptic catheter in the internal jugular
CBF, and local tissue oxygenation was performed in 14 patients vein, with the tip of the catheter located in the jugular bulb. The
who had sustained a severe head injury; 37% of the episodes catheter is usually inserted into the jugular vein with the dominant
involving decreased CBF, CPP, and saturation were related to clin- cerebral venous drainage (the right jugular vein in 80% to 90% of
ical and nursing procedures.20 the population), but some prefer to insert the catheter at the site
Monitoring of the most significant brain damage. A-VDO2 is calculated ac-
cording to the following formula:
A variety of bedside devices are currently available for monitoring
ICP, local CBF, and local and global cerebral oxygenation.18,20,21 A-VDO2 = (SaO2 − SjvO2) × 1.34 × Hb +
[(PaO2 − PjvO2) × 0.0031]
ICP monitoring Monitoring of ICP has never been sub- The contribution of the variables within the brackets, which is
jected to a prospective, randomized clinical trial designed to small, is usually ignored for practical purposes. Because calcula-
assess its efficacy in improving patient outcome. Nevertheless,
tion of A-VDO2 requires the drawing of blood samples, it can be
many clinical studies indicate that ICP monitoring is useful for
done only intermittently.
early detection of intracranial mass lesions; that it allows calcu-
For continuous monitoring, SjvO2, the result of arterial oxygen
lation of CPP, an important clinical indicator of CBF; that it lim-
input and cerebral extraction, is used. In normal individuals, SjvO2
its the indiscriminate use of potentially harmful therapies for
ranges from 50% to 70%. If SjvO2 values below 50% last for more
control of ICP; that it helps determine prognosis; and that it may
than 15 minutes, they are considered desaturations, resulting from
improve outcome. ICP monitoring is indicated in patients with
insufficient arterial oxygenation (SaO2), inadequate oxygen-carry-
a GCS score of 3 to 7 after resuscitation and in selected patients
ing capacity (Hb concentration), or, when arterial saturation and
with a GCS score of 8 to 12 and an abnormal CT scan at the
oxygen-carrying capacity are normal, from inadequate CBF. A
time of admission. In patients with a GCS score of 8 to 9 and a
normal CT scan, ICP monitoring is indicated if the patient is 1994 study described a relation between the occurrence of desat-
urations and neurologic outcome in patients with severe head
injuries [see Table 3].22 Without desaturation, mortality was 16%;
with one documented desaturation, 42%; and with multiple
Table 2—Constitutional Signs and Symptoms desaturations, 70%. High SjvO2 values indicate low oxygen extrac-
Necessitating Follow-up Nonenhanced Head tion, which is the case when the cerebral metabolic rate of oxygen
CT Scan in Patients with Loss of Consciousness (CMRO2) is low.
and GCS Score of 14 or 15 The limitations of jugular bulb oximetry should be kept in mind
when SjvO2 values are interpreted.23,24 Because SjvO2 represents
Headache Perseveration global oxygenation, regional ischemia may go undetected if the
Somnolence Neurologic deficit ischemic region is too small to be represented in the total hemi-
Mental-status changes or Blurred or double vision spheric SjvO2 value. Ischemia may also occur in a part of the brain
confusion Vertigo
Nausea or vomiting being drained by the opposite jugular vein. In addition, extracere-
Hemotympanum
Seizure bral veins drain into the internal jugular vein approximately 2 cm
below the jugular bulb.With low flow values, significant extracere-
bral contamination may occur, resulting in deceptively high SjvO2 The recommended regimen for treatment of ICP starts with
values. Finally, artifactual readings are often encountered as a drainage of CSF through a ventriculostomy-ICP catheter and
result of reduced light intensity when the catheter lodges against continues as necessary in a stepwise fashion with sedation, paral-
the vessel wall. Technical improvements in catheters, however, ysis, osmotic therapy, hyperventilation, induction of a metabolic
have markedly reduced the number of artifacts observed. coma, and decompressive surgery [see Figure 2].
Although drainage of CSF has no documented deleterious side
Tissue oxygen monitoring Tissue oxygen monitoring has effects, it does have the potential to aggravate brain shift. There-
been employed for years in Europe to treat patients with brain fore, only a minimal amount should be drained, sufficient to bring
injuries but was not approved by the Food and Drug Admin- the ICP below 20 mm Hg.
istration for use in the United States until relatively recently.Tissue Sedation with morphine sulfate, 2 to 5 mg/hr I.V., is standard
oxygen tension (PtiO2) in the brain is measured via a fiberoptic treatment; fentanyl, lorazepam, and midazolam are commonly
monitor locally inserted through a separate bur hole.25 The oxygen used alternatives. In some centers, propofol is now used for rou-
pressure recorded thus reflects a combination of oxygen supply tine sedation. Propofol has a short half-life, which is advantageous
and cerebral oxygen extraction, which makes interpretation of the for the purposes of neurologic evaluation, but it is expensive and
values less than straightforward. Nevertheless, several investigators can have deleterious side effects after prolonged use (i.e., > 48 to
have demonstrated a relation between low local tissue O2 values 72 hours).30
and poor outcome and have documented improved cerebral oxy- Muscular paralysis is employed by many clinicians as the next
genation after introduction of resuscitative measures (e.g., opti- step in therapy. Its major downside is that it renders neurologic
mization of CPP and blood oxygenation).25 In normal persons, examination pointless, except for assessment of the pupillary re-
PtiO2 ranges from 25 to 30 mm Hg. Critical thresholds for PtiO2 val- sponse. In addition, the risk of respiratory complications is in-
ues include prolonged and repeated episodes below 10 to 15 mm creased with neuromuscular blockade.
Hg and any episode below 5 mm Hg.26 Mannitol is usually administered in I.V. boluses of 0.25 to 1
g/kg over 10 to 15 minutes until either ICP is controlled or serum
Management of Cerebral Perfusion Pressure osmolarity reaches 320 mOsm/L. It now appears, however, that
The rationale behind CPP therapy is expressed in Poiseuille’s higher doses (e.g., 1.4 g/kg) may be more effective.16,17 Because
law [see Discussion, Pathophysiology, below]. Although the effect of volume depletion is an important side effect of mannitol therapy,
CPP therapy has not been investigated in a randomized, con- urine losses should be replaced. Hypertonic saline (3% to 10%)
trolled clinical trial, several studies suggest that a CPP of 70 to 80 may be used in place of mannitol: it appears to be just as effective
mm Hg may be the clinical threshold below which mortality and as or even more effective than mannitol for ICP control, especial-
morbidity increase.27-29 In addition, there are now class II data ly in higher concentrations (e.g., 7.5%).31 In addition, hypertonic
(not yet published as of December 2003) indicating that mainte- saline is not associated with volume depletion but actually increas-
nance of a CPP higher than 60 mm Hg is sufficient to ensure opti- es intravascular volume.The effect probably is not purely osmotic
mal cerebral perfusion and oxygenation (personal communica- but is partly related to viscosity, as is the case with mannitol.32
tion, American Brain Injury Consortium). As noted, hyperventilation reduces ICP (by vasoconstriction)
CPP therapy involves manipulation of both arterial BP and and CBF, which may be at ischemic levels in certain parts of the
ICP, but its objective is the reduction of ICP. If ICP reduction brain. Therefore, hyperventilation (PaCO2 < 30 mm Hg) should
does not achieve a CPP of 60 mm Hg, arterial hypertension is not be instituted prophylactically but should be reserved for acute
instituted. Mean arterial BP should be raised first by optimizing decompensation and employed as a short-term temporizing mea-
volume status: ample fluids, including albumin (25 to 30 ml/hr), sure until more definitive therapy can be instituted. If PaCO2 must
are administered to maintain central venous pressure at 5 to 10 be reduced to extremely low levels, hyperventilation can be com-
mm Hg. A pulmonary arterial catheter is suggested for patients bined with mannitol, thereby improving CBF by reducing blood
older than 50 years and for individuals with known cardiac dis- viscosity. Jugular bulb oximetry is recommended in these situa-
ease, multiple trauma (particularly chest or abdominal injuries), or tions because it will determine how much the cerebral vessels can
a need for vasopressors or high-dose barbiturates. Pulmonary arte- be constricted.
rial wedge pressure (PAWP) should be maintained between 10
and 14 mm Hg. If necessary, an alpha-adrenergic drug (e.g., Hemoglobin, Hematocrit, and Blood Viscosity
phenylephrine, 80 mg in 250 or 500 ml of normal saline) can be The hematocrit and viscosity are inversely related, and a bal-
combined with the fluids. ance must be established to optimize oxygenation. If the hemat-
ocrit is too high, viscosity increases; if the hematocrit is too low, the
Management of Intracranial Pressure oxygen-carrying capacity of blood decreases. Maintaining the
Because ICP is a determinant of CPP, treatment of ICP inevit- hematocrit between 0.30 and 0.35 is recommended: below 0.30,
ably affects CPP. Given that the goal is maintenance or improve- oxygen-carrying capacity falls without a significant change in vis-
ment of CBF, measures for treating ICP should be evaluated in cosity, and above 0.35, viscosity increases out of proportion to
the light of their effect on CBF. It is not possible to establish an oxygen-carrying capacity.33 Preferably, blood that has been banked
arbitrary threshold for treatment of elevated ICP that would be for less than 2 weeks should be used for transfusion. There
applicable in all situations. Any interpretation of ICP must be are some data indicating that the effect of transfusion on cerebral
combined with assessment of clinical features and evaluation of oxygenation is linearly related to the duration of storage of packed
CT scan findings. It is possible, for example, to have transtentori- red cells.34
al herniation with an ICP of 15 mm Hg in the presence of a mass
lesion. Conversely, with diffuse brain swelling, adequate CPP can Brain Protection
be maintained despite an ICP as high as 30 mm Hg. As a general When oxygen delivery cannot be sufficiently improved, the
rule, ICP values between 20 and 25 mm Hg indicate that therapy brain can be protected by decreasing CMRO2. Barbiturates appear
should be initiated. to protect the brain and lower ICP through several mechanisms,
• Decompressive craniectomy
Treatment is initiated for ICP of 20–25 mm Hg and Decompressive Surgery • Lobectomy
escalated to next level as necessary to prevent
• ICP > 20 mm Hg (age > 3 yr) Metabolic Coma • Pentobarbital
• ICP > 18 mm Hg (age 2–3 yr) • Propofol
• ICP > 15 mm Hg (age < 2 yr)
• PaCO2 30–32 mm Hg
Hyperventilation*
• Prevent SjvO2 < 60%
• Mannitol, 0.25–1.0 g/kg every 1–6 hr p.r.n

Mannitol _ 320 mOsm/L
until serum osmolarity >
Hypertonic Saline
• 7.5% NaCl, 2 ml/kg every 1–6 hr p.r.n.
• Vecuronium, 4–10 mg/hr

Chemical Paralysis
• Pancuronium, 4–8 mg/hr
• Morphine, 2–5 mg/hr

• Fentanyl, 50–100 µg/hr
Sedation
• Lorazepam
• Midazolam
CSF Drainage • Drain at ear level p.r.n.
Basic measures:
• Head of bed at 30°
• Minimize patient manipulation *At baseline, PaCO2 is kept ~
~ 35 mm Hg.
and transportation
Figure 2 Illustrated is a stepwise approach to the management of ICP.
including alteration of vascular tone, suppression of metabolism, when propofol is administered, indicating that cerebral oxygena-
and inhibition of free radical lipid peroxidation. The most impor- tion is adequate. If propofol is used, correction of hypovolemia is
tant effect may involve coupling of CBF to regional metabolic recommended to prevent hypotension associated with bolus injec-
demands, so that the lower the metabolic requirements, the lower tion. Finally, because of its preservative-free, lipid-base vehicle,
the CBF and the related cerebral blood volume (CBV), with sub- there is an increased risk of bacterial or fungal infection, and the
sequent beneficial effects on ICP and global cerebral perfusion. high caloric content (1 kcal/ml) may be problematic during a pro-
Barbiturate therapy (usually pentobarbital to a blood level of 4 longed infusion.
mg/L) is instituted when other measures to control ICP fail. In Hypothermia produces a balanced reduction in energy produc-
one series of 25 patients with an ICP higher than 40 mm Hg, bar- tion and utilization, decreasing CMRO2 and CBF proportionally.
biturates not only controlled ICP but also improved outcome.35 Protocols for hypothermia include cooling to 32º to 33º C (89.6º
Of the patients whose ICP was controlled by barbiturates, 50% to 91.4º F) within 6 hours of injury and maintenance of this tem-
had a good recovery; of the patients whose ICP was not con- perature for 24 to 48 hours. Hypothermia to 33º C has been shown
trolled, 83% died. In another trial, prophylactic barbiturate thera- to be effective for the control of refractory high ICP.Two pilot clin-
py failed to improve neurologic outcome.36 Of the barbiturate- ical trials reported improved neurologic outcome,40,41 but a multi-
treated patients, 54% were hypotensive, compared with 7% of the center randomized clinical trial failed to demonstrate any overall
control subjects; however, this trial was conducted before the pre- improvement.42 Side effects of therapy, which in this case mainly
sent emphasis on maintaining CPP was recognized. included medical complications in the elderly patients, resulted in
Etomidate, a rapidly acting agent with hypnotic properties sim- the absence of a treatment effect. In addition, rewarming of pa-
ilar to those of barbiturates, has fewer adverse effects on systemic tients who were hypothermic on admission appeared to be detri-
BP or ICP. However, it suppresses adrenocortical function, and its mental. However, a subgroup of patients who were already hy-
solvent, propylene glycol, can cause renal insufficiency.37 po-thermic on admission (i.e., those younger than 45 years) did
Propofol is a sedative hypnotic with a rapid onset and a short benefit from continued treatment with hypothermia, and these
duration of action.38,39 It depresses CMRO2, but not as effectively pa-tients were subsequently enrolled in a second phase III trial
as barbiturates and etomidate do. Studies of patients with head (NABISH-II).
injuries have demonstrated that ICP decreases with administra- The main side effects of hypothermia are cardiac arrhythmias
tion of propofol, but systemic BP usually decreases as well, result- and coagulation disorders, reported after cooling to 32º to 33º C.
ing in a net decrease in CPP. Blood lactate levels do not increase Other drawbacks of hypothermia include the difficulty of detect-
ing infection because of the lack of warning signs (e.g., spiking and
elevated temperature) and the need for specialized equipment Patient has apparent spinal cord injury
(e.g., rotor beds with cooling control) and personnel to induce and (In the field, all patients with significant trauma, any trauma
maintain the condition. A body temperature between 35° and patient who loses consciousness, and any patient with minor
35.5° C may be optimal for treating patients with severe traumat- trauma who has complaints referable to the spine or the
ic brain injury.43 spinal cord should be treated as having spinal cord injury
until proven otherwise.)
Resuscitate according to ATLS principles.
Spinal Cord Injury Immobilize spine, and use spine board, cervical orthosis,
sandbags, straps, log-roll, and tape on forehead as necessary.
DIAGNOSIS AND INITIAL MANAGEMENT
In the field, all patients with significant trauma, any trauma

Perform trauma evaluation.
patients who lose consciousness, and any patients suffering minor
Perform emergency diagnostic or therapeutic procedures as
trauma who have complaints referable to the spine or the spinal indicated.
cord should be treated as if they had a spinal cord injury until
Maintain oxygenation; intubate and ventilate as needed.
proven otherwise [see Figure 3]. If cardiopulmonary resuscitation is
Maintain systolic BP > 90 mm Hg with volume replacement
necessary, it takes precedence [see 7:1Life-Threatening Trauma]. The (isotonic fluids), MAST, vasopressors (dopamine, 2–10
objectives are to maintain adequate oxygenation and maintain BP µg/kg/min), and, if bradycardia (< 45 beats/min) occurs,
by administering fluids and vasopressors. The main concerns of atropine, 0.5–1.0 mg I.V.
management in the field are immobilization before and during Place NG tube to prevent vomiting and aspiration.
extrication from a vehicle (or removal from the scene of another Place Foley catheter to prevent urinary retention.
type of accident) and immobilization during transport to prevent Normalize T°.
active or passive movement of the spine. Subsequently, the patient Perform detailed neurologic examination.
may require a rigid Philadelphia collar, support from sandbags
and straps, a spine board, or a log-roll for turning. A brief motor
examination may detect possible deficits. Evalute axial skeleton, and obtain x-rays of spine.
When the patient arrives at the hospital, care should be taken to
Cervical spine: lateral view showing craniocervical and C7–T1
provide adequate oxygenation, prevent hypotension, and maintain junctions, followed by AP and odontoid views.
immobilization. Patients with an injury above C4, who may have Thoracic and lumbosacral spine: AP and lateral views.
respiratory paralysis, may need ventilatory assistance. Lesions
Urgent MRI is indicated if (1) there is an incomplete lesion with
above T5 may be accompanied by loss of sympathetic tone and normal alignment, (2) deterioration occurs, (3) fracture level
consequently by significant venous pooling and arterial hypoten- ≠ deficit level, or (4) a bony injury cannot be identified.
sion. Because paralytic ileus is common, usually lasting several
days, a nasogastric tube should be placed to prevent vomiting and
aspiration. Urinary retention is also a common occurrence, and a
Foley catheter should therefore be inserted. Vasomotor paralysis Patient has suspected Patient has suspected
may cause poikilothermia (uncontrolled temperature regulation), cervical spine injury thoracolumbar spine injury
and normothermia should therefore be maintained.
[See Figure 5.] [See Figure 6.]
A detailed neurologic examination is required to determine
whether the injury is complete or incomplete and at what level of the
Figure 3 Shown is an algorithm for management of the patient
spinal cord the injury occurred. If possible, a history should deter- with an acute spinal cord injury.
mine the mechanism of injury (e.g., hyperflexion, extension, axial
loading, or rotation). The American Spinal Injury Association
(ASIA) (www.asia-spinalinjury.org) has developed a protocol for
sensory and motor examination of patients with spinal cord injuries fined as partial spinal cord sensory or motor deficits that resolve
that is precise and relatively easy to follow [see Figure 4]. completely within 24 to 72 hours and that are never associated
Spinal shock consists of loss of all or most motor, sensory, and with permanent spinal cord injury. Spinal concussion is rare and
autonomic function below the level of the lesion. It usually devel- has never been described in conjunction with spinal shock.
ops in the setting of a severe spinal cord injury that occurs over a All patients with possible spine injuries should be examined
brief period, and it is most commonly witnessed immediately after radiologically. Roentgenography of the cervical spine with the
the injury (though it may also appears hours later in cases of pro- patient is in a rigid collar includes a lateral view showing both the
gressive injury). As originally defined, the term spinal shock referred craniocervical and the cervicothoracic (C7-T1) junction. If the lat-
to arterial hypotension resulting from loss of sympathetic tone after eral view is normal and the patient is coherent and has no neck
spinal cord injury. Currently, however, most authors use the term tenderness or neurologic deficit, the collar can be removed for
to refer to the complex of symptoms associated with the loss of anteroposterior and odontoid views. If the lower cervical spine or
spinal reflex activity below the level of the lesion, which may or may the cervicothoracic junction is not well visualized, a lateral view
not include arterial hypotension.44 The motor component of spinal with caudal traction on the arms, or a swimmer’s view, is required.
shock may consist of paralysis, flaccidity, and areflexia. The senso- If areas of the spine are still not visualized or if there is a neuro-
ry component may involve both spinothalamic and dorsal column logic deficit, a CT scan with sagittal reconstruction should be
sensory function, and the autonomic component may include sys- obtained through the poorly visualized levels.
temic hypotension, bradycardia, skin hyperemia, and warmth. The use of flexion-extension films (i.e., testing of the active
Spinal shock should be differentiated from spinal concussion. range of motion of the cervical spine from maximal anterior-pos-
Spinal concussion is a poorly understood phenomenon. It is de- terior flexion to extension) is typically limited to patients who are
awake and able to cooperate.45 Although spinal instability is ment, and nondisplaced spinous process fractures. Moreover, it
probably best demonstrated with this type of imaging, it should sometimes misses superior articular process fractures.46
be noted that in patients with neck pain, muscle spasm can limit MRI of the cervical spine is the study of choice for evaluating in-
range of motion and thereby mask a subluxation. Accordingly, it jury to the soft tissues and ligaments. Intrinsic cord damage (e.g.,
is recommended that patients with posttraumatic neck pain who edema, hematoma, or contusion) and injury to the surrounding liga-
are neurologically intact, whose plain radiographs are normal, ments, disks, and paravertebral soft tissues are well visualized. In ad-
and who are capable of limited flexion and extension effort (i.e., dition, MRI is helpful in the assessment of brachial plexus injury,
< 30° of motion) be placed in a rigid cervical collar and reeval- though a series of special coronal images is usually required. A fat-
uated 1 to 2 weeks later. In comatose patients, dynamic films are suppression image usually identifies ligamentous injury to the poste-
sometimes obtained under direct fluoroscopic guidance, though rior elements quite well, and fine-cut gradient echo (GRE) imaging
magnetic resonance imaging appears to render such studies of the transverse ligament of C2 is extremely sensitive in detecting
unnecessary. disruption.47 The major drawbacks of MRI are the length of the
CT is particularly helpful in the further evaluation of fractures imaging time, which may be a problem in the critically ill trauma pa-
diagnosed on plain films: it shows bone in greater detail and at tient, the susceptibility to movement artifacts, and the need for MRI-
higher resolution than plain films do, it achieves better visualiza- compatible monitoring devices and traction equipment. Moreover,
tion of fixed subluxations, and it allows more accurate assessment in this setting, it is often difficult to obtain an adequate medical his-
of the central bony canal and the neuronal foramina. CT is high- tory with regard to implanted medical devices or old bullet frag-
ly accurate in visualizing body fractures, Jefferson (C1) and hang- ments, both of which preclude MRI. Radiologic evaluation and
man (C2) fractures, and bilateral locked facets. It appears to be clearance of the cervical spine can be facilitated by the use of an es-
less accurate, however, in visualizing transverse C2, posterior ele- tablished protocol [see Figure 5].
Figure 4 Shown is a form developed by the American Spinal Injury Association to record the principal information about
motor, sensory, and sphincter function required for accurate neurologic classification of spinal cord injury. For the motor
examination, 10 key muscles are tested (left). For the sensory examination, 28 key dermatomes are tested (right).
Patient has suspected cervical

spine injury
Obtain plain x-rays.
Plain x-rays are abnormal Plain x-rays are normal
Obtain evaluation from specialist.
Patient is asymptomatic Patient is symptomatic and alert Patient is obtunded

or comatose, and early
recovery is not expected
Perform MRI of cervical

Distracting injury, Distracting injury, Neurologic exam is Neurologic exam spine in 48 hr.
intoxication, and intoxication, or normal, and pain is is abnormal
depressed mental depressed mental present
status are absent status is present Perform MRI of
Obtain flexion-extension cervical spine.
Clear cervical spine. Keep patient in x-rays.
cervical collar.
Reevaluate.
Flexion-extension Flexion-extension MRI of cervical MRI of cervical

x-rays are abnormal x-rays are normal spine is normal spine is abnormal
Obtain evaluation from Obtain evaluation from

specialist. specialist.
Clear cervical spine.
Figure 5 Shown is an algorithm depicting the protocol for radiologic evaluation and clearance of cervical
spinal cord injury.
Anteroposterior and lateral views of thoracic and lumbosacral TREATMENT

vertebrae should be obtained for all trauma patients who were
thrown from a vehicle or fell more than 2 m to the ground, com- Traction
plain of back pain, are unconscious, cannot reliably describe back The objectives of craniocervical traction are to reduce fracture-
pain or have altered mental status preventing adequate examina- dislocations, to maintain normal alignment or immobility of the
tion, or have an unknown mechanism of injury or other injuries cervical spine, to prevent further injury, to decompress the spinal
that suggest the possibility of spinal injury. If a fracture or sublux- cord and roots, and to facilitate bone healing. A common tech-
ation is found on the plain films, a CT with sagittal reconstruction nique is placement of Gardner-Wells tongs, a U-shaped device
extending from one level above the fracture/subluxation to one with pins that are anchored to the skull just above the pinna.
level below it is recommended. Traction is applied with the patient in supine position by adding
Indications for urgent MRI include the following: an incomplete weights to the traction ring. Alternatively, traction may be applied
lesion with normal alignment (to rule out the possibility of compres- with the patient in a halo ring. A special traction triangle is then
sion); deterioration (worsening deficit or rising level); a fracture level added to the ring. The advantage of this approach is that the
different from the level of deficit; and inability to identify a bony inpatient can be stabilized in a halo vest as soon as reduction is
jury (to rule out the possibilities of soft tissue compression, disk her- obtained. Furthermore, the halo vest is helpful in dealing with a
niation, or hematoma that would necessitate surgery). Radiologic highly unstable spine that requires instrumentation because the
evaluation of patients with suspected thoracolumbar spine injuries is patient can be easily turned onto the operating table without the
also facilitated by use of a protocol [see Figure 6]. risk of significant movement of the spine.
In most patients, the spine can be cleared on the basis of plain Traction should always be applied under strict neurologic mon-
x-rays and neurologic examination. Obtunded or comatose itoring. If the patient’s condition deteriorates when the weight is
patients whose plain x-rays are normal but who are at high risk for increased, the additional weight should be removed and the
spine injury (e.g., those injured in high-speed motor vehicle acci- patient should immediately undergo imaging (e.g., with plain
dents or by falls from great heights) should be evaluated by a spine films, MRI, or both). In the case of a highly unstable fracture, trac-
specialist before spine clearance. tion should be guided by fluoroscopy rather than serial x-rays.
Pharmacologic Treatment after injury. A total of 14 muscle groups were examined and grad-
A number of drugs are known to interfere with the processes of ed on a scale of 0 to 5. The scores were added, with a total score
secondary injury. The challenge is to identify the most effective of 0 indicating no motor activity below the level of the lesion and
treatment or combination of treatments with the fewest severe side a total score of 70 representing normal motor function. For sen-
effects—a task requiring many experiments for each treatment sory assessment, 29 spinal cord segments were similarly evaluated
tested. Methylprednisolone (MP), thought to act by scavenging and graded on a scale of 1 to 3. A total score of 29 indicated no
free radicals, has been reported to be neuroprotective in patients response in any segment, and a total score of 87 indicated that all
with spinal cord injuries.48-50 Considerable controversy remains, sensory segments were normal.The authors reported a statistical-
however, regarding the clinical benefit of MP administration after ly significant mean motor and sensory improvement after MP
acute spinal cord injury. administration. In the MP group, there was a mean improvement
Three multicenter, randomized, controlled clinical trials carried of 16.0 in the motor score, compared with a mean improvement
out in the United States evaluated MP in this setting: National of 11.2 in the placebo group.The mean changes in sensory scores
Spinal Cord Injury Study (NASCIS) I, NASCIS II, and NASCIS were 11.4 (MP) and 6.6 (placebo) for sensation to pinprick and
III.48-50 In NASCIS I, reported in 1984, the administration of a 8.9 (MP) and 4.3 (placebo) for sensation.
100 mg MP bolus followed by 100 mg/day for 10 days was com- In NASCIS III, patients who received a 24-hour regimen of MP
pared with administration of a 1,000 mg MP bolus followed by (a 30 mg/kg bolus followed by 5.4 mg/kg/hour), a similar 48-hour
1,000 mg/day for 10 days. There was no placebo group. No dif- regimen, or a 48-hour regimen of tyrilazad mesylate (2.5 mg/kg
ference was noted between the two MP groups with respect to every 6 hours) were evaluated.There was no placebo group. No dif-
motor or sensory outcome at 6 weeks, 6 months, and 1 year. ferences in sensory or motor recovery were observed between
Because data from animal studies suggested that the MP doses groups. In a subgroup analysis, it was noted that in patients whose
used in NASCIS I were too low to yield a significant difference in treatment was initiated more than 3 hours after injury, motor func-
outcome, NASCIS II was initiated in 1985. In this trial, adminis- tion improved more with the 48-hour MP regimen than with the 24-
tration of high-dose MP (i.e., a 30 mg/kg bolus followed by 5.4 hour regimen.The Functional Independence Measurement (FIM)
mg/kg/hour for 23 hours) was compared with administration of did not show any statistically significant differences between groups.
naloxone (a 5.4 mg/kg bolus followed by 4 mg/kg/hour for 23 NASCIS II and III have been criticized for flaws in research
hours) and with placebo. Neurologic outcome was graded by design and data analysis. For example, patients with a normal
evaluating sensory and motor function at 6 weeks and 6 months motor examination and patients with a combined conus-cauda
injury were included. Furthermore, only motor and sensory scores
from the right side of the body were reported. Moreover, in the
statistical analysis, the only statistically significant results were the
Patient has suspected thoracolumbar
result of a post hoc analysis.
spine injury A 2000 study presented a statistical reanalysis of the NASCIS
II and III data.51 In this reanalysis, no difference in neurologic
Obtain plain x-rays. recovery between the placebo, 24-hour MP, and 48-hour MP
groups was found, but an increased mortality was documented in
the 48-hour MP group—a finding that was not reported in the
NASCIS studies. Current guidelines take the position that the
Plain x-rays are normal Plain x-rays are abnormal available medical evidence does not conclusively establish the exis-
tence of a significant clinical benefit from administration of MP
Perform CT with fine cuts and sagittal for either 24 or 48 hours and that the harmful side effects may
reconstructions through affected levels.
actually outweigh any clinical benefits.52 MP administration is
Perform MRI of thoracolumbar spine if
• Deficit level is not the same as therefore considered a treatment option to be used at the discre-
fracture level. tion of the treating physician.
• Deterioration occurs. The calcium channel blocker nimodipine causes significant in-
• Patient has incomplete injury with creases in blood flow in the spinal cord,53,54 but, paradoxically, the
normal spinal alignment.
dosage necessary to exert this effect is accompanied by significant
Obtain evaluation from specialist.
systemic hypotension. Administration of GM1 ganglioside, a com-
pound that occurs naturally in the membranes of mammals and is
particularly abundant in the CNS, has been shown to have short-
term neuroprotective effects and long-term regenerative effects in
Patient has no Patient has Patient is obtunded animal models. In a prospective, placebo-controlled, double-blind
neurologic deficit neurologic deficit or comatose; study, some improvement in motor, sensory, and bladder function
mechanism of injury was seen in patients treated with GM1 ganglioside, but no overall
Clear thoracolumbar Perform CT through suggests high risk
spine and sacrum. suspected affected of spine injury improvement in neurologic outcome was noted.55 This agent is
levels. currently an optional treatment for patients with spinal cord
Perform MRI of Obtain evaluation injuries.Treatment with GM1 ganglioside is started after the com-
thoracolumbar spine. from specialist. pletion of MP therapy and continued for 56 days.
Obtain evaluation
from specialist. Surgical Treatment
The role of neurosurgery in the treatment of spinal fractures
Figure 6 Shown is an algorithm depicting the protocol for radio- and spinal cord injury remains controversial.There is considerable
logic evaluation and clearance of thoracolumbar spinal cord disagreement as to whether surgery should be performed, what
injury. type of surgery should be done, and when should it be done. The
primary goals of treatment are to decompress and protect under- dislocation (AOD) is rare, occurring in approximately 1% of pa-
lying neural structures, to restore spinal stability and alignment, to tients with cervical spine injuries. Many of these patients die im-
facilitate early mobilization and rehabilitation, and to maximize mediately after trauma as a result of brain stem injury and respi-
neurologic recovery. ratory arrest. Since the 1980s, advances in emergency patient
There is general agreement among physicians that immobiliza- management in the field, reduced transport time, and better
tion of the patient to prevent further injury and early stabilization recognition of the condition have improved the survival rate after
of fractures and dislocations of the spine are necessary.The single AOD. Nevertheless, since 1966, fewer than 100 survivors of AOD
widely accepted indication for early urgent surgical treatment is have been reported in the literature. Patients who survive AOD
ongoing neurologic deterioration in the presence of spinal canal often have neurologic deficits, such as lower cranial neuropathies,
compromise from bone and disk fragments, hematoma, or unre- unilateral or bilateral weakness, and quadriplegia. Some 20% of
duced subluxation. Surgical indications still under debate include patients, however, exhibit no abnormalities on neurologic exami-
incomplete spinal cord injury (with persistent spinal cord com- nation at presentation. AOD is difficult to diagnose and is often
pression) and complete spinal cord injury with the possibility of missed on the initial cervical radiograph. Accordingly, a high index
some neurologic recovery. of suspicion for this condition should be maintained, particularly
In some studies, early surgical intervention has been associated when signs such as prevertebral soft tissue swelling on the plain
with an increased risk of systemic complications (especially pul- cervical radiograph or subarachnoid hemorrhage at the craniover-
monary complications) and neurologic deterioration. One group tebral junction on CT are present. Additional investigation with
of investigators found that one third of all cases of neurologic dete- MRI may be necessary.
rioration could be attributed directly to surgical intervention; four Because AOD mostly involves ligamentous injury, treatment
of 26 patients who underwent spinal surgery within 5 days expe- generally consists of operative fusion. Traction is rarely employed,
rienced deterioration, whereas none of the patients treated after 5 because even a small weight may cause distraction injury with
days had any neurologic sequelae.56 these highly unstable dislocations.
Other studies, however, have not found an increased risk of deteri- Atlantoaxial dislocations are often fatal as well. Like AODs, they
oration with early intervention. One study evaluated 110 patients are highly unstable lesions associated with severe ligamentous
with cervical spinal cord injury, of whom 88 underwent surgery for injury.
spinal stabilization; in the 39 patients treated within 24 hours, the in- Atlas (Jefferson, or C1) fractures, which represent 5% to 10% of
cidence of systemic complications was reduced by 50% in compari- all cervical spine fractures, result from axial loading. Because of the
son with the incidence in the 49 patients treated 24 hours to 3 weeks large diameter of the spinal canal and the tendency of fragments to
after injury.57 In addition, the incidence of neurologic deterioration move outward, these fractures usually are not accompanied by sig-
was 0% in the early-stabilization group compared with 2.5% in the nificant neurologic injury. However, 40% of patients with an atlas
late-stabilization group. Data from NASCIS II showed improved fracture have another cervical fracture as well (usually involving C2).
outcome in patients undergoing surgery within 24 hours of injury The integrity of the transverse ligament largely determines whether
compared with patients treated after 200 hours, but the difference the fracture is stable.47 Injuries that involve the midportion of the
was not statistically significant.58 transverse ligament or the periosteal insertion (e.g., types Ia and Ib)
We adhere to the following protocol in treating patients with will not heal spontaneously and must be treated with surgical fixa-
cervical spine fracture-dislocations. After systemic stabilization, tion of the C1-C2 complex. In contrast, type II injuries (e.g., avul-
patients are placed in a halo ring and traction as soon as possible. sion injuries or comminuted lateral mass fractures) will usually heal
We prefer to set up traction in the neurologic ICU, but this can be in a rigid external orthosis (e.g., a halo vest). Most other atlas frac-
done in the emergency department when necessary. Closed reduc- tures can be managed in a rigid cervical collar, except for widely dis-
tion is attempted under the guidance of fluoroscopy or serial x- placed or comminuted fractures, which also require that the patient
rays, depending on the degree of spinal cord compromise or be immobilized in a halo vest.
expected instability. Patients are then secured in their halo vests Axis (C2) fractures account for 10% to 20% of all cervical spine
and undergo MRI evaluation, regardless of whether reduction fractures in adults and 70% of cervical fractures in children. The
attempts succeeded or failed. Patients with reduced and realigned odontoid process is the part of C2 that is most commonly frac-
injuries and no cord compromise are kept in their halo vests and tured (accounting for 60% of axis fractures). The management of
offered nonurgent surgical stabilization, depending on the nature odontoid fractures remains controversial: only class III data are
of the injury. Patients with irreducible fractures or continued com- available, which are insufficient to establish practice guidelines.59
promise of the neural elements are taken to the OR promptly for Three different types of odontoid fractures are recognized.
urgent surgical decompression and fixation, regardless of whether Fractures of the tip of the odontoid process (avulsion fracture,
the neurologic injury is complete or incomplete. type I) are uncommon but are thought to be stable in most cases.
The efficacy of early surgical decompression in patients with They can be treated by using a hard cervical collar with or with-
thoracolumbar fractures is not established, except in cases where out preceding cervical traction or by immobilizing the patient in a
the neurologic examination reveals deterioration. Most surgeons, halo vest.
however, advocate urgent decompression in patients who have Fractures of the neck (type II) and fractures at the junction of the
canal compromise and an incomplete injury; patients who do not odontoid process and the axis body (type III) are more common (ac-
fall into this category can be kept on strict spinal precautions, with counting for 65% to 80% and 20% to 35% of odontoid fractures, re-
definitive therapy instituted on a nonurgent basis. spectively). Management of type II fractures depends on the degree
to which the dens is displaced: fractures with more than 5 mm of dis-
Diagnosis and Treatment of Specific Fractures placement are typically managed surgically, whereas fractures with
and Dislocations less than 5 mm of displacement can be treated nonsurgically with a
Cervical spine Injuries to the cervical spine include atlas halo vest or a semirigid orthosis (e.g., a sterno-occipito-mandibular
fractures, axis fractures, fractures of the lower cervical spine, and immobilizer [SOMI] brace).60 The management of type II fractures
atlanto-occipital and atlantoaxial dislocations. Atlanto-occipital also depends on the age and general medical condition of the pa-
tient. Halo-vest immobilization is associated with a significantly in- accompanied by translation of the inferior posterior margin of the
creased risk of pulmonary complications and death in elderly pa- vertebral body into the neural canal. About 75% of patients have
tients and thus should be used with caution in this population. Sur- neurologic involvement.Translations of more than 3 mm result in
gical stabilization and fusion is recommended for type II fractures in a complete spinal cord lesion in most cases.
patients older than 50 years.60 Extension and compression injuries are usually caused by a
The type IIa subcategory of odontoid fracture warrants special blow to the forehead and result in fractures of the posterior com-
mention. These fractures have either anterior or posterior chip- plex. About 40% of patients with unilateral vertebral arch fractures
fracture fragments at the base of the dens and are considered (articular process, pedicle, or lamina) have a neurologic deficit
unstable. They are often widely displaced and have a nonunion (most often a radiculopathy). Bilaminar fractures are accompa-
rate of 75% to 85% with halo-vest immobilization. Accordingly, nied by a complete cord lesion in 40% of cases. Bilateral vertebral
surgical management is recommended.The integrity of the trans- arch fractures with complete anterior translation of the vertebral
verse ligament should be evaluated in patients with type II injuries; body present with radiculopathy (30% of cases), central cord syn-
fixation with an odontoid screw is contraindicated, and C1-C2 fix- drome (30%), or an incomplete cord lesion (30%). In one series,
ation should be performed instead. no complete cord lesions were observed with this type of injury.61
Most type III odontoid fractures will fuse with rigid external mo- Treatment of injuries to the lower cervical spine has not been
bilization (i.e., either cervical traction followed by placement in a standardized. As a general rule, severe ligamentous involvement
rigid cervical collar or placement in a halo vest). Again, more than 5 and severe vertical compression call for surgical intervention.
mm of displacement is an indication for surgical stabilization.60 Severely comminuted vertebral body fractures may also necessi-
Traumatic spondylolisthesis, or hangman’s fracture, accounts tate surgery because of the high risk of progressive kyphosis.
for approximately 20% of C2 fractures. Injury usually results from Isolated spinous process fractures and unilateral lamina and pedi-
axial compression in combination with hyperextension of the occip- cle fractures are usually managed conservatively with placement in
ito-atlanto-axial complex on the lower spine, resulting in bilateral a rigid cervical collar. If there is a fracture through the transverse
fracture of the pars interarticularis. Fractures affecting the ring of foramen above C6, the vertebral artery should be evaluated for
the axis without C2-C3 angulation are stable and can be treated dissection by means of magnetic resonance angiography (MRA),
with immobilization in a Philadelphia collar or a SOMI brace. CT angiography, or catheter angiography.45 Surgical intervention
Halo-vest immobilization is recommended in unreliable patients should be carefully considered, especially in young trauma victims.
or patients with both C1 and C2 fractures. The average healing In a series from 1988, 87% of patients with distractive flexion
time is 12 weeks. Fractures with angulation, subluxation, or C2- injury and 88% of those with compressive flexion injury healed
C3 locked facets are treated with halo-vest immobilization if they with halo-vest immobilization.62
are adequately reducible and with surgical intervention if they are
nonreducible, are associated with disruption of the C2-C3 disk Thoracolumbar spine Approximately 64% of fractures of
space, or are subject to recurrent subluxation.47,60 the spine occur at the T12-L1 junction, and 70% of these fractures
Approximately 80% of all fractures of the lower cervical spine are unaccompanied by immediate neurologic injury. Evaluation
are produced by indirect forces. The vertebra most commonly according to Denis’s three-column principle [see Figure 7] is use-
involved is C5, and dislocations are most frequent at the C5-C6 ful for determining whether a fracture is stable, though the precise
level. The following injury mechanisms are observed: flexion and definition of stability remains controversial.63 Fractures of the tho-
distraction (approximately 40% of cases), flexion and compression racic spine are more stable because of support from the sur-
(22%), vertical compression (8%), extension and compression rounding rib cage and the strong costovertebral ligaments. When
(24%), extension and distraction (6%), and lateral flexion (3%). two of the three columns are affected, the fracture is considered
Flexion and distraction injuries usually result from a blow to the unstable, and surgical intervention is generally required.
occiput from below. The initial disruption is within the posterior The four major types of thoracolumbar spine injuries are com-
ligamentous complex, leading to facet dislocation and an abnor- pression fractures, burst fractures, seat-belt fractures (Chance
mally large divergence of the spinous processes. Unilateral facet fractures), and fracture-dislocations. These four types of fracture
dislocation and facet interlocking result when a rotatory compo- involve the anterior, middle, and posterior columns of the spine in
nent is involved. Bilateral facet dislocation with anterior transla- different ways [see Table 4]. Transverse process fractures are rarely
tion of the superior vertebra results from severe hyperflexion; the unstable and are typically managed conservatively with analgesics
translation is usually at least 50% in such cases. Cord and root or muscle relaxants.
involvement vary with the degree of subluxation and translation: Minimal to moderate compression fractures (< 50% loss of
50% of patients with unilateral facet dislocation present with mod- height or < 30° of angulation) with an intact posterior column
erate cord and root injury, and 90% of patients with bilateral facet can be treated with analgesics and bed rest. Ambulation should
dislocation and a full translation of the vertebral body have a neu- be started early, and depending on the degree of kyphosis,
rologic deficit (most often a complete cord lesion).Teardrop frac- external immobilization (with a thoracolumbar orthosis or a
tures (characterized by a bone chip just beyond the anterior infe- Boston brace) may or may not be indicated. Severe compres-
rior edge of the vertebral body) result from severe hyperflexion sion injuries should be treated with external immobilization in
injury, and the fractured vertebra is usually displaced posteriorly extension. If the loss of anterior height of the vertebral body
on the vertebra below; these patients are often quadriplegic. exceeds 50%, there is an increased risk of progressive kyphosis;
Flexion and compression injuries, usually observed at the C4- evaluation with follow-up radiographs is indicated. Occasion-
C5 and C5-C6 levels, typically result from a blow to the back of ally, surgical intervention is required. An anterior injury is con-
the head. The effect on the anterior vertebral body varies from a sidered unstable if it involves more than three adjacent elements
moderate rounding or loss of anterior height to a wedge shape or if height loss in a single element exceeds 50% with more than
with an oblique fracture from the anterior surface to the inferior 30° of angulation.64
subchondral plate. Approximately 50% of patients with the latter Burst fractures are considered unstable even if there is no initial
type of injury have a neurologic deficit. More severe injuries are neurologic deficit. Early ambulation should be avoided because
the axial loading may result in progressive collapse or angulation, than they once were because of the widespread use of shoulder
with concomitant neurologic damage. Indications for the surgical belts in addition to lap belts, which prevents upper torso flexion
treatment of burst fractures are as follows64: during deceleration. Chance fractures are treated with surgical sta-
bilization, and decompression and correction of spinal alignment
1. Loss of more than 50% of body height.
may be required as well.64
2. Retropulsed bony fragments narrowing the canal by more than
Fracture-dislocations, also known as fracture subluxations, are
50%.
three-column injuries that usually involve disruption of the liga-
3. Kyphotic angulation of 25° or more.
mentous structures or the disk space. Dural lacerations and neu-
A Chance fracture is a horizontal fracture through all three rologic injury are common with such injuries. Fracture-disloca-
columns. It occurs most commonly in the lower lumbar spine and tions are considered unstable and are treated with surgical decom-
is a highly unstable injury. Chance fractures are now less frequent pression and stabilization.
Discussion
Pathophysiology maintenance and restoration of ion gradients across the cell mem-
brane; and the remaining 25% is used for molecular transport,
HEAD INJURY biosynthesis, and other, as yet unidentified, processes.
Cell metabolism involves the consumption of adenosine triphos-
Cerebral Metabolism phate (ATP) during work and the ensuing consumption of meta-
At 1,200 to 1,400 g, the brain accounts for only 2% to 3% of bolic substrates to resynthesize ATP from adenosine diphosphate
total body weight and does not do any mechanical work; yet it (ADP). ATP is generated both in the cytosol (via glycolysis) and in
receives 15% to 20% of all cardiac output to meet its high meta- the mitochondria (via oxidative phosphorylation). Glucose is the
bolic demands. Of the total energy generated, 50% is used for sole energy substrate, unless there is ketosis, and 95% of the ener-
interneuronal communication and the generation, release, and gy requirement of the normal brain comes from aerobic conversion
reuptake of neurotransmitters (synaptic activity); 25% is used for of glucose to water and CO2. ATP generation is highly efficient.
Glycolysis and subsequent oxidative phosphorylation result in the
generation of 38 molecules of ATP for each molecule of glucose:
ANTERIOR MIDDLE POSTERIOR 1 glucose + 6 O2 + 38 ADP + 38 Pi → 6 CO2 + 44 H2O
+ 38 ATP
In the absence of oxygen, anaerobic glycolysis can proceed, but
energy production is much less efficient. Two molecules of ATP
and two molecules of lactate are generated for each molecule of
glucose:
1 glucose + 2 ADP + 2 Pi → 2 lactate + 2 ATP
Regulation of Blood Flow
Because the reserves of glucose and glycogen within the astro-
cytes of the brain are limited and there is no significant storage
capacity for oxygen, the brain depends on blood to supply the oxy-
gen and glucose it requires. More specifically, substrate availabili-
ty is determined by its concentration in blood, flow volume, and
the rate of passage across the blood-brain barrier.
Under normal circumstances and with certain physiologic alter-
ations, an adequate supply of substrates can be maintained by reg-
ulation of CBF. CBF increases with vasodilatation and decreases
with vasoconstriction. Caliber changes take place mainly in cere-
bral resistance vessels (i.e., arterioles with a diameter of 300 µm
down to 15 µm).65,66 Control of CBF by influencing vessel caliber
is commonly referred to as autoregulation of blood flow.
Metabolic autoregulation CBF is functionally coupled to

cerebral metabolism, changing proportionally with increasing or
Interspinal
decreasing regional or global metabolic demand. Thus, the brain
Anterior Posterior Ligament precisely matches local CBF to local metabolic needs. Because
Longitudinal Longitudinal Intertransverse Supraspinal 95% of the energy in the normal brain is generated by oxidative
Ligament Ligament Ligament Ligament metabolism of glucose, CMRO2 is considered to be a sensitive
measure of cerebral metabolism. The relation between CBF and
Figure 7 Illustrated is the three-column concept for assessment metabolism is expressed in the Fick equation:
of spinal stability. If two or more columns are destroyed or non-
functional, instability is likely. CMRO2 = CBF × A-VDO2
Table 4—Column Failure in the Four Types

of Major Thoracolumbar Spinal Injury63
Fracture Type Anterior Column Middle Column Posterior Column
Compression Compression Intact Intact, or distraction if severe
Burst Compression Compression Intact
Intact or mild compression

Seat belt of 10%–20% of anterior Distraction Distraction
vertebral body
Fracture-dislocation Compression, rotation, shear Distraction, rotation, shear Distraction, rotation, shear
CMRO2, expressed in milliliters per 100 g of brain tissue, is nor- stant new level of PaCO2, the pH in blood and in the perivascular
mally about 3.2 ml/100 g/min in awake adults. The average CBF space returns to baseline, and the diameter of the cerebral blood
value for mixed cortical flow is 53 ml/100 g/min in a healthy adult. vessels also returns to baseline.69 With CO2 reactivity, changes in
A-VDO2, a measure of cerebral oxygen extraction, can be calcu- CBF are compensated for by changes in A-VDO2, so that a con-
lated by subtracting the oxygen content of jugular venous blood stant supply of substrates is maintained at the level set by metabo-
(6.7 ml/dl) from that of arterial blood (13 ml/dl), resulting in a lism (CMRO2). A constant A-VDO2 is a common feature of meta-
value of 6.3 ml/dl; this value can then be corrected for hemoglo- bolic, pressure, and viscosity autoregulation; because CBF is tuned
bin content according to the formula discussed earlier [see Head to metabolism, A-VDO2 can be kept constant.
Injury, ICU Management, above]. Under conditions of increasing
Cerebral Circulation and Metabolism after Severe
metabolic demand (increased CMRO2), such as seizures or fever,
Head Injury
CBF increases proportionally, thus keeping A-VDO2 constant.
With decreasing metabolism (anesthesia, deep coma), CBF Arterial hypoxia and hypotension It is known from eye-
decreases. witness reports of head injury and experimental studies immedi-
ately after the impact that arterial hypotension and interruption of
Pressure autoregulation Another important physiologic normal respiration, sometimes with a period of prolonged apnea,
property of the cerebral circulation is maintenance of a constant are common findings. In the days after a head injury, there are
supply of substrates at the level set by metabolism. According to many occasions and opportunities for hypoxic and hypotensive
Poiseuille’s equation, insults. Studies have identified hypotension (systolic BP < 90 mm
Hg) and hypoxia (PaO2 < 60 mm Hg) as major determinants of
4
CBF = k CPP × d poor outcome.9,19,70
(8 × l × v) The effect of hypotension on the brain depends on the status of
autoregulation. If autoregulation is defective, decreased BP leads
in which k is a constant of proportionality, d is vessel diameter, l directly and linearly to a reduction in CBF. If autoregulation is
is vessel length, and v is blood viscosity, changes in CPP (e.g., intact, arterial hypotension can lead to a considerable increase in
arterial hypotension or increases in ICP) are followed by changes ICP, which interferes with CBF by decreasing perfusion pressure.
in CBF, unless diameter regulation (pressure autoregulation)
takes place.67 In humans, the limits of pressure autoregulation Elevated ICP According to the Monro-Kellie doctrine,71,72
range from 40 to 150 mm Hg of CPP. ICP is governed by three factors within the confines of the skull:
brain parenchyma plus cytotoxic edema; CSF plus vasogenic
Viscosity autoregulation In accordance with Poiseuille’s edema; and CBV.When the volume in one compartment increas-
equation, CBF can vary with changes in the viscosity of blood. es, ICP increases unless there is a compensatory decrease in vol-
Blood viscosity changes with variations in hematocrit, γ-globulin, ume in the other compartments.The relation between intracranial
and fibrinogen components of plasma protein. Increased visco- volume and ICP is expressed in the pressure-volume index
sity would increase cerebrovascular resistance (8 × l × v /d4). (PVI).73 PVI is defined by the volume that must be added to
By means of diameter adjustment (viscosity autoregulation), or withdrawn from the craniospinal axis to raise or decrease ICP
cerebrovascular resistance is decreased and CBF can be kept 10-fold:
constant.68
∆V
PVI =
CO2 reactivity Vascular caliber and cerebral blood flow are log ICPi /ICPο
also responsive to changes in PaCO2. Cerebral blood flow changes where ∆V is the change in volume, ICPo is ICP before the volume
2% to 3% for each mm Hg change in PaCO2 within the range of change, and ICPi is ICP after the volume change. PVI is thus a
20 to 60 mm Hg. Hypercarbia (hypoventilation) results in vasodi- measure for the compliance (∆V/∆P) or tightness of the brain.
latation and higher CBF, and hypocarbia (hyperventilation) Under normal circumstances, PVI is 26 ± 4 ml; 26 ml of volume
results in vasoconstriction and lower CBF. Autoregulation is a will raise ICP from 1 to 10 mm Hg, but the same volume will also
compensatory or adaptive response adjusting CBF to metabolism; raise ICP from 10 to 100 mm Hg. Conversely, a change in volume
with CO2 variation, vessel caliber changes and CBF follow pas- of only 6.4 ml is necessary to increase ICP from 10 mm Hg (nor-
sively. The vessels respond not to changes in PaCO2 but to the pH mal) to the treatment threshold of 20 mm Hg. Thus, small
in the perivascular space. CO2 can cross the blood-brain barrier changes in volume have a relatively large effect on ICP. PVI values
freely, thus changing the pH, but over 20 to 24 hours, with a con- as low as 5 ml have been reported in patients with head injuries.
Apart from mass lesions, ICP typically increases after severe Table 5—Changes in CBF, CBV, ICP,
head injury because of cerebral edema. Initial compensation is by and A-VDO2 Associated with Primary
displacement of CSF from the cranium, which is visualized in a
Reduction of Selected Variables81
CT scan of the head as small ventricles and basal cisterns. Sub-
sequent compensation would be by a decrease in CBV, which can Variable Reduced CBF CBV (ICP) A-VDO2
be accomplished by means of vasoconstriction.
CMRO2 ↓ ↓ —
Relation between vessel diameter, CBV, and ICP The CPP (autoregulation intact) — ↑ —
total diameter of the cerebrovascular bed determines CBV. Cere-
bral veins contain most of the total blood volume, but their diam- CPP (autoregulation defective) ↓ ↓ ↑
eter and thus their volume are relatively constant. Approximately Blood viscosity (autoregulation intact) — ↓ —
20 ml of blood (i.e., one third of total CBV) is located in the cere-
bral resistance vessels (which range in diameter from 300 µm down Blood viscosity (autoregulation defective) ↑ — ↓
to 15 µm).69 Because most autoregulatory and CO2-dependent PaCO2 ↓ ↓ ↑
variations in diameter take place in these vessels, CBV is deter-
Conductance vessel diameter
mined mainly by their diameter. Typically, the diameter ranges ↓ ↑ ↑
(vasospasm above ischemia threshold)
from 80% to 160% of baseline, resulting in volume changes be-
A-VDO2—arteriovenous oxygen content difference—CBF—cerebral blood flow—
tween 64% and 256% of baseline. With a baseline value of 20 ml CBV—cerebral blood volume—CMRO2—cerebral metabolic rate of oxygen—CPP—cerebral
in the resistance vessels, CBV will range from 13 ml (maximal vas- perfusion pressure—ICP—intracranial pressure—PaCO2—arterial carbon dioxide tension
oconstriction) to 51 ml (maximal vasodilatation). Given a PVI of
26, change from maximal vasoconstriction to maximal vasodilata-
tion will be accompanied by an almost 29-fold change in ICP.
mia was seen in 80% of cases.78 One group of investigators found
that ischemia (CBF < 18 ml/dl with abnormally high A-VDO2 val-
CBV, ICP, and CBF CBF and CBV are governed by vascu-
ues) occurred in 20% to 33% of patients with severe head injuries
lar diameter. Thus, depending on other parameters influencing
within 4 to 12 hours of injury and that the ischemia was associat-
CBF (such as mean arterial BP, ICP, and blood viscosity), changes
ed with a poor prognosis.79 Of the intracranial lesions, acute sub-
in vascular caliber also affect CBF.
dural hematoma and diffuse cerebral swelling were most often
Hypocarbia reduces ICP by means of vasoconstriction, conse-
associated with ischemia.
quently improving CPP. However, net CBF is decreased because
The relation between cerebral metabolism and CBF is expressed
in Poiseuille’s equation, vessel diameter is carried to the fourth
in the Fick equation [see Metabolic Autoregulation, above].The nor-
power. A randomized clinical trial has shown that preventive
mal brain tends to keep A-VDO2 constant and to react to changes in
hyperventilation retards clinical improvement after severe head
metabolism by adjusting blood flow. When CBF decreases in re-
injury, perhaps through reduction of CBF to ischemic levels.74 sponse to metabolism (as with hyperventilation or decreasing CPP
However, its rapid effect on ICP is a great advantage in cases of with impaired autoregulation), oxygen supply is maintained by in-
acute neurologic deterioration (e.g., in the presence of an expand- creasing oxygen extraction (i.e., A-VDO2 increases). A rising A-VDO2
ing mass lesion before evacuation can take place) and should be is thus a sensitive marker of insufficient cerebral perfusion. However,
reserved for these situations. the extent to which oxygen extraction can be increased is limited,
There are two methods of reducing ICP by means of vasocon- and this limit is reached when A-VDO2 is doubled (13.2 ml/dl). Con-
striction without affecting CBF.The first is to reduce blood viscosity. sequently, any further reduction in CBF results in neuronal dysfunc-
As can be deduced from Poiseuille’s equation, decreasing the blood tion (i.e., CMRO2 decreases). Because 50% of the energy is used for
viscosity will, by itself, lead to vasoconstriction, provided that viscos- synaptic activity, a reversible and functional loss is usually observed
ity autoregulation is intact.With impaired autoregulation, decreased first. Further decline, however, will result in ion pump failure, loss of
viscosity will result in an increase in CBF but no decrease in ICP. membrane integrity, consequent cell swelling (cytotoxic edema), and
However, this effect can be used to maintain CBF under vasocon- cell death (irreversible infarction).The occurrence of irreversible in-
striction with hypocarbia.The effect of mannitol on ICP is thought farction depends on both the level and the duration of ischemia.
to be mediated in part by lowering blood viscosity.75,76 When CBF falls to approximately 18 ml/100 g/min for more than 4
The second method of reducing ICP without affecting CBF is hours, it reaches the threshold for irreversible infarction.80
to increase CPP, which can be done by raising blood pressure. Maintenance or improvement of CBF is thus essential to the
Again, with intact autoregulation, an increase in CPP will lead treatment of severe head injury, and A-VDO2 is a sensitive marker of
to vasoconstriction, with net CBF remaining constant. With im- the adequacy of therapy.When therapeutic measures fail to sustain
paired autoregulation, CBF will follow CPP passively, and mainte- CBF, CMRO2 can be decreased to reinstate the match between CBF
nance of normal BP may be indicated in these cases. More im- and metabolism. CNS suppression can be achieved by administer-
portant, however, is the avoidance of hypotension under these cir- ing hypnotic agents (e.g., barbiturates or propofol) or inducing hy-
cumstances; the effect of CPP therapy may be attributable in part pothermia. Decreasing cell metabolism will result in reduced pro-
simply to prevention of hypotension.28,77 duction of CO2, lactic acid, or both and (with blood vessels almost
always remaining responsive to perivascular pH changes) in vaso-
Cerebral ischemia Cerebral ischemia, defined as CBF that constriction accompanied by reductions in both CBF and ICP.The
is inadequate to meet the metabolic demands of the brain, is an relations between CMRO2, CBF, CBV, CPP, and A-VDO2 are com-
important mechanism of secondary injury in patients with severe plicated. An overview is available elsewhere [see Table 5].81
head injury, and the adequacy of CBF has been associated with
neurologic outcome. In autopsy findings from patients dying after Altered cerebral metabolism Anaerobic metabolism of
severe head injury, histologic damage indicative of cerebral ische- glucose to the end product lactate is characteristic of cerebral hy-
poxia/ischemia.82 Increased lactate production, hyperglycolysis, surviving traumatic injury are dysfunctional and that many of
and low tissue glucose levels have been observed after severe head these axons have lost part or all of their myelin sheath, which is the
injury, suggesting an increased turnover of glucose by the anaero- structural component that improves the reliability and speed of
bic glycolytic pathway. Increased lactate levels have also been found conduction. 4-Aminopyridine, an axon-excitatory drug used for
in the presence of preserved CBF, suggesting impairment not only the treatment of multiple sclerosis, has significantly improved con-
of oxygen delivery but also of oxidative metabolism (i.e., of mito- duction in animals and humans with spinal cord injury.93 Unfor-
chondrial function).83,84 Data from animal and human models tunately, the drug must be given continuously to support axon
indicate that mitochondrial function is impaired after severe head function, and this is not feasible in humans because of its side
injury, which may explain the poor outcomes despite adequate effects (seizures, tachycardia, and hyperthermia).
CBF levels; ATP generation by anaerobic glycolysis is usually Injury initiates complex responses in the body and the spinal
insufficient to maintain the metabolic activity of the brain.85-87 In cord. Ischemia is a prominent feature of events occurring after
part, however, such poor outcomes may be attributable to the spinal cord injury.94,95 Within 2 hours of a spinal cord injury, there
effects of lactate production (acidosis), because high lactate and is a significant reduction in spinal cord blood flow. It is unclear
hydrogen ion levels interfere with the functional recovery of tissue. whether this reduction is mechanically or biochemically induced.
Like the brain, the spinal cord possesses autoregulatory capacity
SPINAL CORD INJURY
(pressure autoregulation). When this autoregulation is impaired,
Spinal cord injury is often viewed as an all-or-nothing event blood flow becomes dependent on systemic blood pressure. In a
that is irreversible from the moment of injury. By this view, spinal patient with multiple injuries or vasogenic spinal shock (a lesion
cord injury is classified as either incomplete or complete. This above T5) complicating the spinal cord injury, severe systemic
dichotomy is not absolute, however, because some functional hypotension may exacerbate the effects of spinal cord injury.
recovery occurs even after severe spinal cord injury. NASCIS II Edema, another prominent feature of spinal cord injury, tends
revealed that patients with so-called complete loss of neurologic to develop first at the injured site, subsequently spreading to adja-
function recovered, on average, 8% of the function they had lost, cent and sometimes distant segments.The relation between spread-
and patients with an incomplete injury recovered 59%.88 ing edema and potential worsening of neurologic function is poor-
An injury classified as complete does not necessarily involve ly understood.The inflammatory response to injury is mounted in
loss of all connections. Several studies have demonstrated that part to scavenge cellular debris and repair tissue. This response is
many patients with a clinically complete lesion show evidence of accompanied, however, by the release of toxic substances, which
residual connections.89 A certain number of intact connections is cause further tissue damage, or secondary injury. Processes result-
probably necessary for functional recovery. The determinants of ing in secondary injury involve generation of free radicals, exces-
functional outcome are complex, however, and probably include sive calcium influx and excitotoxicity, the release of eicosanoids
not only the extent of axonal loss but also the level of dysfunction and cytokines, and programmed cell death.
of the surviving axons and the plasticity of the spinal cord. Some evidence from experimental studies of spinal cord injury
Animal studies have shown that a small number of axons may suggests that macrophages may play a key role in CNS repair.
be sufficient to support functional recovery.90-92 Animals recover Administration of stimulated macrophages to the CNS, where the
evoked potentials and the ability to walk with as few as 10% of number of macrophages is limited and their activity restricted in
their spinal axons. Nerve sprouting, one of the mechanisms of comparison with other tissues, has led to partial motor recovery in
plasticity, allows a few nerves to carry out the function of many. a completely transected spinal cord in adult rats.96 Clinical trials
Finally, animal studies have also shown that many of the axons have been initiated to evaluate this approach further.
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7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 1
3 INJURIES TO THE FACE AND JAW

Seth Thaller, M.D., and F.William Blaisdell, M.D.
Assessment and Management of Maxillofacial Injuries
Tremendous progress has been made in the management of sification of malocclusion, which is more than 100 years old,
patients with facial injuries. Reconstructive surgeons are treat- remains one of the most commonly used systems. The maxil-
ing an increasing number of challenging facial injuries because lomandibular relation is determined by the position of the
of excellent advances in the transportation of trauma victims mesiobuccal cusp of the maxillary first molar in relation to the
and the regionalization of care in trauma centers. Although buccal groove of the mandibular first molar. Angle’s class I, or
severe facial injuries are often associated with devastating cos- neutroclusion, exists when the permanent maxillary first molar
metic and functional defects, reconstructive surgeons are is ideally positioned—that is, the buccal cusp of the maxillary
achieving better long-term surgical results and are able to first molar and the mesiobuccal groove of the mandibular first
repair certain injuries that were once considered nonrecon- molar occlude, resulting in a normal anteroposterior relation
structible by employing craniofacial surgical techniques devel- of the maxillary and mandibular dentition. Angle’s class II, or
oped through the pioneering efforts of Dr. Paul Tessier, of distoclusion, exists when the maxillary first molar is mesial
Paris. These techniques include widespread subperiosteal (i.e., toward the midline) to the corresponding mandibular
exposure, rigid internal fixation with miniature plates and first molar. Angle’s class III, or mesioclusion, exists when the
screws, and widespread primary bone grafting. mandibular first molar is mesial to the maxillary first molar.
AIRWAY ASSESSMENT
Initial Survey Facial bone fractures, bleeding, loose
Maxillofacial injuries are secondary to dentition, debris, and laryngeal injuries
either blunt or penetrating trauma. can contribute to airway compromise.
Motor vehicle accidents remain the most Accordingly, whenever there is any evi-
common cause of facial injuries charac- dence of maxillofacial injuries, it is
terized by bony comminution and dis- essential to monitor the airway status
traction. However, penetrating injuries, carefully. If the patient is conscious,
such as knife wounds, can cause exten- alert, and breathing at a rate of less than
sive soft tissue injuries to skin and under- 20 respirations/min, without excessive airway secretions or
lying nerves, blood vessels, parotid structures, and other struc- excessive hemorrhage, it can be assumed that the patient has
tures of the upper aerodigestive system. Gunshot wounds can an adequate airway.
cause devastating injuries that necessitate extensive flap recon- In a comatose patient with compromised vital reflexes (i.e.,
struction to provide satisfactory soft tissue coverage of the gag, cough, and swallow), an endotracheal tube must be insert-
underlying bone. ed immediately to prevent aspiration. In the presence of
On initial assessment, the physician must always pay special nasopharyngeal bleeding, major maxillofacial injuries, or cere-
attention to correcting the most life-threatening problems, brospinal fluid leakage, nasal intubation should be avoided
including an obstructed airway, bleeding, and shock [see 7:1 because of the potential for intracranial contamination. If there
Life-Threatening Trauma, 8:3 Shock, and 1:4 Bleeding and Trans- is a possible fracture of the cribriform plate, either an orotra-
fusion]. Patients with facial injuries often have multisystem cheal tube should be placed or a cricothyrotomy should be
involvement; priorities in the evaluation and treatment of asso- performed. In an agitated or restless patient, only a single
ciated significant injuries are discussed elsewhere. attempt should be made at inserting an endotracheal or naso-
tracheal tube; if the attempt is unsuccessful, an emergency
After establishing that the patient is stable, the exam- cricothyrotomy should be performed [see 7:1 Life-Threatening
iner should quickly make note of lacerations and contusions, Trauma]. In slightly more elective circumstances, a deliberate
extensive bony disruptions, loss of vision, malocclusion, tris- tracheotomy may be the optimal means of ensuring an ade-
mus, and bleeding. quate airway. Cricothyrotomy and tracheotomy must never be
In the evaluation of facial injuries, a quick analysis of occlu- taken lightly, because they can lead to significant complica-
sion provides extremely important diagnostic information that tions. In addition, because newer treatment modalities using
serves as the foundation for future fracture repair. Angle’s clas- rigid fixation decrease the time required for extensive maxillo-
Assessment and Management

of Maxillofacial Injuries
Known or suspected facial injury
Assess airway, breathing, and circulation.
Airway compromise No airway compromise
Perform orotracheal intubation, Assess for major

cricothyrotomy, or tracheotomy. nasopharyngeal bleeding.
Major nasopharyngeal No major bleeding

bleeding
Attempt control of bleeding

by packing oropharynx or
nasopharynx with anterior or
posterior nasal packing.
Bleeding is not controlled Bleeding is controlled Treat truncal and central

nervous system injuries
Transport patient to operating
room for fracture reduction, • Evaluate facial injuries.
ligation of external carotid • Suture facial lacerations.
artery, or both. • Perform routine and
specialized x-ray evaluations.
Treat specific facial injuries
• Eye and orbital injuries.

• Maxillary injuries.
• Mandibular injuries.
• Soft tissue injuries.
mandibular fixation, more conservative methods of airway In major maxillofacial injuries with extensive pharyngeal
control are often indicated. bleeding, immediate airway access is mandatory, either with an
If the respiratory rate is higher than 25/min or if there is evi- endotracheal tube or by cricothyrotomy. Once airway control
dence that the airway is obstructed or compromised, the has been achieved, the patient should be brought to the oper-
patient should be carefully monitored. When the respiratory ating room for reduction of gross bony injuries, which will
rate increases to 30/min or higher, an immediate assessment of often stop uncontrollable hemorrhage. In those rare instances
arterial blood gases should be made under close observation. when maxillofacial injuries are associated with serious and
A respiratory rate higher than 35/min is an indication for both uncontrollable hemorrhage, it may be necessary to obtain
intubation and respiratory support unless the cause of the access to the external carotid artery for ligation of the major
rapid rate can be identified and immediately reversed. trunk or a branch if either is the source of bleeding [see 7:4
Injuries to the Neck].
MAXILLOFACIAL BLEEDING
Once the airway has been satisfactori-

ly stabilized, the next priority is to man- Definitive Evaluation
age maxillofacial bleeding. There is a When there is no associated airway
misconception that patients do not bleed compromise, facial injuries are a lower
profusely from facial injuries and that priority than potential thoracic, abdomi-
facial bleeding can be controlled easily.1 nal, or head injuries.
Unfortunately, this is not necessarily
always the case. In addition, because In fact, in the absence
facial injuries themselves can be so striking, associated signifi- of airway compromise and severe hemor-
cant hemorrhage can often be overlooked or underestimated. rhage, definitive diagnostic evaluation and management of
Firm compression with moist sponges will temporarily stop maxillofacial injuries can be delayed until the more life-threat-
most arterial and venous bleeding. Careful application of dig- ening injuries have been stabilized and treated.
ital pressure or definitive ligation of the bleeding point can
EXAMINATION
often control external bleeding.These procedures are best per-
formed in the operating room, with the patient under general Like any other anatomic region, the face must be examined
anesthesia. in an orderly fashion, with careful attention paid to gross
If the source of hemorrhage is in the depths of a narrow lac- asymmetry, paralysis, weakness, eye movements, occlusal dis-
eration, bleeding can be controlled temporarily by packing. crepancies, and ecchymosis. Areas of hypesthesia or anesthesia
Blind clamping or suture ligation can damage important should be noted. Special attention should be directed toward
underlying facial structures, particularly branches of the facial bimanual palpation of bony prominences within the craniofa-
nerve; therefore, such procedures must be avoided. Insertion cial region to look for crepitus, tenderness, irregularities, and
of an anterior pack moistened with 1:10,000 epinephrine may step-offs. Palpation should start with the frontal bones and lat-
be used to control nasal bleeding. However, persistent eral and inferior orbital rims.
nasopharyngeal hemorrhage will necessitate either placement The zygomatic arch should be palpated for evidence of
of a posterior pack or ligation of the internal maxillary artery depression, and the region of the malar eminence should be
or the external carotid artery. evaluated for recession [see Figures 1 through 4]. Fracture of the
Ecchymosis
Flattened Cheek
Figure 1 Broken nose. Figure 2 Fractured zygoma.

Figure 3 Infraorbital fracture. Figure 4 Fractured mandible.
zygomatic complex is often identified with an inferiorly dis- palpation of the mandible is accomplished by placing the
placed lateral canthus, paresthesias of the infraorbital nerve, thumbs over the molar occlusal surfaces and the index fingers
visual impairment, displacement of the globe, or trismus sec- externally over the inferior border of the mandible and
ondary to impingement of the zygomatic arch on the coronoid torquing the bone to check for movement. Any missing or
process or temporal muscle. mobile teeth must be recorded. The floor of the mouth should
Orbital evaluation is key to the assessment of facial injuries. also be examined with bimanual palpation.
The nasolacrimal duct should be inspected, and the distance The ears should be examined for evidence of lacerations or
between the medial canthi should be measured for the pres- contusions of the external auditory canal that may be caused
ence of telecanthus. (The normal intercanthal distance in the by condylar neck fractures. A simple diagnostic method is to
average adult is less than 35 mm.) Pupils should be checked insert the fingertip into the external auditory canal on one
for reactivity, and extraocular muscle motion should be side; if no movement can be determined with mandibular
assessed. Diplopia secondary to extraocular muscle entrap- excursion, a diagnosis of condylar fracture can be made.
ment should be determined. The position of the globe should
FACIAL X-RAYS
also be assessed; orbital floor fractures may cause enophthal-
mos and severe swelling, and a blow-in type fracture may result A spectrum of available radiologic modalities plays a signif-
in exophthalmos. A visual acuity test must be performed be- icant role in the diagnosis and treatment of facial injuries.
fore any surgical intervention for correction of facial fractures. Appropriate studies are mandatory. In addition, x-rays provide
An ophthalmologic consultation is essential if there is any evi- an excellent permanent record for medicolegal purposes. The
dence of ocular damage, such as lens displacement, hyphema, initial x-rays of patients in the emergency room (the first level
retinal detachment, acute visual impairment, or global disrup- for assessment and clarification of maxillofacial injuries)
tion. should be performed using conventional films and should con-
Next, the nose should be gently palpated. Any depression, sist of a cervical spine series (with all the cervical vertebrae
abnormal motion, or deviation of the nasal bones and carti- adequately visualized), skull x-rays, and facial x-rays, including
lages should be noted. The nasal cavity should be examined the anteroposterior, lateral, Waters, Towne, submentovertex,
specifically for the presence of septal deviation, septal he- panorex, and mandibular views. More definitive x-rays can be
matoma, or leakage of cerebrospinal fluid. A septal hema- obtained later for complete evaluation of specific injuries. The
toma can be ruled out by aspiration with an 18-gauge or 20- Caldwell view defines the orbital walls and the frontal sinus
gauge needle and syringe; if bleeding is present, an incision structures. The Waters view is important for determining the
and drainage and placement of a drain are necessary. If left bony continuity of the orbit, nose, zygoma, and lateral portion
untreated, a septal hematoma may lead to the development of of the maxilla. The lateral skull view is helpful for evaluation of
a saddle-nose deformity. Flattening of the face, or dish-face frontal sinus fractures. Oblique views of the orbit are excellent
deformity, is characteristic of midfacial fractures. for demonstrating the apex and the medial, lateral, and orbital
Mobility of the maxilla is determined by placing one hand walls.
over the bridge of the nose while the other grasps the palate The lateral oblique and modified Towne views are used to
and upper dentition and moves the maxilla anteriorly and pos- evaluate the mandible.The lateral oblique is the most common
teriorly, checking for separation of the midfacial structures. and useful view and provides evaluation of the body, angle of
The mandible should be palpated carefully with both hands to the body, and the ascending ramus. A posteroanterior view is
locate any intraoral mucosal lacerations or lesions. Bimanual helpful in assessing the symphyseal and body regions as well as
the condylar and coronoid processes. Panoramic x-rays are the sue damage to already traumatized skin and lead to less scar
best screening views for assessing mandibular fractures, espe- formation.
cially within the condyles. Associated injuries to the dentition
and supporting structures may necessitate dental spot films for NERVE INJURIES
more specific information. The facial nerve is the nerve most vulnerable to maxillofa-
cial trauma, and its function must be thoroughly evaluated
OTHER STUDIES
before the administration of any local anesthetic. In addition,
Computed tomographic scanning can be of great value in facial nerve injuries result in the most serious functional dis-
diagnosing the more complex traumatic injuries, such as crani- abilities and aesthetic defects. Sensory nerves, such as the
omaxillofacial injuries and associated central nervous system infraorbital and supraorbital nerves, can also be involved in
injuries. Computed tomography is used to evaluate most criti- traumatic injures; however, the associated hypesthesia causes
cally injured patients with craniocerebral trauma, and the only minimal long-term disability.
studies can easily be extended to include the patient’s facial Whenever the posterior half of the parotid gland suffers a
skeleton with little additional risk. Both 3 mm axial and coro- deep laceration, it should be assumed that a major branch of
nal CT cuts of the facial skeleton should be obtained, espe- the facial nerve has been divided, and the face should be care-
cially for examination of the orbit. A lateral oblique scan fully examined. If there is a clean, sharp division of one of the
through the midportion of the globe provides additional infor- five major trunks or of the proximal main nerve trunk, it can
mation regarding the bony architecture of the orbit.This infor- be repaired immediately with microanastomotic techniques. If
mation can be reformatted, and three-dimensional reconstruc- there is substantial nerve loss, the nerve ends should be iden-
tions can be made for further evaluation. Magnetic resonance tified and appropriately tagged for future nerve grafting. If a
imaging is proving to be of benefit in assessing both bony and nerve laceration occurs anterior to the region of the lateral
soft tissue injuries. Arteriography may be needed to evaluate canthus, nerve repair is generally unnecessary because there is
the source of a hemorrhage or to rule out major vascular sufficient crossover from the opposite side. Peripheral branch
injuries. injury is manifest by inability to raise the eyebrow (frontal
branch), inability to close the eyelids (malar), smoothness of
the cheek (infraorbital), inability to smile (buccal), and inabil-
Treatment of Soft Tissue Injuries ity to frown (marginal mandibular).
Soft tissue injuries are most often the result of penetrating
PAROTID DUCT INJURIES
trauma but can also be the result of blunt trauma [see
Treatment of Maxillofacial Fractures, below]. Any patients who The parotid duct is located between the parotid gland and
need general anesthesia, such as a child or a patient with exten- the oral mucosa, opening opposite the second upper molar.
sive complex lacerations involving deeper structures, should be Any deep laceration of the anterior parotid gland can damage
treated in the operating room after appropriate evaluation of this duct. If there is a possibility that the parotid duct
their overall status. Soft tissue injuries can involve nerves, is injured, the orifice of Stensen’s duct should be probed.
parotid ducts, lacrimal ducts, and other critical facial struc- Should the probe enter the wound, division of the duct is ver-
tures. Abrasions must be thoroughly cleaned, and lacerations ified. The proximal cut end of the duct can be located by ex-
should be irrigated with normal saline and conservatively pressing saliva from the gland. A catheter should then be
debrided as necessary. With deeply embedded foreign materi- passed through Stensen’s duct and through the area of lacera-
al, debridement and irrigation must be particularly meticulous tion, and the duct should be repaired over the catheter [see
and extensive to prevent residual cosmetic deformities. Derm- Figure 5].
abrasion is especially good for large involved areas. Most facial
LACRIMAL DUCT INJURIES
lacerations can be closed primarily with standard suturing pro-
cedures [see 1:7 Acute Wound Care]. Antibiotic coverage is left to Whenever there is a laceration involving the medial canthal
individual preferences; however, 24 hours of prophylactic peri- region, a lacrimal duct injury should be assumed. Acute recon-
operative antibiotic coverage with a cephalosporin is strongly struction of the lacrimal duct is controversial. If both ends of
recommended. The examiner must always consider the possi- the duct can be easily discerned, the severed ends should be
bility of underlying injuries, and careful palpation and visual- realigned, splinted internally, and repaired. This procedure is
ization of important underlying structures should be part of best accomplished over a fine Silastic rod. Dissection to locate
the definitive wound evaluation and treatment. the residual parts of the duct should be delicate and meticu-
Local anesthetic agents used in the head and neck region lous, because traumatic dissection can aggravate the injury and
should always contain epinephrine for hemostasis. To decrease result in further permanent damage.
pain and discomfort, the local anesthetic should be adminis-
SCALP INJURIES
tered through the margins of the wound rather than through
the surrounding skin. Regional nerve blocks are preferred for When scalp injuries are repaired, extensive shaving is unnec-
suture closure of lacerations involving the forehead, cheeks, essary. Scalp injuries can be associated with profuse bleeding
lips, and chin.The forehead can be blocked by local infiltration because of the scalp’s extensive vascular supply. To obtain ade-
of the supraorbital nerve, which is located just superior to the quate control of hemorrhage from the wound margins, closure
eyebrow. The upper lip, side of the nose, and adjacent skin can can be achieved in a single layer with a running, locking 3-0
be blocked by anesthetizing the infraorbital nerve. Injection of chromic suture on a large cutting needle. Associated underly-
the mental nerve, located between the first and second bicus- ing skull fractures are always a possibility, and the skull should
pids, will anesthetize the lower lip and surrounding chin. be palpated and inspected through any full-thickness scalp
Regional blocks also provide the advantage of minimizing tis- wound.
Figure 5 Injuries to the parotid duct are repaired by passing a catheter through Stensen’s duct and through the
area of laceration and then repairing the parotid duct over the catheter.
EYELID INJURIES Repair of ear wounds should be done in three layers by using
If the patient reports excessive eye pain, the initial examiner fine nonabsorbable sutures to approximate the cartilage and
must always first rule out an associated ocular injury. In addi- the skin. If the ear is completely detached, the cartilage should
tion, when faced with through-and-through lid lacerations, be preserved within a subcutaneous pocket in the mastoid
the examiner must perform a very careful eye examination. region for future reconstruction.
Lacerations of the eyelid should be meticulously repaired by Hematomas can occur secondary to the shearing of the
approximation of the margins of the lid defect, followed by clo- vascular mucoperichondrium from the underlying cartilage.
sure of the laceration in three layers. The conjunctiva may be These must be evacuated early, and a conforming pressure
left unsutured if good apposition can be obtained by closing dressing should be placed to maintain the normal ear contour.
the tarsal plate and the pretarsal muscles that occupy the mid-
NASAL INJURIES
dle layer, which is preferably closed with fine absorbable
sutures. Fine nonabsorbable skin sutures are employed to close Through-and-through lacerations of the nose and near-
the final layer. All skin sutures should be removed within 48 avulsion injuries are cosmetic problems. Because the nose is
hours. When there is extensive tissue loss, it may be necessary extremely vascular, repair of these injuries should be especial-
to use plastic techniques to mobilize sufficient conjunctiva for ly meticulous and done in layers.The cartilage and skin should
closure. be aligned with fine nonabsorbable interrupted sutures.
Absorbable sutures should be employed for repair of the
EYEBROW INJURIES mucosa. Key cosmetic points (i.e., epidermal-mucosal junc-
For optimal cosmetic results, the eyebrows should be closed tions, nasal fold junctions, or critical angles in jagged lacera-
meticulously in layers with careful alignment of the eyebrow tions) should be sutured first to ensure that no deformity
margins. Lacerations passing through the eyebrow should not results.
be shaved; leaving them intact facilitates good plastic closure.
Because the hairs of the eyebrow run obliquely to the surface LIP INJURIES
of the skin, any incision for debridement should follow the line If the margin of the lip has been divided, the vermilion bor-
of the eyebrows to avoid further loss of hair. der should be carefully identified and tattooed, and the first
sutures should be placed to approximate this critical margin.
EXTERNAL-EAR INJURIES
A common problem in the treatment of lip injuries is that it
If avulsions of the ear are properly repaired, the chances are may become more difficult to identify landmarks when they
good that they will heal because of the highly vascular pedicle. are obliterated by local anesthetic injections or associated
Circulation is maintained if even a small pedicle is present. edema.
Treatment of Maxillofacial Fractures ZYGOMATIC FRACTURES
Management of maxillofacial fractures can be extremely The zygoma is a tetrapod structure that forms the malar
challenging. The common maxillofacial fractures include prominence and the inferior and lateral aspects of the orbit.
nasal, mandibular, orbital, zygomatic complex, sinus (e.g., Fractures of the zygomatic complex should be repaired to pre-
maxillary, sphenoid, ethmoid, and frontal), and maxillary frac- vent the development of serious aesthetic and functional
tures (e.g., Le Fort I, II, or III). Management of these fractures deformities. Satisfactory stabilization requires three-point fix-
often requires sophisticated specialty treatment involving plas- ation achieved through incisions placed within the regions of
tic surgeons, ophthalmologists, neurosurgeons, otolaryngolo- the upper and lower lids and the upper buccal sulcus.23
gists, or a combination of these.2-7
MAXILLARY FRACTURES
FRONTAL SINUS FRACTURES
In 1901, maxillary fractures were classified by René Le Fort
The frontal sinus region is prone to injury because of its into three types.24 Although the Le Fort classification system
prominent location and relatively thin anterior bony wall.8,9 remains entrenched in the literature and serves as a basis for
Injuries to the frontal sinus area require comprehensive treat- both communication and description, it is rare that patients
ment, often with a team approach. The key to treatment lies in exhibit pure Le Fort fracture patterns. Instead, trauma sur-
determining the status of the nasofrontal ducts.10,11 Patients
with such injuries also require careful, regular, long-term fol-
low-up care because potentially life-threatening complications,
such as meningitis, osteomyelitis, and mucopyocele, may
develop.12-15
NASAL AND NASO-ORBITO-ETHMOIDAL FRACTURES
The nasal bone is the most commonly fractured facial

bone.16 Before any treatment is embarked on, it is always help-
ful to have the patient provide a preinjury photo of himself or
herself so that it can be determined whether the nasal defor-
mity is from the acute episode.17 If a patient is seen almost
immediately after injury and the associated swelling and
ecchymosis are minimal, closed reduction can be performed at
once. Nasal bone fractures can be reduced simply by inserting
a scalpel handle or large hemostat into the nostril; the fracture
segments can then be elevated and relocated. Usually, the
nasal cavity is packed with petroleum jelly gauze to maintain
alignment of the fracture and nasal septum, and a malleable
splint is taped over the nose to provide counterpressure and
assist in maintaining alignment. Packing is removed within
48 hours. However, treatment is generally not urgent and, Figure 6 Le Fort I fractures (black line) affect the upper jaw
depending on the individual situation, may be delayed for 7 to alone. In Le Fort II fractures (red line), the upper jaw and the
central portion of the face are separated from the skull.
10 days.
Naso-orbito-ethmoidal fractures generally occur secondary
to direct force applied over the nasal bridge, resulting in pos-
terior displacement of bony structures and involvement of the
medial canthus, lacrimal duct, canaliculi, and sac.18 Repair of
naso-orbito-ethmoidal fractures can be extremely challenging
because of the number of important structures involved and
their extensive comminution.19 Satisfactory surgical manage-
ment should be conducted through a coronal approach, there-
by permitting precise three-dimensional reduction and stabi-
lization and extensive primary bone grafting for replacement
augmentation.20 If there is associated CSF rhinorrhea, neuro-
surgical assistance should be obtained and early fracture
reduction done.
ORBITAL FRACTURES
Orbital fractures can occur as isolated events or as a com-

ponent of more extensive injuries. Orbital fractures, such as
lacrimal duct lacerations and injuries to the globe, require
highly specialized management with the aid of an ophthalmol-
ogist. Naso-orbital fractures with telecanthus should be treat-
ed with open reduction and fixation, as should all displaced Figure 7 In Le Fort III fractures, all of the facial bones are
fractures of the orbital rim and floor.21,22 separated from the skull.
Figure 8 Findings in patients with Le Fort III maxillary fractures immediately after injury, before
obliterative edema develops.
geons are generally challenged by severe bony comminution and itive treatment results in a decreased number of complications.
distraction. Preinjury occlusal relations remain the keystone to treatment.
Le Fort I, or lower maxillary fractures, are the simplest type Mandibular fractures can be repaired by closed reduction with
of maxillary fracture, consisting of horizontal detachment of maxillomandibular fixation or by open reduction and fixation
the tooth-bearing segment of the maxilla at the level of the with wire osteosynthesis. However, newer techniques with rigid
nasal floor [see Figure 6]. Le Fort II, or central or pyramidal internal fixation with miniature plates and screws have attained
fractures, pass through the central portion of the face, which widespread popularity because of increased patient comfort.25-31
includes the right and left maxillae, the medial aspect of the In cooperative patients, a nondisplaced fracture can some-
antra, the infraorbital rim, the orbital floor, and the nasal times be handled conservatively with a dental soft diet and
bones. Le Fort III, or craniofacial disjunction, is characterized serial x-rays.
by complete separation of all facial structures from the crani-
um [see Figures 7 and 8]. Le Fort III fractures pass through the
upper portions of the orbits as well as through both zygomas.
All Le Fort fractures require highly specialized treatment
that involves the use of craniofacial techniques, consisting of
exploration and visualization of the entire fracture pattern,
precise reduction, and rigid stabilization of bony segments.
MANDIBULAR FRACTURES
Diagnosis of mandibular fractures can usually be made on

physical examination. Common findings include malocclu-
sion, intraoral lacerations, and mobility at the fracture site.
Radiographs are useful for planning treatment. Fractures of
the mandible rarely involve the midline or symphyseal region.
Most often, fractures will pass through areas of weakness,
including the parasymphyseal region and the angle or neck of
the condyle [see Figure 9].The fracture pattern is usually deter-
mined by the site and mechanism of injury. Because of the
mandible’s architectural arrangement, more than one half of
mandibular fractures involve multiple sites.
Mandibular fractures are not an emergency, but early defin- Figure 9 Mandibular fractures.
Discussion
Because the face is so thoroughly exposed, it is one of the most sue, with minimal dead space and no tension.
frequently injured areas of the body. Facial injuries can occur If the wound cannot be closed within the first 24 hours,
under a variety of circumstances, such as automobile acci- delayed primary closure may be undertaken after 48 hours. In
dents, altercations, or falls; more specifically, these injuries can this event, the patient should be given systemic antibiotics, and
be the results of bites, fires, explosions, lacerations, and contact the wound should be kept moist and protected as much as pos-
with sharp or blunt objects. In automobile accidents, shards of sible in the interval before closure. For best cosmetic results,
glass may penetrate the wound, and these shards may not be the wound should be closed in multiple layers.
radiopaque. If abrasions are present, note should be made of Sutures made of fine monofilament nylon, such as 6-0, are
the abrading agent, whether it be grease, particles of dirt, grav- ideal for approximating the skin because they are nonreactive.
el from a highway, or other contaminants. Underlying bony The sutures should be applied loosely so that they do not
injury may or may not be obvious near the wounds. Because strangulate tissue.
such injuries can expose the patient to tetanus or other anaer- Key anatomic points should be identified and tattooed,
obic infections, antitetanic agents should be administered as mucosal edges should be approximated, and irregular margins
part of the treatment regimen [see I:7 Acute Wound Care]. If of the skin should be excised and squared to provide the best
treatment is delayed for any reason, a systemic prophylactic possible fit. Margins of damaged structures, such as the nose
antibiotic should be administered. Minor lacerations of the or the ear, should be defined, and the critical margins should
face caused by domestic assaults or household accidents can be determined and approximated initially. While the wound is
be adequately treated in the emergency department under being closed, all dead space in the wound should be obliterat-
local anesthesia [see I:7 Acute Wound Care]. Lacerations that are ed and the edges everted. If the needle is passed through the
contaminated are often best treated in the operating room with skin at right angles, the edges of the skin will abut and eversion
the patient under general anesthesia. will occur. If, however, the needle is passed through the skin
Only as much hair should be removed as is necessary for edge obliquely, inversion will result, and healing will be com-
adequate assessment of the wound or for effective suturing. promised. Subcutaneous or subcuticular sutures should be
Eyebrows are best left unshaved to facilitate cosmetic repair. placed in such a way as to allow the skin edges to be approxi-
Local anesthesia should be induced, and abrasions should be mated with minimal tension. If this procedure is done,
scrubbed with a stiff brush until every particle of dirt is through-and-through sutures can be removed in 3 days, and
removed. If the dirt is deeply embedded, some tissue may have no marks will be left on the skin.
to be excised; this step can often be accomplished through the Any skin defects that require closure should be closed by
use of a fine curette or the point of a No. 11 blade. If dirt is not grafting. No facial wound should be allowed to heal by granu-
removed initially, it may be extremely difficult to remove later, lation, because this would lead to excessive scarring. Instead, a
and permanent tattooing may result. temporary cover in the form of a skin graft should be provided
Any dead or devitalized tissue should be excised, but there to minimize scar formation; any deformity that results from the
is no place for radical debridement of facial wounds. Tissue graft can be repaired at a later date [see 3:7 Surface Recon-
can survive on small pedicles. Full-thickness skin loss can be struction Procedures].
replaced with a free graft, which provides a better cosmetic The more complex of the maxillofacial fractures, such as
match than a split-thickness skin graft [see 3:7 Surface Recon- major maxillary fractures, orbital fractures, malar fractures,
struction Procedures]. If the wound is so ragged that it cannot be and mandibular fractures [see Treatment of Maxillofacial
approximated, careful squaring of the edges may be advisable Fractures, above], must be treated with specialty techniques;
to facilitate a cosmetic closure. Dead or devitalized subcuta- therefore, corresponding specialty consultation must be
neous tissue should be removed conservatively. sought. However, in treating these fractures and soft tissue
Most facial wounds can be closed by simple suturing. Al- injuries [see Treatment of Soft Tissue Injuries, above], the pri-
though the deadline for closure of wounds to other sites is usu- orities are to ensure adequacy of the airway and to control
ally 6 to 8 hours, facial wounds, unless heavily contaminated, immediate bleeding. Once these aims have been achieved,
can be closed as long as 24 hours after injury, particularly if none of the defects described, except for facial lacerations,
meticulous attention is paid to procedural details. Such details require emergency treatment; they can be repaired days to
include irrigation of the wound, removal of all foreign bodies, even months later, if necessary, without jeopardizing a good
excision of devitalized tissue, and accurate approximation of tis- cosmetic result.
References
1. Thaller S, Beal S: Maxillofacial trauma: a poten- managed with exploration with or without obliter- Trauma 37:243, 1994
tially fatal injury. Ann Plast Surg 27:281, 1991 ation over 10 years. Laryngoscope 98:516, 1988 24. Le Fort R: Etude expérimentale sur les fractures
2. Tung TC, Tseng WS, Chen CT, et al: Acute life- 13. Shockley W, Stucker F, White L, et al: Frontal de la mâchoire supérieure. Rev Chir 23:208,
threatening injuries in facial fractures: a review of sinus fractures: some problems and some solu- 1901
1025 patients. J Trauma 49:420, 2000 tions. Laryngoscope 98:18, 1988 25. Pogrel M: Compression osteosynthesis in
3. Girotto JA, Gamble WB, Robertson B, et al: 14. Wallis A, Donald P: Frontal sinus fractures: a mandibular fractures. Int J Oral Maxillofac Surg
Blindness after reduction of facial fractures. Plast review of 72 cases. Laryngoscope 98:593, 1988 15:521, 1986
Reconstr Surg 104:875, 1999 15. Rohrich R, Hollier L: Management of frontal 26. El-Degwi A, Mathog R: Mandible fractures: eco-
4. Manson PN, Clark N, Robertson B, et al: sinus fractures. Clin Plast Surg 19:219, 1992 nomic considerations. Otolaryngol Head Neck
Subunit principles in midface fractures: the Surg 108:213, 1993
16. Spira M, Hardy S: Management of the injured
importance of sagittal buttresses, soft tissue 27. Eid K, Lynch D, Whitaker L: Mandibular frac-
nose. Tex Med 67:72, 1971
reductions, and sequencing treatment of segmen- tures: the problem patient. J Trauma 16:658,
tal fractures. Plast Reconstr Surg 104:875, 1999 17. Rohrich RJ, Adams WP: Nasal fracture manage-
1976
ment: minimizing secondary nasal deformities.
5. Gruss JS, Whelan MF, Rand RP, et al: Lessons 28. Thaller S, Reavie D, Daniller A: Rigid internal
Plast Reconstr Surg 106:266, 2000
learnt from the management of 1500 complex fixation with miniplates and screws: a cost-effec-
facial fractures. Ann Acad Med Singapore 18. Gruss J: Naso-ethmoid-orbital fractures: classifi-
tive technique for treating mandible fractures?
28:677, 1999 cation and role of primary bone grafting. Plast
Ann Plast Surg 24:469, 1990
Reconstr Surg 75:303, 1985
6. McDonald WS,Thaller SR: Priorities in the treat- 29. Bayles SW, Abramson PJ, McMahon SJ, et al:
ment of facial fractures for the millennium. J 19. Gruss J, Pollock R, Phillips J, et al: Combined Mandibular fracture and associated cervical spine
Craniofac Surg 11:97, 2000 injuries of the cranium and face. Br J Plast Surg fracture, a rare and predictable injury: protocol
42:385, 1989 for cervical spine evaluation and review of 1382
7. Mauriello JA, Lee HJ, Nguyen L: CT of soft tis-
sue injury and orbital fractures. Radiol Clin 20. Manson P, Crawley W, Yaremchuk M, et al: cases. Arch Otolaryngol Head Neck Surg
North Am 37:241, 1999 Midface fractures: advantages of immediate 123:1304, 1997
extended open reduction and bone grafting. Plast 30. Chu L, Gussack GS, Muller T: A treatment pro-
8. Stanley R: Management of frontal sinus fractures.
Reconstr Surg 76:1, 1985 tocol for mandible fractures. J Trauma 36:48,
Facial Plast Surg 5:231, 1988
21. Koutroupas S, Meyerhoff W: Surgical treatment 1994
9. Stanley R: Fractures of the frontal sinus. Clin
of orbital floor fractures. Arch Otolaryngol 31. Troulis MJ, Kaban LB: Endoscopic approach to
Plast Surg 16:115, 1989
108:184, 1982 the ramus/condyle unit: clinical applications. J
10. Wolfe SA, Johnson P: Frontal sinus injuries: pri- Oral Maxillofac Surg 59:503, 2001
22. Antonyshyn O, Gruss J, Galbraith D, et al:
mary care and management of late complications.
Complex orbital fractures: a critical analysis of
Plast Reconstr Surg 82:781, 1988
immediate bone reconstruction. Ann Plast Surg
11. Luce E: Frontal sinus fractures: guidelines to 22:220, 1989
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23. Covington DS, Wainwright DJ, Teichgraeber JF,
Acknowledgment
12. Wilson B, Davidson B, Corey J, et al: Comparison et al: Changing patterns in the epidemiology of
of complications following frontal sinus fractures treatment of zygoma fractures: 10-year review. J Figures 1 through 9 Carol Donner.
7 TRAUMA AND THERMAL INJURY 4 Injuries to the Neck— 1
4 INJURIES TO THE NECK

David H.Wisner, M.D., F.A.C.S., and Robert C. Jacoby, M.D., F.A.C.S.
Assessment and Management of Neck Injuries
Injuries to the neck can be secondary to handed surgeon) and to stabilize the cartilaginous framework by
both blunt and penetrating trauma. holding the thyroid cartilage in place with the left hand. A trans-
Occasionally, blunt trauma to the neck verse incision should be made at the level of the cricothyroid mem-
causes injury to the airway, the carotid brane and developed rapidly through the subcutaneous tissue [see
artery system, or the vertebral artery sys- 7:1 Life-ThreateningTrauma]. As with any transversely oriented inci-
tem. Blunt airway injuries are sometimes sion of the anterior neck, the anterior jugular veins are at risk for
surgical emergencies; the approach to these injury. If such injury occurs, the damaged veins are best controlled
injuries is similar to that of penetrating with suture ligation after an airway is obtained. In true emergency
injuries [see Airway Compromise and circumstances when the exact site of injury is unknown, a vertical
Isolated Laryngotracheal Injuries, below]. rather than transverse incision should be used to allow access to as
Blunt arterial injuries are almost always discovered by angiography much of the anterior surface of the airway as possible and to
and are usually treated nonoperatively [see Discussion, Screening decrease the chance of injury to the anterior jugular veins.
Criteria for and Recommended Management of Blunt Cervical After the skin and the subcutaneous tissue have been divided, an
Arterial Injuries, below]. In the rare instance of a patient who under- incision should be made through the cricothyroid membrane.This
goes operative treatment for a blunt injury to carotid or vertebral is most rapidly done with a No. 11 knife blade. It is important to
arteries, the operative and postoperative principles for penetrating avoid pushing the knife blade too far and causing injury to the pos-
arterial injuries should be applied [see Injuries to the Carotid terior wall of the airway or to the posteriorly located hypopharynx
Arteries, Jugular Veins, Pharynx, and Esophagus, below]. and esophagus. After the incision has been made, the opening
Patients with penetrating wounds of the neck can be loosely cat- should be enlarged by placing the knife handle in the incision and
egorized into the following six groups according to the location twisting it 90º. At this point, an indwelling endotracheal airway
and nature of the wound: should be placed and secured. In most adults, a No. 6 airway is the
largest that can be inserted; a No. 4 or larger airway is adequate for
1. Patients with emergency or impending airway compromise.
initial placement. Any incisional bleeding from the anterior jugular
2. Patients with an isolated injury to the larynx or trachea.
veins or other vessels should be controlled. Cricothyrotomies
3. Patients with suspected or known injuries to the carotid arter-
should be converted to tracheotomies within 48 to 72 hours as
ies, jugular veins, pharynx, or esophagus.
long as the patient’s general condition permits [see Discussion,
4. Patients with wounds at the base of the neck (particularly when
Conversion of Cricothyrotomy to Tracheotomy, below].
intrathoracic injury is suspected).
5. Patients with known injury to the vertebral arteries. TRACHEOTOMY
6. Patients with obviously superficial wounds of the neck.
In some instances, airway compromise may not be extreme but
Division of patients into these groups, though somewhat arbi- a surgical airway may still be necessary for safety or subsequent
trary, helps in choosing an incision and determining the initial management of a laryngeal injury. In such circumstances, a tra-
operative priorities at exploration. cheotomy rather than a cricothyrotomy should be done, because
cricothyrotomy is more likely than tracheotomy to make definitive
treatment more difficult.
Airway Compromise The initial approach for emergency tracheotomy is similar to
Some patients will present with emer- that for cricothyrotomy, the difference being that a so-called collar
gency or impending airway compromise. incision is made at a point one to two fingerbreadths inferior to the
The initial priority should be to ensure an level of the cricothyroid membrane. The incision should be wide
adequate airway. In some patients, this enough to provide rapid exposure and should extend as far as the
requires orotracheal intubation. In other anterior border of the sternocleidomastoid bilaterally. Anteriorly
patients, a surgical airway must be created located injuries at the level of the cricoid or the trachea may
by means of either cricothyrotomy (in already have a hole in the airway. In such cases, if the need for a
emergency cases) or tracheotomy (in less surgical airway is immediate, the wound should be enlarged and
extreme cases). Nasotracheal intubation is used as a route of access to the airway.
not advisable in most trauma settings. On rare occasions, the injury is in the distal cervical or proximal
intrathoracic trachea. In such circumstances, access to the trachea
CRICOTHYROTOMY
may not be possible through a cervical incision alone. Median
In true emergency situations, a cricothyrotomy should be done. sternotomy and lateral retraction of the innominate artery and the
The landmarks of the superior (notched) and inferior borders of left internal carotid artery allow exposure of the anterior surface of
the thyroid and the cricoid cartilage should be palpated. For this the trachea at the thoracic inlet. Right thoracotomy provides
task, it is helpful to stand on the patient’s right side (for a right- access to the more distal intrathoracic trachea.
Patient has penetrating neck injury
Determine the location and nature of the injury.

Emergency airway
compromise
Perform cricothyrotomy.
Airway compromise
Ensure an adequate airway by

orotracheal intubation or by creating Nonemergency or potential
a surgical airway. airway compromise
Perform tracheotomy.
Isolated laryngotracheal injuries

Small injuries to trachea
Perform collar incision.
Close primarily, without
tracheotomy.
Known or suspected injuries to

carotid arteries, jugular veins,
pharynx, and esophagus Large injuries to trachea
Perform anterior sternocleidomastoid • Anterior injuries: convert to

incision for exposure and exploration tracheotomy.
of sites of injury [see Figure 1]. • Lateral and posterior injuries:
close primarily and protect
with tracheotomy.
Wounds to the base of the neck

Injuries to larynx
Assess known or suspected injuries
to innominate or right subclavian Perform tracheotomy and
artery [see Figure 5] and to left minimal debridement of
subclavian artery [see Figure 6]. laryngeal structures. Defer
definitive treatment.
Known vertebral artery injuries
Assess injuries [see Figure 7].

Assessment and
Management
Superficial wounds
of Neck Injuries
Achieve vascular control and
debride the wound.
Isolated Laryngotracheal Injuries

important in patients with a true emergency condition, such as
Most commonly, the presence of an iso- external bleeding, a focal neurologic deficit, coma, or an expand-
lated laryngotracheal injury is not recog- ing neck hematoma. When bilateral exploration is necessary, sep-
nized preoperatively. On occasion, howev- arate sternocleidomastoid incisions should be done.
er, isolated injuries to the larynx and tra- An anterior sternocleidomastoid incision has several important
chea are recognized preoperatively on the advantages [see Figure 2]. For example, it can be lengthened to
basis of a suspicious history and the results provide more extensive proximal or distal exposure. If a superior
of diagnostic studies, such as laryngoscopy extension to below the earlobe is necessary, the incision should be
and bronchoscopy. curved posteriorly to avoid injury to the marginal mandibular
Injuries to the larynx that result in air- branch of the facial nerve. Another advantage of the sternocleido-
way compromise should be treated initially with a collar incision mastoid incision is that it provides exposure of the carotid sheath,
for the creation of a surgical airway [see Airway Compromise, the pharynx, and the cervical esophagus.
Tracheotomy, above]; however, definitive treatment should be
deferred. Minimal debridement of laryngeal structures should be Operative Technique
carried out during the initial operative procedure. Injuries to the The patient is placed in the supine position, with the head
larynx should be handled on a semielective basis by otolaryngol- turned away from the side of exploration and the neck extended.
ogists with expertise in laryngeal repair and reconstruction. In this regard, it is helpful to clear the cervical spine before oper-
Further investigation of the larynx, including laryngeal x-rays, ation if possible. If both sides of the neck are to be explored, the
laryngoscopy, and computed tomography, may be necessary. head is left in the midposition, facing up.The entire neck and the
Small injuries of the trachea can be repaired primarily without appropriate side of the face and head are prepared. The anterior
tracheotomy. Absorbable 3-0 or 4-0 sutures should be placed chest is also included in the preparation in case a median ster-
transversely, if possible, and should include tracheal rings above notomy is necessary for proximal control [see Exploration and
and below the site of injury. Large anterior defects should be con- Exposure, Arteries and Veins, below].The patient is draped so that
verted to a tracheotomy, whereas defects to the lateral or posteri- the lateral neck is left as the primary field while the chest is kept
or aspects of the trachea should be closed primarily and protected easily accessible.The lateral chin and the tip of the earlobe are also
with a tracheotomy.Tension can be relieved from a repair by mobi- kept in the field to provide landmarks. If the possibility exists that
lizing the trachea proximally and distally. During this mobilization, the injury is to the distal subclavian artery or the axillary artery,
the recurrent laryngeal nerves are subject to injury if the dissection the patient’s arm should be draped in a way that allows it to be
is carried into the tracheoesophageal groove. Laryngotracheal manipulated.
injuries do not require routine drainage unless there is an associ- The skin incision is carried through the dermis and the platys-
ated injury to the pharynx or esophagus [see Injuries to the Carotid ma. After the platysma is divided in the direction of the incision,
Arteries, Jugular Veins, Pharynx, and Esophagus, below]. the investing fascia overlying the anterior border of the sternoclei-
If a large segment of trachea has been destroyed, primary anas- domastoid muscle is incised, and the muscle is retracted laterally
tomosis can be accomplished for defects up to five or six tracheal and posteriorly to expose the carotid sheath. It is often necessary
rings in length. Anastomosis requires mobilization of the intratho- to divide a venous branch that connects the external jugular vein
racic trachea inferiorly and the laryngeal complex superiorly and posterolaterally to the anterior jugular vein anteromedially. This
is best done electively.1,2 vein lies in a plane immediately deep to the platysma.
Patients with laryngeal injuries should be watched carefully in
the postoperative period for signs of mediastinitis, which may Exploration and Exposure
result from persistent airway leak or a missed pharyngoesophageal When possible, proximal and distal control should be obtained
injury. The chest x-ray should also be checked for pneumomedi- before exploration of a carotid artery injury. In practice, obtaining
astinum as a sign of continued airway leakage, particularly in proximal control before entering a perivascular hematoma is all
patients who remain on positive pressure ventilation. that is absolutely necessary. If necessary, distal bleeding can be
controlled with digital pressure while the dissection of the injured
vessel is completed. Although it is often difficult to obtain control
Injuries to the Carotid Arteries, before addressing the area of injury, proximal and distal control of
Jugular Veins, Pharynx, and the vessel should be obtained at some point before any attempts at
Esophagus definitive repair. For injuries near the carotid bifurcation, it is nec-
Probably the most common situation in essary to control the common, internal, and external carotid arter-
penetrating cervical trauma is the patient ies, as well as the proximal branches of the external carotid artery.
with underlying structural injuries, the pre-
cise location and nature of which are Arteries and veins The initial exploration should attempt
unknown. An anterior sternocleidomastoid to rule out arterial or venous injury, unless an overt airway injury
incision provides good access to most of is present and requires immediate attention [see Airway Compro-
the vital structures in the neck and can be mise, above]. The location of the carotid artery can then be con-
done relatively rapidly. firmed by the presence of a pulse. It is often necessary to retract
the jugular vein posterolaterally to provide adequate arterial expo-
STERNOCLEIDOMASTOID INCISION
sure [see Figure 3]. During dissection of the carotid sheath and
If the location of underlying neck injuries is either unknown or retraction of the jugular vein, care must be taken to keep from
confirmed by preoperative studies to be in the carotid arteries, the injuring the associated vagus nerve. Jugular vein retraction is facil-
jugular veins, the pharynx, or the esophagus, an incision along the itated by division of the facial vein, which is superficial to the
anterior border of the sternocleidomastoid muscle should be used carotid bifurcation. The severed ends of the facial vein should be
[see Figure 1]. The sternocleidomastoid incision is particularly suture-ligated to ensure that the ties will not come off with
Known or suspected injuries to carotid arteries,

jugular veins, pharynx, and esophagus
Perform anterior sternocleidomastoid incision for

exposure and exploration of sites of injury.
Pharyngoesophageal
Carotid artery injuries Jugular vein injuries injuries
Repair injuries and

drain for approximately
1 wk. Institute antibiotic
therapy for oral flora
Common carotid and Internal carotid Small injuries Large (several postoperative
external carotid arteries artery injuries doses).
Repair vein.
Simple injuries Complex injuries Minimal or no Back-bleeding Stable patient Unstable patient
or complex or injuries in a back-bleeding is present with minimal with severe other
injuries in a highly unstable is present other injuries injuries
stable patient patient with other
with no other severe injuries Ligate artery. Repair vein Ligate vein.
severe injuries surgically.
Ligate artery.
Repair artery.
Stable patient Patient in

with minimal extremis with
Figure 1 Algorithm outlines operative other injuries severe other
management of known or suspected injuries injuries
to the carotid arteries, jugular veins, phar- Repair artery.
ynx, and esophagus. Ligate artery.
increased intravenous pressure in the postoperative period—for

example, secondary to a cough or a Valsalva maneuver.
Exposure of the proximal common carotid artery at the base of
the neck is easier after division of the omohyoid muscle at the point
where its superior and inferior bellies are joined. Division of the
omohyoid muscle results in minimal functional deficit postopera- Facial
Nerve
tively. For proximal control of the common carotid artery, it may be
necessary to enter the chest via median sternotomy. To minimize
blood loss, the decision to do a sternotomy should be made with- Sternocleidomastoid
Muscle
out undue delay. Control of the proximal right common carotid
artery via this route is relatively easy and is accomplished by first
obtaining control of the innominate artery and then dissecting dis-
tally. Proximal control of the left common carotid artery via medi- External
an sternotomy is more difficult, because its origin from the aortic Carotid
arch is more posterior than the origin of the innominate artery. Artery
Exposure of the distal internal carotid artery can be very diffi- Incision
cult, particularly if there is an injury in that location. As dissection
is carried distally on the internal carotid artery, a number of
important structures should be identified and protected [see Figure
4]. The hypoglossal nerve is usually encountered within several
centimeters of the carotid bifurcation and should be dissected free
of the internal carotid and retracted upward. This is facilitated by
division of the occipital artery, which crosses superficial to the
hypoglossal nerve on its course from the external carotid artery
toward the occiput. It is also helpful to divide the ansa cervicalis
branches that run inferiorly from the hypoglossal nerve to supply Figure 2 In general, exposure of structures in the anterior areas
the muscles of the neck. Injury to the hypoglossal nerve results in of the neck is best done through an incision oriented along the
impaired motor function of the tongue and can lead to dysarthria anterior border of the sternocleidomastoid muscle.
Facial Vein
(Ligated)
Carotid
Internal
Bifurcation
Jugular Vein
Omohyoid
Muscle
Figure 3 After a plane along the anterior border of the sternocleidomastoid muscle has been
developed, dissection is carried down to the level of the carotid sheath. Suture ligation of the
facial vein facilitates this dissection. Lateral retraction of the internal jugular vein improves
exposure of the carotid bifurcation.
and dysphagia. Injury to or sectioning of the ansa cervicalis caus- the intrapetrous portion of the internal carotid after removal of the
es little or no morbidity. overlying bone of the mastoid with a high-speed bone drill.
Further distal exposure of the internal carotid artery may require
unilateral mandibular subluxation or division of the ascending Pharynx and esophagus The oropharynx, hypopharynx,
ramus of the mandible.3 Such maneuvers are somewhat easier and cervical esophagus are exposed via the same anterior ster-
when the patient is nasotracheally intubated.They increase the size nocleidomastoid incision used for arterial and venous injuries. If
of the small area immediately behind the condyle and allow easier the patient has a known right-side injury, the incision should be
division of the stylohyoid ligament and the styloglossus and sty- made in the right neck. If the injury is on the patient’s left side or
lopharyngeus muscles. These three structures can be divided if the exact site of injury is unknown, the exposure should be made
together adjacent to their common origin at the styloid process. If from the left because the cervical esophagus is located slightly to
this is done, care should be taken to preserve the facial nerve, which the left of the midline. After the initial incision, the contents of the
lies superficial to these muscles and must be dissected free of the carotid sheath are retracted laterally to expose the lateral aspects
muscles before they are divided. The underlying glossopharyngeal of the pharynx and the esophagus. This maneuver is made easier
nerve, which lies deep to these muscles and superficial to the inter- if the anesthesiologist places a large colored esophageal dilator
nal carotid artery, should also be protected by dissecting it free of through the mouth. The dilator makes identification of the other-
the muscles before their division. Injury to the facial nerve results wise flat esophagus easier, and the colored tubing of the dilator can
in loss of function of the muscles of facial expression. If the glos- sometimes be seen through defects in the esophageal wall.4
sopharyngeal nerve is injured, loss of motor and sensory supply to Sometimes, a pharyngoesophageal injury is suspected but can-
parts of the tongue and pharynx increases the risk of aspiration. not be confirmed preoperatively. In such cases—especially when
Once the muscles originating from the styloid process have been the injury is more than 1 or 2 hours old—salivary amylase may be
divided, the styloid process itself can be resected to gain a further present in the wound, giving the surgeon’s gloves a greasy feel.The
short distance of distal exposure. In very rare instances, it may presence of salivary amylase can be a valuable clue to the existence
prove useful to remove portions of the mastoid bone to provide of an otherwise unknown occult injury.
even more distal exposure of the internal carotid artery as it enters
CAROTID ARTERY INJURIES
the carotid canal. This can generally be accomplished via a cervi-
cal incision. For more distal lesions, it is necessary to place a pos- During dissection of the external carotid artery, the branches
terolateral scalp incision, reflect a medially based scalp flap, and should be identified. They can be ligated if necessary but should
divide the ipsilateral external auditory canal.This approach results be preserved if possible (this usually depends on whether they can
in better exposure of the mastoid process and allows exposure of be temporarily occluded with vessel loops, a looped suture, or
Internal Carotid Artery
Styloid Process
Facial Nerve
Posterior Belly of
Digastric Muscle
Glossopharyngeal Nerve (IX)

Sternocleidomastoid
Stylohyoid Muscle
Muscle
Accessory Nerve (XI)
Hypoglossal Nerve (XII) Occipital Artery
Carotid Sinus Nerve

(Branch of Nerve IX) Vagus Nerve (X)
Superior Laryngeal Nerve
Sympathetic Trunk
(Branch of Nerve X)
External Carotid Artery
Internal Jugular Vein
Ansa Cervicalis
Figure 4 During distal dissection of the internal and external carotid arteries, a number of
important structures are encountered, including the hypoglossal nerve and the occipital artery.
clips). During dissection around the common and internal carotid associated injuries should be taken into account [see Discussion,
arteries, care should be taken to avoid cutting or clamping the pos- Repair versus Ligation of Carotid Arteries, below]. If the patient is
terolaterally located vagus nerve; the recurrent laryngeal nerve hemodynamically stable and has minimal or moderate associated
runs with the vagus nerve at this level, and damage to the laryn- injuries, the internal carotid artery should be repaired. If the
geal nerve can lead to paralysis of the ipsilateral vocal cord. patient is hemodynamically unstable or has devastating associated
For wounds of the distal internal carotid artery, distal control injuries, the internal carotid artery should be ligated even when
may be a problem, particularly in the presence of vigorous ongo- back-bleeding is present.
ing bleeding, in which case a 3 to 5 French Fogarty balloon If a carotid artery injury involves minimal loss of vascular wall,
catheter should be placed through the area of injury or through a primary repair is straightforward and can be done with either a
proximal arteriotomy. The catheter should be advanced distally, continuous or an interrupted technique; interrupted sutures will
and the balloon should be inflated to provide a dry field for arte- not purse-string the vessel. In younger patients who are still grow-
rial repair. Repair can be done around the catheter; the balloon is ing, interrupted sutures should be used to prevent later stenosis.
deflated near the conclusion of the repair, and the catheter is As in elective vascular surgery, nonabsorbable sutures should be
removed before the final several sutures are tied. used; the carotid arteries generally require a 5-0, 6-0, or 7-0
If associated injuries allow, a 5,000 to 10,000 unit bolus of monofilament suture, depending on the location of the injury and
heparin should be given before any of the arteries in the neck are the type of suture material employed.
occluded. Because they have no branches, the common and inter- Defects longer than 1 to 2 cm should not be repaired primari-
nal carotid arteries can be safely mobilized for some distance from ly, because this will place excessive tension on the repair. For large
the injury to ensure a tension-free repair. defects limited to one surface of the vessel, a patch repair should
Management of common or external carotid artery injuries is be done. Either a venous patch or a synthetic patch can be used;
governed by the extent of injury and the overall status of the pa- when available, a venous patch is preferred for better long-term
tient. Small, simple injuries should be repaired. Complex injuries patency and to avoid placing a foreign body in a potentially con-
should be repaired in stable patients and ligated in patients with taminated wound. Saphenous vein from the groin is preferable for
severe hemodynamic instability or major associated injuries. patches because of its durability; a saphenous vein from the ankle
Initial management of injuries to the internal carotid artery is easiest to harvest when time is of the essence. Although the jugu-
depends on a determination of the amount of back-bleeding from lar vein is in the operative field and can be easily harvested, it is
the artery distal to the site of injury.5,6 If back-bleeding is minimal better not to interfere with venous outflow in a neck in which the
or absent, the artery should be ligated. If significant back-bleeding arterial inflow is to undergo repair; in addition, the jugular vein is
is present, the overall status of the patient and the nature of the very thin and difficult to handle.
PHARYNGOESOPHAGEAL INJURIES
For repairs near the carotid bifurcation, an alternative to venous
patches and synthetic patches is the use of the proximal external Injuries to the pharynx and the esophagus may be repaired in
carotid artery. This approach is especially appropriate when the either one or two layers with either 3-0 or 4-0 absorbable sutures.
origin of the external carotid artery is itself involved in the area of Attempts should be made to repair nearly all injuries, even when
injury. If the injury is to the proximal internal carotid artery and they are severe or their discovery is delayed. In extreme cases of
the origin of the external carotid artery is free of injury, it is better very large injuries or very delayed operative intervention, it may be
to leave the external carotid artery patent and to use a venous necessary simply to drain the neck widely and turn the injury into
patch or a synthetic patch instead; if the repair fails, the external a cervical esophagostomy. Esophageal diversion with distal esoph-
carotid artery provides collateral distribution to the internal ageal ligation is rarely necessary in patients with isolated cervical
carotid artery via the ophthalmic artery. esophageal injuries, except when the injury is very low in the neck
Repair of circumferential loss of the common or internal carotid or in the thoracic esophagus.
arteries is difficult. In this circumstance, if the defect is too long for Pharyngoesophageal injuries should be drained; either closed or
primary anastomosis and the patient’s general and neurologic con- Penrose drainage can be used. The drains should be left in place
dition permits, an interposition graft is indicated. As with patch for approximately 1 week, at which time a radiographic contrast
grafts, though either venous or synthetic material can be used, study should be obtained to determine whether the repair is com-
saphenous vein from the groin is generally the donor material of first petent. If the contrast study is negative for extravasation and the
choice because of its strength.The saphenous vein from the groin is patient’s general status permits, feeding can begin. If the feedings
also well suited for reconstruction of the common carotid artery. are well tolerated, the drains can be removed.
Completion angiography should be done after interposition Patients with pharyngoesophageal injuries should receive sever-
graft placements and complex repairs of the common or internal al postoperative doses of antibiotics appropriate for oral flora. If
carotid arteries. In general, patients with carotid artery injuries the repair is inadequate or breaks down, the resultant fistula often
should be admitted postoperatively to an intensive care unit. ICU heals with nonoperative management, provided that drainage is
observation need not be prolonged but should be continued for at adequate. A high index of suspicion for mediastinitis should be
least 12 to 24 hours postoperatively. In the early postoperative maintained; the prevertebral space provides a ready route of access
period, the patient should be observed for bleeding or for the from the pharynx and the cervical esophagus into the medi-
development of a neck hematoma; large postoperative hematomas astinum. Missed or inadequately drained injuries may result in
may compromise the airway. If a tense hematoma develops post- profound infection and a septic response.
operatively, the neck should be reexplored. Acute changes in the
neurologic examination are a potential sign of thrombosis or
embolism from the site of injury and should prompt further inves- Wounds at the Base of the Neck
tigation or reexploration. Patients with wounds at the base of the
Labile blood pressure—particularly in patients with extensive neck should be identified early—particu-
dissection around the carotid bifurcation—is another potential larly when an intrathoracic injury is sus-
postoperative problem. It is related to manipulation of the carotid pected—so that the appropriate incision
body, and control may require pharmacologic intervention. Labile and operative approach can be undertaken.
blood pressure is usually self-limiting and disappears over the first A median sternotomy should be done
1 to 3 days after operation, but it is another reason why patients for unstable patients with injuries at the
with carotid artery repairs should be monitored initially in the base of the right neck or patients in whom
ICU. the superior mediastinum is the most like-
Antibiotics should be administered to cover common skin flora ly site of injury and the most likely arterial injuries are to either the
and should generally be continued only for one or two postopera- innominate artery or the right subclavian artery [see Figure 5].
tive doses. Exposure of injuries to the proximal left subclavian artery is
extremely difficult via sternotomy because of the artery’s posteri-
JUGULAR VEIN INJURIES
or location; in patients with such injuries, a left thoracotomy is
Any of the veins in the neck can be ligated when necessary. An needed [see Figure 6]. If it appears likely that a left thoracotomy will
exception to this rule is the rare instance when both internal jugu- be necessary, it is helpful to bump up the patient’s left hip and
lar veins have been injured, in which case an attempt should be shoulder to position the left chest 20° to 30° anteriorly. The head
made to repair one of the veins, if possible. Even in such cases, is turned to the right, and the left arm is prepared as far as the
however, bilateral internal jugular ligation, if necessary, is usually elbow and draped so as to allow it free movement. Moving the arm
tolerated. It is particularly important to use suture ligatures rather is helpful when proximal exposure and control are obtained
than simple ligatures on the cut ends of the internal jugular vein. through the chest and distal exposure and control are obtained
If the injury to the internal jugular is simple, the vein should be through a supraclavicular incision. It also allows improved expo-
repaired. Large jugular vein injuries should be repaired only if the sure of the axillary artery if necessary.
patient’s general condition and associated injuries allow; if the In stable patients with angiographically diagnosed injuries to
patient is hemodynamically unstable or has severe associated either subclavian artery, a supraclavicular approach alone can be
injuries, large jugular vein injuries should be treated with ligation. used, thereby eliminating the need for initial entry into the chest.
It is not always necessary to encircle the jugular vein complete- Because proximal control may not be feasible via this limited inci-
ly both proximal and distal to the site of injury; pressure with a fin- sion, the patient should still be positioned, prepared, and draped
ger or a sponge stick sometimes suffices to control bleeding while so that sternotomy or thoracotomy is possible. If the injury is on
simple lateral venorrhaphy is done. In the case of more elaborate the right side of the neck and proximal control is not possible, a
repairs, it is better either to encircle and occlude the proximal and median sternotomy should be done. If the injury is on the left side
distal vein or to place a side-biting vascular clamp for control dur- of the neck and proximal control is not possible, a left thoracoto-
ing repair. Nonabsorbable 4-0 or 5-0 sutures should be used. my should be performed.
Known or suspected injuries to

innominate or right subclavian artery
Assess patient’s hemodynamic stability.
Unstable patient with proximal injury Stable patient with distal injury
Perform median sternotomy, extending Perform right supraclavicular incision.

incision as needed.
Small injury, patient Large injury

stabilizes
Repair artery.
Stable patient Highly unstable patient
Repair artery. Ligate artery.
Proximal control Proximal control is not possible

is possible
Perform median sternotomy, extending
incision as needed.
Patient remains Patient becomes Patient remains Large injury

stable highly unstable and stable
injury is devastating
Repair artery. Repair artery.
Ligate artery.
Figure 5 Algorithm outlines operative manage- Patient remains Patient becomes

ment of wounds to the base of the neck causing stable highly unstable
known or suspected injuries to the innominate
artery or the right subclavian artery. Repair artery. Ligate artery.
If a median sternotomy has been done for exposure of an carried medially in the subperiosteal plane to the sternoclavicular
innominate artery or right subclavian artery injury, it may prove joint, which is disarticulated.7 If necessary, this dissection and
necessary to extend the incision into the right neck to obtain ade- resection can be accomplished in a matter of a few minutes.
quate distal control and exposure. Either a right supraclavicular or After adequate exposure and control of innominate or subcla-
an anterior sternocleidomastoid extension can be used. Although vian artery injuries have been obtained, further management is
both are easily accomplished, the anterior sternocleidomastoid determined by the nature of the injury and the status of the
extension is the more versatile of the two. If a left thoracotomy is patient. Small injuries should always be repaired. Large injuries
done for proximal control and exposure of the left subclavian are not often seen, because they are usually incompatible with sur-
artery, the distal subclavian artery should be exposed via a left vival to a point where medical attention is available. Nonetheless,
supraclavicular incision. Improved exposure of the left subclavian such injuries do occur, and their management is influenced by the
artery at the thoracic outlet can be obtained either by resecting the status of the patient. Attempts at repair should be made for most
medial one third to one half of the left clavicle or by making a so- such injuries, but in highly unstable patients, the artery should be
called trapdoor incision. The trapdoor incision consists of a supe- ligated. However, arterial ligation is sometimes associated with
rior sternotomy and connection of the medial aspects of the thora- severe morbidity and should therefore be avoided if possible.
cotomy and supraclavicular incisions. We find the trapdoor The wall of the subclavian artery is thin, and extra care should
approach limited and cumbersome and strongly prefer clavicular be taken in dissecting around it. Primary repair should be done
resection. Medial clavicular resection is accomplished by encircling with either interrupted or continuous nonabsorbable 4-0 or 5-0
the midclavicle in the subperiosteal plane via the supraclavicular sutures, laterally placed. Because of its location and the large num-
incision. A Gigli wire saw is passed around the clavicle, and the ber of branches, the subclavian artery is difficult to mobilize exten-
clavicle is divided. The medial aspect of the divided bone is then sively. None of the branches are vital, however, and all can be
grasped with a bone hook or a Kocher clamp, and the dissection is divided as necessary to gain mobility. The origin of the vertebral
artery should be preserved if possible, because in rare instances, side of dissection can indicate injury to the phrenic nerve, which
ligation of the artery can lead to cerebral ischemia. Even with divi- courses in the field of dissection on the anterior surface of the
sion of arterial branches, only short segments of the subclavian anterior scalene muscle.
artery can be removed without the need for an interposition graft
to prevent an anastomosis under tension. The saphenous vein is
usually too small to be used as a graft, even when it is harvested Known Vertebral Artery Injuries
from the groin. Accordingly, a synthetic graft is usually the better On occasion, patients who present with
choice. Infections in this location are rare, even when the graft is penetrating cervical wounds and are
placed in a contaminated field.8 hemodynamically and neurologically sta-
Complex injuries of the innominate and subclavian veins should ble are demonstrated on angiographic
be treated with suture ligation, particularly when the patient has workup to have an injury to the vertebral
severe associated injuries. Simple injuries can be treated with later- artery. In rarer instances, the location of an
al venorrhaphy. Depending on the circumstances, formal control injury in the posterior triangle of the neck
of the proximal and distal vein can first be obtained, or pressure and the presence of ongoing hemorrhage
can be applied proximally and distally to provide for a bloodless may also indicate the high likelihood of an
field during repair. Another alternative for control of bleeding dur- injury to the distal vertebral artery [see Figure 7].
ing venous repair is the use of a side-biting vascular clamp. Most vertebral artery injuries occur in stable patients and are
Some patients with injuries to the subclavian artery or the sub- discovered on angiography. Because operative attempts at ligation
clavian vein require dissection of the supraclavicular area. The su- are associated with blood loss that can be problematic, an alterna-
praclavicular fat pad contains a large number of lymph nodes and tive approach utilizing angiographic embolization has been devel-
lymphatic channels, and dissection of the fat pad can result in con- oped.9 In most cases of injury to the distal vertebral artery, the
siderable weeping of lymphatic fluid; these wounds should therefore angiographic approach is preferred if available [see Discussion,
be drained. Either a closed or an open drain can be used, and the Angiographic Embolization of Distal Vertebral Artery Injuries,
drain should be brought out through a separate stab wound near below]. If angiographic expertise is not available and the patient is
the incision. After a left-side procedure, persistent milky drainage stable enough for transfer, it is preferable to send the patient to a
via either drains or the wound suggests injury to the thoracic duct center with angiographic embolization capability if at all possible.
and may necessitate repeat operative intervention if it persists. In urgent circumstances, an angiographic approach is not practi-
Elevation or paralysis of the hemidiaphragm ipsilateral to the cal, and a direct surgical approach is necessary.10
Known or suspected injuries to left

subclavian artery
Assess patient’s hemodynamic

stability.
Unstable patient with proximal Stable patient with distal injury

injury
Perform left supraclavicular
Perform left thoracotomy, incision.
extending incision and resecting
clavicle as needed.
Patient stabilizes Highly unstable patient
Proximal control is possible Proximal control is not possible
Perform left thoracotomy,

extending incision and resecting
clavicle as needed.
Patient remains Patient becomes Patient remains Patient becomes

stable highly unstable stable and injury highly unstable and
is small injury is devastating
Figure 6 Algorithm outlines operative management of wounds to the base of the neck causing
known or suspected injuries to the left subclavian artery.
Known vertebral artery injuries The third and most distal portion of the vertebral artery is most
easily approached between the atlas and the axis. The segment of
the artery between the transverse processes of these two vertebrae
is longer and more exposed than the segments between the other
Active, severe Angiographically cervical vertebrae and is therefore, in theory, somewhat easier to
bleeding diagnosed lesion expose. In practice, rapid exposure of this portion of the vertebral
artery is very difficult, particularly in an actively bleeding patient.
Perform anterior
sternocleidomastoid
As with exposures to the second portion of the vertebral artery,
incision. Achieve lesions requiring this exposure are best treated with angiographic
proximal control via Distal lesion Isolated proximal lesion embolization. If angiographic expertise is available, it may prove
ligation and distal wisest to pack the wound as a temporizing measure and then take
control via ligation or Perform supraclavicular
embolectomy catheter. incision and ligate
the patient for embolization. If angiographic embolization is not
artery. an option, a surgical approach may be necessary.
The standard anterior sternocleidomastoid incision is used but
is carried superiorly with a curved extension to a point just below
the tip of the ear. Once the plane is developed along the anterior
Angiographic embolization Angiographic embolization border, the sternocleidomastoid muscle is divided near its origin
is available is unavailable at the mastoid process. The spinal accessory nerve, which enters
the sternocleidomastoid 2 to 3 cm below the tip of the mastoid, is
Embolize artery. Perform anterior dissected free of the muscle and mobilized anteriorly. After divi-
sternocleidomastoid incision.
Achieve proximal control via sion of the sternocleidomastoid muscle and anterior retraction of
ligation and distal control via the spinal accessory nerve, the transverse process of the atlas is pal-
ligation or embolectomy pable and the prevertebral fascia is visible in the depths of the
catheter.
wound. The fascia is incised in a line with the spinal accessory
nerve, and the laterally placed levator scapulae and splenius cervi-
Figure 7 Algorithm outlines management of known injuries to the cis are divided as close to the transverse process of the atlas as pos-
vertebral artery, which are most often discovered by angiography.
sible [see Figure 9]. The anterior ramus of the nerve root of C2 is
closely associated with the anterior edge of the levator scapulae
EXPOSURE AND EXPLORATION and should be protected. After division of the levator scapulae and
In the rare case of a patient who presents with active, severe the splenius cervicis, the distal vertebral artery is visible in the
bleeding and in whom the most likely source of bleeding is the dis- medial aspect of the wound. Venous branches associated with the
tal vertebral artery, surgical exposure of the vertebral artery is nec-
essary. Such exposure is reviewed more fully elsewhere.11 Initial
exposure should be obtained via an anterior sternocleidomastoid
incision [see Injuries to the Carotid Arteries, Jugular Veins,
Pharynx, and Esophagus, above]. This approach can be used for C1 Transverse
exposure of both the proximal and the distal vertebral artery. The Process
incision is developed down to the level of the carotid sheath. The Anterior
lateral margin of the internal jugular vein is developed sharply, and Longitudinal
the internal jugular vein and the other contents of the sheath are Ligament
retracted medially. After retraction of the carotid sheath, the plane
just superficial to the prevertebral muscles is encountered. The Anterior C3 Spinal Nerve
ganglia of the cervical sympathetic chain are located here and Paraspinous
should be protected, though this is not always possible in emer- Muscles
gency circumstances. The anterior longitudinal ligament, located
deep in the medial aspect of the wound, is incised longitudinally. Left Vertebral
The ligament, the underlying periosteum, and the overlying Artery
longus colli and longissimus capitis are mobilized anterolaterally
Vertebral Veins
with a periosteal elevator [see Figure 8].The elevation is carried lat-
erally along the lateral margin of the bodies of the cervical verte-
brae and along the anterior aspect of the transverse processes of
the cervical vertebrae. To avoid injury to the laterally and posteri-
orly placed cervical nerve roots, the dissection should not be
extended laterally beyond the tips of the transverse processes.
After the anterior aspects of the transverse processes of the cer-
vical vertebrae have been exposed, they can be removed with a
small rongeur.This should be done distal to the area of injury only;
proximal ligation of the vertebral artery can be done in its more
easily exposed proximal portion. Although the vertebral artery is Figure 8 Throughout most of their course, the vertebral artery
also accessible in the spaces between the transverse processes, and the vertebral veins are surrounded by the transverse process-
there are a number of venous branches in these regions, and it is es of the cervical vertebrae. Exposure of this portion of the verte-
therefore safer to approach the artery within the confines of the bral artery is best done with anterior and lateral mobilization of
bony foramina. the longus colli and the longissimus capitis.
vertebral artery are most likely to be located near the transverse

processes; therefore, ligation should be preferentially directed to
C1 the middle of the interspace between the transverse processes.
Transverse
Process Exposure of the proximal vertebral artery at the base of the neck
can also be achieved via an incision along the anterior border of
the sternocleidomastoid muscle. Initial exposure is identical to
that used for exposure of the carotid arteries [see Injuries to the
Carotid Arteries, Jugular Veins, Pharynx, and Esophagus, above].
At the level of the carotid sheath, however, dissection is carried lat-
Levator Scapulae
eral to the internal jugular vein, which is retracted medially to
expose the supraclavicular fat pad. The proximal vertebral artery
Splenius Cervicis
can then be controlled after dissection deep to the fat pad, as
described for the supraclavicular approach to isolated proximal
vertebral artery injuries (see below).
Vertebral Artery
Accessory
TREATMENT
Nerve (XI)
As opposed to injuries of the carotid arteries, in which either
repair or ligation is an option, injuries to the vertebral arteries
should always be treated with interruption of flow by surgical or
other means. Proximal ligation should usually be done at the ori-
Figure 9 Exposure of the distal vertebral artery is done via an
gin of the vertebral artery because the approach to the artery at
incision along the anterior border of the sternocleidomastoid this point is easier than the approaches to the more distal seg-
muscle. The sternocleidomastoid muscle is then divided near its ments.The artery should be suture-ligated as close to its origin as
origin at the mastoid process. The spinal accessory nerve is possible so as not to create a thrombogenic blind pouch off the
mobilized anteriorly. The vertebral artery is accessible after divi- subclavian artery. Distal ligation can be accomplished by first
sion of the levator scapulae and the splenius cervicis. exposing the artery (see above) and then ligating with ligatures,
suture ligatures, or surgical clips. The use of clips minimizes dis-
section around the artery, which, in turn, decreases the likelihood
of further injury to surrounding veins.
In emergency circumstances, a useful technique is to approach
the proximal artery surgically at the base of the neck and pass a
thrombectomy catheter distally to the site of injury [see Figure 10].
First, the proximal vertebral artery is exposed and ligated at its ori-
gin. Next, the thrombectomy catheter is passed distally via an arte-
riotomy. The catheter balloon is then inflated, and the wound is
checked to determine whether bleeding has been controlled. If
Catheter bleeding has been controlled, the distal end of the catheter is left in
Balloon place, and the proximal end is brought out through the wound.
The catheter is left in situ for approximately 48 hours, at which
Laceration time the balloon is deflated and the wound is again checked for
bleeding. If there is no bleeding for 4 to 6 hours, the catheter can
be withdrawn. Use of a thrombectomy catheter can also serve as a
bridge to angiographic embolization. If the thrombectomy catheter
technique is unsuccessful, a direct surgical approach to the second
or third portion of the artery is necessary. A potential disadvantage
Catheter of a surgical approach, however, is that proximal ligation of the ver-
Vertebral Artery tebral artery precludes angiographic embolization except via the
(Ligated) contralateral vertebral artery. Embolization via the contralateral
vertebral artery is extremely difficult and may result in ischemia or
uncontrolled embolization.
Subclavian If the injury is shown by preoperative angiography to be con-
Artery fined to the first portion of the vertebral artery, both proximal and
distal ligation may be possible via a supraclavicular incision [see
Figure 11]. The patient is positioned with the head turned away
from the side of the injury, and the chest and ipsilateral neck are
prepared and draped. Preparation and draping include the chest
so that a left thoracotomy can be done later if necessary for prox-
imal control of the left subclavian artery. In such cases, it is help-
Figure 10 Bleeding from vertebral artery injuries located with-
in the transverse process of the cervical vertebrae can sometimes
ful to bump the patient up on the left so that an anterolateral tho-
be controlled by exposing the proximal vertebral artery at the racotomy incision can be carried further posteriorly.
base of the neck, passing a thrombectomy catheter distally, and The supraclavicular incision is made approximately one finger-
inflating the balloon at the site of injury. breadth superior to the clavicle and is extended medially to the
Left Vertebral Artery

Inferior Thyroid Artery
Phrenic Nerve
Anterior Scalene
Muscle
Inferior Cervical
Sympathetic Ganglion Subclavian Artery
Vertebral Vein Thyrocervical Trunk
Internal
Jugular Vein Thoracic Duct
Figure 11 The proximal vertebral artery can be approached via a supraclavicular incision. Dissection
of the supraclavicular fat pad reveals the underlying vertebral artery where it diverges from the subcla-
vian artery. During dissection, care should be taken to avoid injuring the phrenic nerve.
midpoint of the sternocleidomastoid insertion and laterally to the After the supraclavicular fat pad has been dissected, the prox-
juncture of the middle and lateral thirds of the clavicle.The skin, the imal portion of the vertebral artery is reached.The vertebral vein,
subcutaneous tissue, and the platysma are incised. The external which usually lies slightly superficial and medial to the vertebral
jugular vein, if in the operating field, is suture-ligated. The clavicu- artery, is divided and suture-ligated to provide better exposure.
lar head of the sternocleidomastoid muscle is encountered next, Care should be taken not to retract the vertebral vein too vigor-
and its lateral aspect is divided with the electrocautery at its inser- ously before suture ligation so that this vessel is not avulsed from
tion on the clavicle. The muscle is then retracted superiorly and the subclavian vein. At the depth of the vertebral artery, the
medially. In the plane deep to the sternocleidomastoid muscle, the white, cordlike elements of the brachial plexus are often visible in
omohyoid muscle is divided in its middle tendinous portion with the superolateral aspect of the wound. If possible, traction should
the electrocautery. not be placed on the brachial plexus, and use of the electro-
At a level just deep to the sternocleidomastoid and omohyoid cautery around the plexus should be minimized. After exposure,
muscles, the carotid sheath is encountered in the medial aspect of the proximal vertebral artery is ligated both proximal and distal
the wound. The lateral border of the internal jugular vein is dis- to the site of injury. No attempts at repairing the injury should be
sected free of adjacent tissue and retracted medially. If the opera- made.
tion is on the left, the thoracic duct may be found in the medial The use of angiographic embolization, the preferred treatment
portion of the wound. The thoracic duct is easily injured with of angiographically diagnosed injuries of the distal vertebral
retraction and should be divided and ligated if it is in the way. artery, depends on the availability of equipment for and expertise
Just lateral to the internal jugular vein at the same depth is the with the procedure [see Discussion, Angiographic Embolization
supraclavicular fat pad, which is dissected from the supraclavicu- of Distal Vertebral Artery Injuries, below]. Stable patients who
lar fossa in which it lies. Exposure is further enhanced by dissec- have angiographically documented injuries to the distal vertebral
tion and division of the anterior scalene muscle. The phrenic artery should be transferred to the closest center with cerebral
nerve, which is closely applied to the anterior surface of the ante- embolization capability. If angiographic embolization is not avail-
rior scalene muscle, is dissected free of the underlying muscle and able, exposure and ligation should be carried out as described
retracted out of the field with a vessel loop. The anterior scalene (see above).
muscle is then divided with the electrocautery. During dissection In cases where angiographic embolization of the vertebral artery
of the supraclavicular fat pad, it may be necessary to divide has been employed, a postprocedure angiogram should be done
branches of the thyrocervical and costocervical trunks. The most several days to weeks after the procedure to ensure that the artery
prominent of these branches is the inferior thyroid artery, which remains occluded and that no arteriovenous fistula has developed
stems from the thyrocervical trunk and courses medially toward between the injured vertebral artery and the surrounding venous
the thyroid. plexus. Duplex scanning has also been used to a limited extent for
follow-up screening. It can serve as an alter- monly, these wounds are slash wounds caused by a knife or other
native to angiography, but its sensitivity rel- sharp object rather than true stab wounds. Rapid exposure and
ative to that of angiography remains to be vascular control are sometimes easily accomplished through these
established. wounds. In such circumstances, the surgical procedure consists of
debridement of the neck wound, and deep dissection is not nec-
essary. If greater access and control are needed to rule out further
Superficial Wounds
injuries or for definitive repair, a standard anterior sternocleido-
Some wounds are obviously superficial mastoid incision should be done [see Injuries to the Carotid
on initial physical examination. Most com- Arteries, Jugular Veins, Pharynx, and Esophagus, above].
Discussion
Screening Criteria for and Recommended Management of
Four-vessel angiography remains the gold standard for imaging
Blunt Cervical Arterial Injuries
the cervical vasculature. Duplex ultrasonography has not proved
Blunt injuries to cervical arteries, though relatively rare, can be sensitive enough for diagnosis of blunt cervical arterial injury, in
difficult to diagnose and can lead to devastating complications large part because so many of the lesions are located high in the
(e.g., stroke and bleeding). Most such injuries result from stretch- neck, where accurate ultrasonography is difficult.18 Magnetic res-
ing of the vessels as a consequence of hyperextension of the neck. onance angiography (MRA) also lacks the sensitivity needed to
Motor vehicle collision is the most common mechanism of this screen trauma patients for blunt cervical arterial injury. MRA
sort of stretch injury; chiropractic manipulation and rhythmic flex- imaging relies on signal subtraction related to flow and thus may
ion and extension of the neck (“head banging”) are less common miss lesions such as pseudoaneurysms, in which flow is dimin-
mechanisms.12,13 Injury may also be caused by direct trauma to ished. CT angiography has been applied with increasing frequen-
the artery or by fracture fragments. Arterial stretching leads to cy in attempts to make this diagnosis, with mixed results. Helical
endothelial tearing with subsequent intimal flaps, dissections, or CT scanners capable of fewer than 16 slices per rotation probably
emboli. lack the sensitivity to make a reliable diagnosis, but small series
The true incidence of blunt cervical vascular injury is unknown. using more sophisticated CT scanners have reported promising
Figures as high as 1.55% of all blunt trauma patients have been results.24 Large series evaluating current CT angiography technol-
reported,14,15 as have figures an order of magnitude lower. Because ogy are lacking at present. CT angiography is particularly attrac-
many patients with pathologic changes on screening tests are tive in that it is noninvasive, it can be performed relatively rapidly,
asymptomatic before diagnosis and remain asymptomatic after and it can be done in the course of CT scanning of the head and
diagnosis, the reported incidences are likely to depend heavily on other parts of the body. Improvements in CT technology and
the screening criteria used.16-21 increased use of CT instead of angiography for screening may
Many recommendations have been made regarding screening make widespread radiographic screening for blunt carotid injury
criteria for blunt cervical arterial injuries. Performing four-vessel much simpler and easier.
cervical angiography on all blunt trauma patients would identify Biffl and associates developed a grading scale for blunt cervical
nearly all cervical arterial injuries, but the logistical considerations, arterial injury based on the arteriographic appearance of the
expense, and potential risks associated with this approach make it lesion.25 On this scale, grade I and II lesions show less than 25%
unfeasible. When aggressive screening with broad criteria is and greater than 25% luminal narrowing, respectively; grade III
employed, approximately 3% to 5% of blunt trauma patients lesions are pseudoaneurysms; grade IV lesions demonstrate
undergo workup and approximately 30% of the workups reveal an thrombosis; and grade V lesions are transections with extravasa-
injury.14 Even with early and aggressive screening, about a quarter tion. Grade I to III lesions may progress to a higher grade. Follow-
of patients exhibit neurologic signs and symptoms before up imaging should be performed 7 to 10 days after diagnosis.
workup.16 Treatment of blunt cervical arterial injury depends on the loca-
Some of the published screening criteria are uncommon and tion and grade of the lesion. Grade I injuries, regardless of loca-
thus, if present, are probably reasonable triggers for diagnostic imag- tion, are best treated with anticoagulation.25 The intimal defect
ing studies. Such uncommon criteria include arterial bleeding from leaves the patient at risk for thromboembolism, and anticoag-
the ears, nose, or mouth; an expanding cervical hematoma; a cervi- ulation protects against subsequent stroke. Grade II lesions ex-
cal bruit in a patient younger than 50 years; evidence of cerebral tending to a location that is inaccessible to traditional surgical ap-
infarction on CT scanning; Horner syndrome; and basilar skull frac- proaches should also be treated with anticoagulation. Carotid
ture involving the carotid canal. Other published screening criteria artery pseudoaneurysms (grade III lesions) located at the base of
are somewhat more difficult to apply, being either quite common or the skull (the usual location) should be treated initially with anti-
highly subjective. These more difficult criteria include neurologic coagulation, then followed up with delayed imaging studies to
symptoms not explained by CT findings; an injury mechanism con- check for enlargement. Pseudoaneurysms that are enlarged should
sistent with severe cervical hyperextension, hyperrotation, or hyper- probably be treated with stenting, though to date, experience with
flexion, especially if associated with a displaced facial fracture or stenting at this location for this indication has been relatively lim-
complex mandible fracture; closed head injury consistent with dif- ited. Stenting may also be indicated for lesions that progress and
fuse axonal injury of the brain; a near-hanging resulting in cerebral threaten to limit flow despite full anticoagulation, as well as for
anoxia; seat-belt abrasion or other soft tissue injury to the anterior high grade V lesions.26 Good results have been obtained with anti-
neck; and cervical vertebral body fracture or distraction injury (iso- coagulation in patients with grade IV injuries.25 Accessible grade
lated spinous process fracture excluded).22,23 II to V lesions, though rare, should be repaired operatively by
means of traditional surgical approaches.

Blunt vertebral artery injuries should be treated nonoperatively
for the most part, and the threshold for employing transcatheter
embolization should be low. As with carotid artery injuries, small
lesions can be treated with anticoagulation. Larger and more dis-
tal lesions should be treated with occlusion of the artery by means
of interventional radiologic techniques.
The best choice of anticoagulation remains unclear. There is
some indication that the use of heparin positively affects patient
outcome, but the evidence is not particularly strong.19,21 The par-
tial thromboplastin time (PTT) should be monitored and main- Zone III
tained within an arbitrary range of 40 to 60 seconds. Patients with
a contraindication to heparin therapy (e.g., an intracranial lesion
at risk for hemorrhage) can be managed with aspirin. Patients
managed with heparin and those managed with aspirin have sim- Zone II
ilar stroke rates; however, the number of patients treated with
either drug in published reports is relatively small, and the evi-
dence that anticoagulation of any kind makes a difference is rela- Zone I
tively sparse. The safety and efficacy of other antiplatelet treat-
ments are unknown. The optimal duration of treatment is
unknown as well, though it appears that 3 to 6 months is adequate
in most cases.21 Therapy may be discontinued when repeat imag- Figure 12 Depicted is the traditional division of the neck into
ing shows that the injury has resolved. three separate zones. This division has been used as a basis for
decision-making with respect to penetrating cervical injuries.
Zones of the Neck and Mandatory versus Selective Neck

Exploration for Penetrating Cervical Injuries ing neck trauma starts by determining the depth of the wound. If
One approach to managing penetrating cervical injuries is to the wound did not violate the platysma, injury to major underly-
categorize them on the basis of their location in the neck. In this ing structures can be ruled out. If the wound clearly violated the
schema, the neck is divided into three distinct zones [see Figure platysma or its depth cannot be determined, further investigation
12], and management is determined by the zone in which the is warranted. If the patient has any obvious signs of underlying vas-
patient happens to have wounds in the skin.The idea is that hemo- cular injury, the neck should be explored via the standard ster-
dynamically stable patients without any obvious sign of vascular nocleidomastoid incision, and the exploration should be expand-
injury (e.g., pulsatile bleeding from the wound, an expanding ed as necessary to obtain proximal or distal control. If the patient
hematoma, a bruit, or a neurologic deficit) who have wounds to is stable and has no obvious signs of underlying vascular injury, a
the base of the neck or the upper neck (zones I and III) may have nonoperative workup should be obtained regardless of the location
injuries that are problematic with respect to proximal or distal vas- of the skin wound.
cular control and thus may require incisions other than the stan- Conventional angiography is the gold standard for ruling out
dard sternocleidomastoid approach. Accordingly, these patients vascular injury, but it is somewhat invasive and can be time con-
undergo imaging studies and endoscopy to rule out injuries to the suming and resource intensive. As experience with CT in this set-
vasculature or the aerodigestive tract. If the study results are neg- ting accumulates, this modality is becoming an increasingly valu-
ative for injuries that call for operative repair, the patients are sim- able imaging adjunct.27,28 CT can be quite helpful in determining
ply observed. Patients with zone II injuries, on the other hand, pre- the course that a knife or bullet takes within the neck and detect-
sumably have underlying injuries to either the vasculature or the ing the presence of vascular or aerodigestive injury. If CT defines
aerodigestive tract that are easily accessible via a sternocleidomas- a knife or bullet tract that is clearly remote from major vascular or
toid incision; such patients therefore undergo neck exploration if aerodigestive structures, no further workup is needed. If CT clear-
the wound has violated the platysma. ly shows an injury that should be repaired, exploration of the
The concept of mandatory exploration of patients with zone II neck is indicated. If CT can neither establish nor rule out the pres-
injuries, though time honored, has a number of problems. ence of vascular or aerodigestive injury, further directed imaging
Division of the neck into three distinct areas results in extremely or endoscopic studies should be done. This selective approach
small zones I and III, and even zone II, in the middle of the neck, reduces the rate of negative neck explorations and decreases the
is not very long in most patients. As a result, determining that a need for invasive, lengthy, and expensive diagnostic modalities.
given wound is clearly in only one of the zones is often very diffi-
cult. Description of a wound as being on the border of zones I and
II or on the border of zones II and III is a common and confusing Repair versus Ligation of Carotid Arteries
occurrence. Moreover, the location of the skin wound is not a reli- Simple injuries to the external carotid artery should be repaired,
able guide to the locations of injuries to underlying structures.This whereas complex injuries should be ligated.
is most obviously true of gunshot wounds, in which the path of the Injuries to the common carotid artery and the internal carotid
missile is clearly as important as the location of the skin wound. It artery are more problematic. If the injury is simple and there is no
is also true of knife wounds: a blade that enters the skin in zone II suggestion that flow in the vessel has been interrupted, repair
can easily injure structures in zones I or III, depending on the should always be undertaken. An example of such an injury is a
direction in which the knife was thrust after it entered the skin. simple stab wound of part of the circumference of the artery with
A more logical approach to the initial management of penetrat- an associated pseudoaneurysm and good distal flow. In this cir-
cumstance, lateral repair can be done quickly and easily with a sized that minimal injuries to the carotid vasculature can be
short cross-clamp time. After proximal and distal control of the approached in a similar fashion.The consequences of distal embo-
vessel is obtained, a check should be made for back-bleeding. If lization or pseudoaneurysm rupture in the carotid circulation make
the back-bleeding from the distal circulation is brisk, as it usually such an approach somewhat risky.29,30 Increasing experience with
is, repair can be done safely. nonoperative management of minor blunt injuries to the cerebral
If an injury to the common carotid artery or the internal carotid vasculature supports the relative safety of this approach, particu-
artery has interrupted flow in the vessel, repair creates a theoreti- larly if the patient can safely undergo anticoagulation to prevent
cal disadvantage. Interruption of flow may lead to focal brain subsequent thromboembolic complications.31 Experience with
ischemia and partial disruption of the blood-brain barrier. Sudden nonoperative management of penetrating injuries is more limited,
restoration of blood flow may cause hemorrhage in the area of the however. Penetrating mechanisms are more likely than blunt
ischemia and worsen the extent of brain injury; an anemic, or mechanisms to involve a full-thickness injury to the vessel, and the
white, infarct of the brain may be converted to a hemorrhagic, or presence of a full-thickness injury makes anticoagulation riskier.
red, infarct.Whether this pathophysiology is important after trau- Furthermore, the apparent degree of vessel injury from penetrat-
matic injury is unclear and controversial. ing trauma on angiography is often significantly less than the actu-
Deciding whether to repair or ligate when flow has been inter- al degree of injury as seen at exploration. Nonoperative manage-
rupted is often difficult.5,6 One approach is to base the decision on ment is currently supported for minor blunt injuries, ideally in con-
the patient’s preoperative neurologic status. If there is no neuro- junction with anticoagulation. Until more experience with nonop-
logic deficit, it is presumed that there are no areas of brain erative management of penetrating injuries is reported in the liter-
ischemia and that repair is safe. Conversely, a focal neurologic ature, accessible penetrating injuries should be repaired surgically.
deficit is presumed to be related to ischemia, and in such cases, There is increasing support for treatment of carotid artery
the risk of worsening the patient’s neurologic status with restora- injuries with intraluminal stenting.32-34 This approach is now com-
tion of blood flow is increased. Even though this approach is ratio- monly used for aneurysms of the thoracic and abdominal aorta, as
nal, it is not applicable in cases in which a detailed neurologic well as for more distal peripheral vascular lesions. On rare occa-
examination before surgery is not possible. Furthermore, this sions, it has also been applied to the management of traumatic
approach may be applicable only to patients in coma or with injuries to the thoracic aorta and selected injuries to the peripher-
severe neurologic deficits. There are indications that milder neu- al and visceral vasculature. Not surprisingly, stenting has also been
rologic deficits respond favorably to revascularization. used for the management of carotid artery injuries, particularly
Yet another approach is to gauge the appropriateness of repair injuries to the distal internal carotid artery that are not easily
according to the nature of the injury itself. In this approach, large, approached surgically. Overall, stents are most frequently used in
complicated injuries requiring involved and lengthy procedures situations where arterial lesions are not surgically accessible or
for repair are ligated, whereas simple injuries requiring only sim- when anticoagulation is contraindicated. The technical success
ple and quick repairs are repaired. Similarly, repair is not indicat- rates have been good in these settings, and there is accumulating
ed in patients with severe or multiple associated injuries. There is (albeit still limited) evidence to suggest that stents in the carotid
also a difference between the management of injuries of the com- circulation remain patent for prolonged periods and are not asso-
mon carotid artery and management of injuries of the internal ciated with a high thromboembolic complication rate.25,35-38 Large
carotid artery. Common carotid injuries are more accessible and pseudoaneurysms in inaccessible areas of the distal carotid circu-
easier to repair, and repair is generally associated with a good out- lation usually do not heal with time and, when persistent, may rea-
come. Continued antegrade flow in the internal carotid artery is sonably be treated with stenting.25
more likely after injury to the common carotid artery than after
injury to the internal carotid artery because of the possibility of
collateral flow via the external carotid artery. Angiographic Embolization of Distal Vertebral Artery
A reasonable way to deal with repair dilemmas is to make the Injuries
decision on the basis of distal back-bleeding. Interruption of blood Most patients with vertebral artery injuries are stable and expe-
flow to the brain is tolerated only for a short time, and restoration rience no external bleeding, and the injury is discovered by
of flow is unlikely to be accomplished quickly enough to improve angiography. A number of such lesions have been successfully
outcome. It is therefore logical to base the decision about revas- treated with angiographic embolization. Given the difficulties of
cularization on the state of back-bleeding from the internal carotid surgical exposure, lesions of the distal vertebral artery should be
artery. If back-bleeding is brisk, the patient is presumed to have treated angiographically when the patient’s general condition per-
good collateral flow, and the chances that there is an area of mits and when the necessary expertise is available. If the patient is
ischemia are low. Repair rather than ligation is safe in such cir- bleeding profusely, such an approach is not possible and a rapid
cumstances. If internal carotid artery back-bleeding is minimal or surgical approach is indicated, with ligation of the proximal verte-
absent, an ischemic infarct is more likely and restitution of arteri- bral artery and an attempt at thrombectomy catheter control or
al inflow is more dangerous. A corollary to this reasoning is that if packing of the wound until an angiographic approach can be
back-bleeding is poor, a clot distal to the area of injury may be pres- attempted. If this is unsuccessful, the lesion should be approached
ent, and return of flow with repair may dislodge the clot distally. directly [see Known Vertebral Artery Injuries, above].
If a patient with a distal vertebral artery lesion is stable—par-
ticularly when the lesion is otherwise silent and has been detected
Nonoperative Management and Stenting of Carotid Artery angiographically—an attempt should be made at angiographic
Injuries embolization if the necessary expertise is available. If the patient is
Some minimal penetrating injuries to the vasculature of the stable, transfer to the nearest center with cerebral angiographic
extremities (e.g., small pseudoaneurysms and endothelial injuries) embolization capability is appropriate. Embolization is done via
need not be repaired if they do not compromise distal flow, and the ipsilateral proximal vertebral artery. Detachable balloons or
they usually heal over time without sequelae. It has been hypothe- coils can be used.
Conversion of Cricothyrotomy to Tracheotomy

structive procedures. Conversely, studies of cardiac patients under-
Cricothyrotomy is typically reserved for life-threatening airway going routine cricothyrotomy do not demonstrate a significant
compromise when the need for a rapid surgical airway is para- increase in the incidence of airway complications. Cricothyrotomy
mount [see Airway Compromise, above, and 6:1 Trauma Resusci- is sometimes favored over tracheotomy in these patients because of
tation]. Tracheotomy is preferred if time and a lesser degree of concerns about the proximity of tracheotomy wounds to the
urgency permit. Similarly, in the postoperative period, tracheotomy patient’s sternotomy incision.The results of studies of routine car-
is preferred to cricothyrotomy.The traditional view, initially prom- diac patients may be different from results of studies showing an
ulgated by Chevalier Jackson in 1921, is that cricothyrotomy is increase in complications after cricothyrotomy, in that the cardiac
more likely than tracheotomy to result in airway stricture or dam- patients were intubated for shorter periods.
age to more proximal structures in the larynx. On the basis of this There have been no studies documenting a high incidence of
rationale, cricothyrotomies are converted to tracheotomies on a complications in trauma patients who have undergone emergency
semielective basis within 24 to 48 hours of admission if the patient’s cricothyrotomy and have remained intubated via the cricothyroto-
general condition permits.39,40 my for longer than 2 or 3 days. Because complications are poten-
The evidence supporting a policy of routine conversion is tially so devastating, however, emergency cricothyrotomies should
mixed. Several series document a low but increased incidence of be converted to tracheotomies within 1 to 2 days after admission
complications to the larynx and trachea from prolonged mainte- in stable patients. In a stable patient, the risks of conversion are
nance of cricothyrotomies. Even though the incidence is low, the minimal, and conversion is justified to avoid the possibility of
complications can be severe and may necessitate extensive recon- future complications.
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7 TRAUMA AND THERMAL INJURY 5 INJURIES TO THE CHEST — 1
5 INJURIES TO THE CHEST

Edward H. Kincaid, M.D., and J.Wayne Meredith, M.D., F.A.C.S.
Most persons who experience torso trauma, whether blunt or pen- TUBE THORACOSTOMY: INDICATIONS AND TECHNIQUE
etrating, sustain some degree of associated injury to the chest. During initial resuscitation, chest tube placement can be both
Thoracic injuries are a primary or contributing cause of death in therapeutic and diagnostic.The two most common indications for
nearly half of all cases of torso trauma.1 Fortunately, many tho- tube placement in this setting are pneumothorax and hemothorax;
racic injuries can be treated effectively, and often definitively, by however, signs and symptoms of these conditions may not be
relatively simple maneuvers that can be learned and performed by readily apparent. In addition, when the patient is in shock, the sur-
most physicians involved in early trauma care. Approximately one geon often cannot afford to take the time to differentiate between
in six patients, however, has life-threatening injuries that necessi- various possible causative conditions. Because tube thoracostomy
tate urgent operative repair. These extremes in injury severity are is quick, relatively safe, and simple, it should be liberally used for
unique to the chest and require a correspondingly broad range of patients in extremis.
knowledge and skills on the part of the treating surgeon. Tension pneumothorax, the most common and easily treated
immediately life-threatening thoracic injury, results when blunt or
Initial Evaluation and Management penetrating trauma disrupts the respiratory system and allows air
to escape from the lung parenchyma or the tracheobronchial tree
PRIMARY SURVEY into the pleural space, thereby increasing intrathoracic pressure.
This increased pressure is transmitted to all the cardiac chambers
Initial evaluation and treatment of patients with thoracic
and retards venous return to the heart, resulting in hypotension.
injuries are guided by the same principles and priorities as initial
The classic signs of tension pneumothorax—decreased breath
evaluation and treatment of patients with other injuries. Eval-
sounds, tympany on the ipsilateral side, tracheal shift, and dis-
uation begins with an organized and rapid primary survey aimed
tended neck veins—commonly are absent or are incompletely
at recognizing and treating immediately life-threatening problems.
manifested in a busy emergency department. The diagnosis is
The first priority is to ensure an adequate airway. An airway
often suggested by the presence of shock accompanied by evi-
often can be established by clearing any blood or debris from the
oropharynx and pulling the mandible or the tongue forward. dence of adequate venous filling on physical examination and
Severely injured patients commonly require nasotracheal or oro- recognition of asymmetric motion of the two sides of the chest.
tracheal intubation, and some, especially those with severe max- Treatment of suspected tension pneumothorax should not be
illofacial trauma, require cricothyroidotomy or tracheostomy. delayed in patients with hemodynamic compromise.
The second priority is to ensure adequate ventilation. If the Chest tube placement in the trauma setting is a straightforward
patient is not breathing, he or she must be intubated promptly. If procedure. The chest is prepared and draped in a sterile fashion.
ventilation is inadequate because of open or tension pneumotho- A local anesthetic (e.g., 1% lidocaine) is not required in uncon-
rax, these problems should be addressed at this stage of care. scious patients but should be used in alert patients. On the midax-
The next priority is control of external hemorrhage and restora- illary line in approximately the fifth interspace, a scalpel is used to
tion of circulation. External hemorrhage is best controlled by make a 2 to 3 cm incision, oriented in the direction of the inter-
direct pressure. Inadequate perfusion generally results from either space, through all layers of the skin and subcutaneous tissue. A fin-
hypovolemia or pump (i.e., cardiac) problems. Hypovolemia from ger or a blunt clamp is inserted to penetrate the intercostal mus-
hemorrhage often must be treated operatively as part of the resus- cles and the parietal pleura.The wound is explored with the index
citative effort. Pump problems are signaled by distended neck finger (in adults) or the fifth finger (in children) to ensure that the
veins and are caused by one of four conditions: (1) tension pneu- pleural space has been entered and allow local exploration of the
mothorax, (2) pericardial tamponade, (3) coronary air embolism, chest cavity.
or (4) cardiac contusion or myocardial infarction (MI).These con- In adults, a 36 French chest tube is then inserted and directed
ditions are discussed in detail elsewhere (see below). At this early posteriorly and towards the apex for optimally effective drainage
stage of treatment, they should be addressed sufficiently to ensure of air and blood. The desired tube position is best achieved
adequate perfusion. through appropriate orientation of the skin incision relative to the
In most blunt trauma patients, urgent treatment of thoracic entrance into the chest cavity: the straight line between these two
injury is accomplished during the primary survey because the points defines the direction of the tube once it is in the chest.The
most common blunt chest injuries can be controlled with endo- tube is then attached to 20 cm of suction with a water seal and a
tracheal intubation or tube thoracostomy. In this setting, thoracot- collection chamber. Visual inspection of air passing through the
omy is indicated for cardiac tamponade, a massive hemothorax, or water seal yields an estimate of the size of the air leak—an impor-
uncontrolled massive air leaks. Neither pulmonary nor cardiac tant consideration with suspected airway injuries.
contusions should delay diagnosis or definitive treatment of Collection chambers for hemothoraces should be of the same
extrathoracic injuries resulting from blunt trauma. design. Those associated with autotransfusion devices (e.g., cell
savers) have immense theoretical potential for rapid retrieval and thrive, are diagnostic. Analysis and culture of fluid obtained at tho-
processing of shed blood. In practice, however, their utility is lim- racocentesis or chest tube placement typically confirms the diag-
ited. For example, with a small to moderate-sized hemothorax (< nosis, but the fluid may be sterile if the patient is already receiving
1,000 ml), the red-cell yield of an autotransfusion device would be antibiotics.
small and not worth the associated time and expense.With a large Antibiotic therapy, either broad-spectrum or specifically direct-
hemothorax, the most important goal of therapy is control of ed against cultured organisms (usually gram-positive pathogens),
bleeding, and arranging for autotransfusion could delay or hinder is certainly an important component of therapy for empyema tho-
the achievement of this goal. In addition, products of autotrans- racis, but the primary goal is removal of the infection while the
fusion may contain harmful cytokines, damaged cells, and debris, fluid is still thin. When this goal is met, a more modest therapeu-
while lacking platelets and other important proteins and coagula- tic procedure can be performed, there is less risk that a restrictive
tion factors.2 pulmonary peel will develop, and the injured patient recovers
Antibiotic prophylaxis after tube thoracostomy is controver- faster overall. In the early stages, tube thoracostomy may suffice
sial.3 Most clinicians, however, would recommend use of a first- for treatment; however, if the infected pleural process cannot be
generation cephalosporin for 24 hours, ideally starting before the completely evacuated via chest tube because of thicker fluid, loc-
initial tube placement. ulations, or pleural adhesions, a formal thoracotomy with decor-
After the primary survey, less dramatic pneumothoraces may tication is generally required.
be recognized on diagnostic images, along with hemothoraces, on Decortication should not be undertaken in the face of severe
various imaging studies. Treatment of occult pneumothoraces sepsis. Instead, antibiotics and chest drainage (via tube thoracos-
(i.e., those seen only on computed tomography) deserves special tomy, CT-directed catheter placement, or open rib resection)
mention. In general, patients with occult pneumothoraces who should be employed until sepsis is controlled. In cases of early
require positive pressure ventilation, those who are hypotensive or empyema,VATS has been successfully used for lysis of adhesions
have respiratory distress of any etiology, and those who have asso- and removal of fluid.9,10 Because of the limited capacity for per-
ciated complex injuries or hemothorax should be treated with forming pleurectomy with this procedure, VATS should not be
tube thoracostomy. One group, however, has questioned the need used when thick peel or a trapped lung is present. In adult patients
for tube thoracostomy in patients requiring positive pressure ven- with posttraumatic empyema, there is no proven role for
tilation on the basis of findings from a small number of patients.4 intrapleural fibrinolytic therapy.
Patients with occult pneumothoraces who are treated without
EMERGENCY DEPARTMENT THORACOTOMY
tube thoracostomy should be observed for at least 24 hours.
ED thoracotomy is a drastic step in the treatment of the injured
Retained Hemothorax and Empyema patient. If possible, the patient should be stabilized and transport-
In treating a hemothorax with tube thoracostomy, the goal is ed to the operating room, where better facilities are available for
complete removal of blood. Complications such as atelectasis and definitive care.
empyema after chest trauma are clearly related to the presence of ED thoracotomy is best reserved for patients who arrive at the
residual blood, fluid, and air, as can occur secondary to improper ED and deteriorate rapidly and those who have undergone car-
positioning of the tube (i.e., within a fissure), obstruction of the diac arrest just before arrival.The results are dismal when it is per-
tube, or blood clot or loculated fluid within the chest. formed in patients who have undergone cardiac arrest some time
A persistent or clotted hemothorax is suggested by the presence before arrival and have required cardiopulmonary resuscitation
of a persistent opacification in the pleural space in a patient with for more than a few minutes. Blunt trauma victims who have sus-
a known previous hemothorax.This radiodensity can be confused tained cardiopulmonary arrest at the scene of injury should not be
with adjacent pulmonary contusion or atelectasis; chest CT con- subjected to thoracotomy, either at the scene or in the ED.11
firms the diagnosis. Because retained blood serves as a nidus for Similarly, patients who are found at emergency thoracotomy to
infection and empyema,5 aggressive attempts at removal are justi- have no cardiac activity have a dismal prognosis, as do those who
fied. Occasionally, removal can be accomplished by placing more do not respond to improvement of systolic blood pressure after
chest tubes, but often, an operative approach is needed. Video- aortic occlusion. Overall, the survival rate for patients undergoing
assisted thoracic surgery (VATS) [see 4:7 Video-Assisted Thoracic ED thoracotomy for blunt trauma is lower than 10%.The report-
Surgery] may be useful for managing small, clotted hemothoraces ed survival rate for patients undergoing ED thoracotomy for pen-
and free-flowing blood in patients who can tolerate single-lung etrating trauma ranges from 16% to 57%,11-13 and that for
ventilation6 ; however,VATS tends to limit the surgeon’s ability to patients with cardiac wounds ranges from 57% to 72%.11-13
control bleeding and perform definitive repair of injuries. In The technique of ED thoracotomy is straightforward. An anti-
patients who have ongoing bleeding or large, clotted hemotho- septic solution may be splashed on the chest, but skin preparation
races, posterolateral thoracotomy is generally required. is not required. An incision is made from the sternal border to the
Empyema thoracis is a relatively common complication after midaxillary line in the fourth intercostal space. A chest retractor is
chest trauma, occurring in 5% to 10% of patients.7,8 Possible caus- inserted and opened widely. The costochondral junctions of the
es include retained hemothorax, pneumonia with parapneumonic fifth, the fourth, and sometimes the third rib are divided quickly
effusion, persistent foreign body, ruptured pulmonary abscess, bron- with the scalpel to provide exposure. Attention is directed first to
chopleural fistula, esophageal leakage, and tracking through the the injury. If there is exsanguination from a great vessel, the hem-
intact or injured diaphragm from an abdominal source. Empyema orrhage is controlled with pressure. If air embolism is the cause of
may be difficult to diagnose and must be differentiated from pleur- the arrest, the hilum is clamped and air evacuated from the aorta.
al thickening, pulmonary contusion, and an uninfected effusion. Otherwise, the pericardium is opened anterior and parallel to the
Chest CT with intravenous contrast usually demonstrates a fluid phrenic nerve. The hemopericardium is evacuated, the cardiac
collection with loculations or an enhancing rim. Such findings, injury is controlled with digital pressure, and a temporary repair
coupled with a clinical scenario of low-grade sepsis or failure to is performed.
After the cause of the arrest has been addressed, the descend- Table 1 Surgical Approaches for Traumatic
ing thoracic aorta is occluded with a vascular clamp or digital pres- Injuries to Thoracic Structures
sure and intrathoracic cardiac compression is initiated. The
patient’s intravascular volume is restored, and electrolyte imbal- Incision
ances are corrected. If the patient can be saved, he or she is trans-
ported to the OR for definitive repair and closure. Site of Injury Right Left
Sternotomy Thoracotomy Thoracotomy
SECONDARY SURVEY AND DEFINITIVE DIAGNOSIS
Right atrium +++ ++ 0
The secondary survey should focus on more subtle evidence of
Right ventricle +++ + +
injury that may be detected on physical examination and chest x- Left atrium +++ + +
ray. Simple rib fractures are clinically relevant when associated Left ventricle ++ 0 +++
with pain and are better diagnosed by palpation than by most Superior vena cava +++ ++ 0
imaging studies. Pneumothorax and hemothorax often go unde- Azygos vein ++ +++ 0
tected during the primary survey but are common findings later in Inferior vena cava +++ ++ 0
the workup. Aortic root +++ + 0
Echocardiography can be an important adjunct for assessing Aortic arch +++ 0 ++
proximity wounds to the heart or evaluating a new murmur. Right subclavian artery ++ ++ 0
Proximal right carotid artery +++ + 0
Because of continuing improvements in CT scanning technology,
Innominate artery +++ ++ 0
this modality is increasingly being used in the evaluation of the Left subclavian artery + 0 +++
widened mediastinum.14 Indeed, CT angiography is now routine- Proximal left carotid artery ++ 0 ++
ly employed for definitive diagnosis of aortic injuries, rendering Descending aorta 0 + +++
standard angiography unnecessary in most cases.15 Main pulmonary artery +++ 0 ++
Right pulmonary artery ++ +++ 0
Left pulmonary artery ++ 0 +++
Operative Considerations Right upper lobe ++ +++ 0
Right middle lobe ++ +++ 0
INDICATIONS FOR OPERATIVE MANAGEMENT Right lower lobe + +++ 0
Left upper lobe + 0 +++
Indications for operative treatment of thoracic injuries fall into Left lower lobe 0 0 +++
five broad categories: (1) hemorrhage, (2) major airway disrup- Right hilum ++ +++ 0
tion, (3) cardiac and vascular injuries, (4) esophageal disruption, Left hilum ++ 0 +++
and (5) diaphragmatic disruption. The extent and location of Pericardium +++ ++ ++
hemorrhage can sometimes be determined from open wounds but Right internal mammary artery ++ +++ 0
are more often established after chest tube insertion. If 1,500 ml Left internal mammary artery ++ 0 +++
of blood or more is obtained initially or ongoing bleeding at a rate Proximal esophagus 0 +++ 0
Distal esophagus 0 ++ +++
of 300 ml/hr or higher for 3 hours is noted, thoracotomy is indi-
Proximal trachea ++ + +
cated.16 Massive air leakage and the presence of gastric or esoph-
Carina 0 +++ +
ageal contents in the chest tube effluent also necessitate surgical Right main stem 0 +++ 0
intervention.The severity of an air leak can be estimated by exam- Left main stem 0 ++ ++
ining the amount of air traversing the water seal chamber. Inter- Right hemidiaphragm + +++ 0
mittent bubbling signifies a small leak, whereas a continuous stream Left hemidiaphragm + 0 +++
of bubbles signifies a large leak. A continuous leak seen in con- Cardiopulmonary bypass +++ ++ ++
junction with inability to expand the lung completely or with inad-
+++—preferred ++—acceptable +—site accessible with difficulty
equate tidal volumes is considered a massive air leak. In stable pa- 0—site inaccessible
tients with no evidence of bleeding, specific diagnostic measures
may be performed to evaluate the thoracic viscera. The likelihood
of associated intra-abdominal injuries must not be overlooked. eral, a median sternotomy provides the best exposure of the right-
side cardiac chambers, the ascending aorta, the aortic arch, and
CHOICE OF INCISION the arch vessels (excluding the left subclavian artery), and it pro-
The choice of thoracic incision obviously depends on many fac- vides adequate exposure of both lungs and both hemidiaphragms.
tors, including the indication for operation, the urgency of the sit- In the setting of exploratory surgery, a median sternotomy is the
uation, the presence of associated injuries, the mechanism of injury, best incision for mantle stab wounds and some precordial gunshot
and the results of preoperative studies. For injuries that are sus- wounds whose trajectory can be reliably determined. Its main lim-
pected or diagnosed preoperatively, the approach to the affected itation is that it does not provide exposure of the posterior medi-
thoracic structure is relatively straightforward [see Table 1]. For astinal structures.
exploratory surgery, the choice of incision should depend on the For exploration of lateral stab or gunshot wounds, a posterolat-
mechanism, the instrument, the location (of the entire injury, not eral thoracotomy on the side of the injury is the incision of choice.
just the entry site), and the symptoms. Stab wounds generally have Besides being the best incision for exploratory purposes, the fifth
a lower potential for deep penetration than missile injuries do. interspace thoracotomy is the most versatile approach to ipsilater-
A median sternotomy is one of the more versatile thoracic inci- al pulmonary and mediastinal pathologic states. Exposure can be
sions. It can be opened and closed more quickly than a thoracoto- markedly enhanced by removal of the fifth rib, which yields an
my, is associated with less postoperative pain, and may be less like- incision that is as long as the rib itself and extends as high as the
ly to result in contamination of the dependent hemithorax. In gen- fourth interspace and as low as the sixth interspace. In general, it
is unwise to perform an exploratory thoracotomy below the fourth air, or hemoptysis), further evaluation with bronchoscopy in the
interspace or above the sixth. OR is indicated before a decision is made to replace the existing
A transverse anterior thoracotomy (clamshell incision) is occa- adequate airway. In the absence of massive air leakage, bronchial
sionally useful for undetermined or transmediastinal injuries in tearing, or hemorrhage into one mainstem bronchus, a double-
urgent situations.When exposure of both hemithoraces is required lumen tube should be advanced into the left mainstem bronchus.
in nonurgent situations, both staged bilateral posterolateral thora- Otherwise, the tube should be placed so as to protect the unin-
cotomies and median sternotomy provide better exposure; one or jured side.
the other is therefore preferred. When a patient with a double-lumen tube in place requires con-
The role of VATS in the trauma setting continues to evolve. In tinued intubation after operation, the tube generally must be
acute situations, VATS is useful for ruling out diaphragm injury replaced with a standard endotracheal tube or a tracheostomy
and may be preferable to laparoscopy insofar as it is less likely to because an adequate pulmonary toilet cannot be performed
cause tension pneumothorax.VATS may also have a role to play in through a double-lumen tube. In contrast, a bronchial-blocker
the management of persistent intercostal or internal mammary tube may be left in place after surgery because a suction catheter
artery bleeding, but this application demands some degree of can be passed down it. A disadvantage of the bronchial-blocker
experience with thoracoscopic surgery. Later after injury, VATS tube, however, is that intraoperative lung isolation may be less
can be employed for evacuation of retained hemothorax and for complete than that obtained with a double-lumen tube.
management of the early stages of empyema. When a patient requiring a thoracic operation presents with an
DAMAGE CONTROL TACTICS inadequate airway, specific airway management depends on the
nature of the injuries. Most of these patients can be intubated in
Whereas the concept of damage control is critically important the standard fashion. If intubation is unsuccessful, however,
in abdominal trauma, it is less important in thoracic trauma. cricothyroidotomy should be attempted without delay. In cases of
Although serious bleeding from most thoracic structures is unlike- tracheal transection, the distal segment must be controlled quick-
ly to be controlled with packing, severe coagulopathy occasionally ly through a neck incision and selectively intubated through the
prevents definitive repair and necessitates abbreviation of surgery
wound. In cases of known or suspected thoracic airway injuries, an
and temporary closure of the chest by suturing or stapling the skin
endotracheal tube should be inserted over a bronchoscope past
incision only.17 The two most common locations of injury in these
the injury or into an uninjured mainstem bronchus.
scenarios are the lung and the chest wall.
Intraoperative management of the airway in patients with com-
Hemorrhage from lung lacerations in patients with metabolic
plex tracheobronchial injuries can be challenging and is discussed
exhaustion generally should not be treated with formal anatomic
in detail elsewhere [see Tracheobronchial Injuries, below]. Injuries
resection: stapled wedge resection, tractotomy, or simple suture
to the thoracic trachea may necessitate placement of temporary
repair is more appropriate. In patients with persistent chest wall
tubes within the operative field to provide ventilation [see Figure 1].
bleeding that is not associated with a major vessel, treatment with
After repair of a tracheobronchial injury, the patient should be
lung reexpansion for local tamponade and correction of coagu-
lopathy usually suffices. In rare circumstances, complex esophageal extubated if at all possible to prevent stress on the repair.
injuries may be associated with extensive loss of tissue, necessitat- The locations of arterial catheters should be considered as well.
ing rapid exclusion and proximal diversion. In most patients with In general, radial arterial lines should be placed in the extremity
any chance of survival, however, the surgeon should attempt pri- opposite the side of the intended thoracotomy and not (obvious-
mary closure of the injury, buttressing the repair with autologous ly) in vessels distal to anticipated cross-clamps. Placement of an
tissue, and employing wide drainage. Even with large defects, this epidural catheter for postoperative pain management [see 1:5
approach has a surprisingly high rate of ultimate success. Postoperative Pain] should also be considered in patients undergo-
ing nonurgent thoracotomy.
ANESTHETIC CONCERNS Control of body temperature is critical for both operative and
Airway management can be extremely complex in patients with nonoperative management. Most thoracic trauma patients are
thoracic injuries, especially when tracheobronchial injury is hypothermic and require a warm OR, warm I.V. fluids, and warm-
involved. Whenever operative management is required for a tho- ing blankets. Occasionally, controlled hypothermia is a useful
racic trauma patient, operative planning should begin with a dis- adjunct to procedures involving the thoracic aorta when spinal
cussion with the anesthesiology team about airway issues. cord injury and paraplegia are risks. For patients with severe coag-
In general, double-lumen and bronchial-blocker endotracheal ulopathy and a core temperature lower than 33.5° C, extracorpo-
tubes, which allow better exposure by partially or completely de- real warming can be lifesaving.This procedure involves placement
flating a selected lung, should be strongly considered for any thoracic of a 21 French femoral venous cannula and a 17 French internal
operation. For any given patient, the improved exposure achiev- jugular cannula and use of a centrifugal pump and a heat exchang-
able with such tubes must be weighed against the disadvantages— er. Heparin is not necessary.
namely, the additional time needed for placement and the require-
ment that single-lung ventilation be tolerable from a cardiopulmonary
Chest Wall Injuries
standpoint. Hemodynamic stability, therefore, is usually a prereq-
uisite for the use of these devices. The extent of the advantage
BLUNT
gained with lung isolation must also be considered. For example,
surgery on the mediastinum or the hilum is greatly facilitated by The greatest significance of certain chest wall injuries is their
lung deflation, whereas surgery on the chest wall is not. If neces- frequent association with other, more life-threatening injuries.
sary, these tubes can often be placed in the ED. These so-called sentinel injuries include first rib fractures, scapu-
If, at presentation, a patient with an otherwise adequate airway lar fractures, sternal fractures, bilateral rib fractures, and lower rib
has signs of airway injury (e.g., a massive air leak, subcutaneous fractures.
Special mention should be made of rib fractures in the elderly.

The mortality associated with rib fractures is twice as high in
patients older than 65 years as in younger patients, and the rela-
tive increase in the incidence of pneumonia in older patients is
even higher, even after the increased comorbidity is taken into
account.18,19
Sternal Fractures
The vast majority of sternal fractures result from motor vehicle
accidents and are associated with the use of three-point restraints.
Isolated sternal fractures in this setting are relatively benign, hav-
ing a low incidence of associated cardiac, great vessel, and pul-
monary injuries. Sternal fractures in unrestrained occupants and
victims of crush injuries, however, are commonly associated with
underlying visceral injuries, which must be excluded.20
The diagnosis of sternal fracture is based on the presence of
severe pain, often associated with instability on sternal palpation.
In many cases, physical examination can clarify the nature of the
fracture. Sternal fractures are almost invariably transverse, with
the majority occurring at the sternomanubrial joint or in the mid-
body of the sternum. They may be characterized as simple (two
fragments) or comminuted (multiple fragments), as displaced or
aligned, or as stable or unstable.The fragments of an unstable frac-
Figure 1 Intraoperative place- ture move substantially with activity.
ment of an endotracheal tube is
useful for airway management
Management Initial management of sternal fracture is direct-
in patients with tracheo-
bronchial injuries. ed toward resuscitation and identification or exclusion of other life-
threatening injuries. In patients with isolated sternal fractures, a
normal electrocardiogram and a normal chest radiograph suggest
that associated serious injuries are unlikely. If the pain is controlled
with oral analgesics, these fractures can usually be managed on an
outpatient basis. Displaced fractures may be reduced by the simple
(albeit painful) maneuver of having the patient simultaneously raise
his or her head and legs from the bed. Such a position requires con-
traction of the rectus abdominis, which distracts the caudad seg-
ment inferiorly, and the sternocleidomastoid muscles, which retract
the cephalad segments superiorly. The physician can then depress
Simple Rib Fractures the anterior segment and allow the patient to relax. This measure
often suffices for alleviation of subsequent pain and sometimes
Rib fractures are the most common chest wall injuries resulting
constitutes adequate long-term treatment.
from blunt trauma. The main pathophysiologic consequences of
The vast majority of sternal fractures heal with nonoperative
rib fractures are pain, splinting, and prevention of adequate cough.
The diagnosis should be suspected if pain or splinting occurs on management. Those that are unstable or are displaced by more
deep inspiration, and it is confirmed by careful physical examina- than 1 cm of overlap are more likely to exhibit malunion or non-
tion, consisting of anterior-posterior and lateral-lateral manual union and subsequent chronic pain; they should be treated with
compression. If an alert patient feels no pain when these maneu- open reduction and internal fixation. Occasionally, a patient with
vers are done, clinically significant rib fractures can be excluded. a clinically stable, minimally displaced sternal fracture associated
Although rib fractures are often identified on routine chest radi- with lower extremity injuries who requires crutches for ambulation
ographs, they are more likely to be undetectable except on rib- experiences such disabling sternal pain during ambulation that
detail films, which are rarely indicated. A variant of rib fracture fracture repair is necessary.
that falls into the same physiologic category is costochondral or Sternal fractures may be repaired with either of two operative
costosternal separation. This condition is usually detected during techniques. In both, the sternum is approached via either a verti-
physical examination but is not seen on routine chest radiographs. cal midline incision or a sweeping transverse inframammary inci-
sion similar to that used for repair of pectus excavatum. The frac-
Management Isolated rib fractures can usually be adequate- ture is exposed, and the ends are mobilized and fixed with either
ly treated by giving oral analgesics and encouraging good pul- reconstruction plates or No. 6 sternal wires. Reconstruction plates
monary toilet.We mention chest wall strapping, taping, and brac- provide a more stable and less painful fixation, and they can be
ing only to condemn these practices. Binding devices generally used in the management of comminuted and crush fractures.Wire
restrict tidal volume and thus promote rather than prevent atelec- repair is unsatisfactory in patients with comminuted or crush frac-
tasis and pulmonary complications.Treatment of multiple rib fractures and in many patients requiring crutches for ambulation.
tures, costochondral separation, and costosternal separation is Both wire fixation and plate fixation are well tolerated and, in fact,
described more fully elsewhere [see Flail Chest, below]. greatly appreciated by properly selected patients.
Flail Chest The mainstay of pain control in patients with flail chest is tho-
Flail chest is the most serious of the blunt chest wall injuries. It racic epidural anesthesia, in which a solution containing 0.002%
is common after any form of blunt thoracic trauma, and though it to 0.005% morphine sulfate and 0.075% to 0.2% bupivacaine is
may occur as an isolated finding, it is usually associated with other infused through a small catheter in the thoracic epidural space at
significant injuries.21 Flail chest represents a disruption of the sta- a constant rate of 0.15 to 0.75 mg morphine/hr. At this low dos-
bility and normal respiratory mechanics of the rib cage. It involves age, bupivacaine acts synergistically with morphine and does not
fractures of adjacent ribs, each of which is fractured in two or more exert a local anesthetic effect on the spinal cord; in addition, it
places, so that a panel of chest wall moves independently of, and generally does not give rise to the respiratory depression frequent-
in the opposite direction to, the remainder of the chest. When it ly observed with systemic narcotics. Epidural anesthesia provides
occurs in conjunction with separation of the costochondral or cos- immediate comfort, dramatically improves vital capacity and tidal
tosternal joints, the sternum can also be part of the flail segment, volume, and, most important, enables the patient to produce a
and the condition is termed a sternal flail chest. forceful cough.22
The following are the three components of the pathophysiolo- The most common serious adverse effect of epidural anesthesia
gy of flail chest: is transient hypotension at the time of insertion.This complication
can be prevented by providing adequate volume resuscitation
1. Alteration of chest wall mechanics.The paradoxical motion of before creating the chemical sympathectomy. Urinary retention
a large flail segment occasionally impairs the patient’s ability occurs in 30% to 50% of cases; in practical terms, this means that
to achieve an adequate tidal volume or an effective cough. most flail chest patients should not have their urinary catheters
2. Underlying pulmonary contusion. In the vast majority of seri- removed until the epidural analgesics are no longer required.
ous flail chest injuries, this is the most significant physiologic Patients who have head injuries and are thus at risk for increased
aberration. In the contused portion of the lung, there is intracranial pressure should not undergo epidural catheterization,
extravasation and accumulation of blood and fluid in the alve- because an unintentional dural puncture could alter cerebrospinal
olar air space, which results in sufficient shunting to produce pressure sufficiently to induce or contribute to cerebral herniation.
hypoxemia. Relative contraindications to epidural catheter placement include
3. Pain. The extreme pain of multiple rib fractures leads to pro- spine fractures and infection; however, fever may be a relative indi-
found splinting and diminution of tidal volume and prevents cation if it is thought to be secondary to splinting with atelectasis
adequate coughing and pulmonary toilet in most alert or pneumonia.
patients. The combination of depressed tidal volume and in- The decision-making process for management of flail chest
adequate coughing leads to hypoventilation, atelectasis, and should begin with assessment of the patient’s ability to cough [see
often pneumonia. Figure 2]. If the patient is able to clear tracheal secretions—that is,
actually cough them up into the oropharynx—then observation in
The diagnosis is typically suspected on the basis of the presence an acute care setting, in conjunction with small, infrequent doses of
of numerous adjacent rib fractures on a chest radiograph, but it narcotics, is appropriate. If the patient has no cough or has a very
can be conclusively confirmed only by the presence of a paradox- truncated cough that moves secretions but does not propel them
ical motion observed in the involved segment in a spontaneously into the oropharynx, an aggressive program to promote pulmonary
breathing patient. A flail segment may be overlooked in a patient toilet, including chest physiotherapy and postural drainage, should
undergoing positive pressure ventilation because there may be no be instituted. If a sufficiently vigorous cough cannot be achieved
paradoxical motion without inspiratory effort. Therefore, in an and there is no specific contraindication, an epidural catheter is
intubated patient, the diagnosis must be sought through careful inserted and the patient followed closely with frequent physical
examination and palpation of the rib cage for instability. examinations in the intensive care unit. Ambulation is encouraged,
and frequent coughing is required.
Management Proper management of flail chest hinges on There is no role for antibiotic prophylaxis in the management
the recognition that the injury is not a static condition but, rather, of flail chest or pulmonary contusion. Pneumonia is common in
an evolving process. Frequent reevaluation and timely, appropri- this setting, occurring in 25% to 50% of flail chest victims, but
ate intervention are essential. During the initial assessment, the prophylactic antibiotics do not reduce the incidence of this com-
patency of the airway and the adequacy of ventilation must be plication: they simply shift the spectrum of offending organisms to
established or confirmed. Immediate intubation is rarely required favor drug-resistant bacteria and fungi. Routine administration of
for patients with isolated flail chest injuries.When early intubation steroids also has no role in the treatment of flail chest.
is indicated, it is usually for associated injuries, most commonly to Given adequate pulmonary toilet, many flail chest victims can
the central nervous system. avoid intubation.23 However, any patient with flail chest who
In virtually all awake and alert patients, management without demonstrates further deterioration of pulmonary function and
intubation should be attempted.To this end, early and aggressive who becomes hypoxic or hypercarbic should undergo mechanical
pain management is essential. Pain cannot be eliminated entire- ventilation aimed at (1) ensuring a tidal volume adequate for
ly, but it usually can be diminished sufficiently to allow an ade- establishing normal chest wall excursion and (2) maintaining a
quate tidal volume and a forceful cough. Oral analgesics rarely respiratory rate adequate for achieving normocarbia. Hypoxia is
suffice for patients with even a small flail segment; stronger managed by increasing the fraction of inspired oxygen (FIO2) and
agents are required for all but the most stoic of patients. applying sufficient positive end-expiratory pressure to achieve ade-
Parenteral narcotics are effective, especially when administered quate oxygenation (usually defined as arterial oxygen saturation
in a patient-controlled analgesia (PCA) device. Intercostal nerve greater than 90%) with nontoxic levels of FIO2.
blocks occasionally provide dramatic pain relief, but only for A few patients with severe disruption of chest wall mechanics as
short periods. If the patient is encouraged to cough vigorously a result of flail chest continue to require positive pressure ventila-
during pain relief, intermittent nerve blocks may be helpful, tion even though adequate pain control has been achieved and the
despite the inherent risk of pneumothorax. pulmonary contusions are beginning to resolve. Some of them
Patient has flail chest

Hemorrhage
Stab wounds and low-caliber gunshot wounds to the anterior
Assess airway status and chest are common in urban areas. Such injuries often can be man-
oxygenation.
aged with tube thoracostomy or observation alone, once serious
injury to intrathoracic organs has been excluded. Indications for
urgent thoracotomy are discussed elsewhere [see Operative
Airway is adequate, Airway is inadequate,
Considerations, Indications for Operative Management, above].
and patient is not or patient is hypoxic In patients with persistent hemorrhage from chest tubes who
hypoxic or hypercarbic or hypercarbic require thoracotomy, the most common source of the bleeding is
a lacerated internal mammary or intercostal artery. Attempts to
Assess ability to cough Intubate patient. control bleeding from these vessels nonoperatively usually fail.
and clear airway
secretions. Angiography to localize the bleeding vessel is unnecessary and
delays definitive care: coupled with embolization of the lacerated
vessel, it is more time-consuming than surgical intervention and
does not address associated injuries and hemothorax.
Penetrating wounds to the midportion of the pectoral muscle
Patient is unable to Patient is able to
clear secretions clear secretion occur with surprising frequency, possibly as a result of an
assailant’s erroneous conception of the location of the heart. Such
Initiate aggressive Administer small doses injuries often lacerate the pectoral branch of the thoracoacromial
pulmonary toilet: of oral narcotics for pain.
artery, which courses along the posterior surface of the pectoral
• Chest physiotherapy
• Postural drainage muscle. Control of this troublesome bleeding is extremely difficult
Give parenteral narcotics. to achieve if exploration is attempted directly through an extension
of the entrance wound, but it is a straightforward and simple mat-
ter if exploration is attempted through an oblique wound along the
lateral pectoral margin after entry into the subpectoral plane.
Effective cough Effective cough Open Chest Wounds
is not achieved is achieved
The diagnosis of an open chest wound is usually obvious, and
Insert epidural catheter their treatment depends on the size of the wound and the size of
into thorax. the chest wall defect. Most small open pneumothoraces can be
managed initially with occlusive dressings, but there is usually an
underlying pulmonary injury with air leakage, which necessitates
early tube thoracostomy to prevent tension pneumothorax. Once
Effective cough is Effective cough the patient’s condition is stable, the wound can be debrided and
not achieved is achieved
closed. Occasionally, primary skin closure must be delayed.
Larger chest wall defects pose a challenging therapeutic prob-
Evaluate frequently.
Risk of pneumonia is lem. Such wounds usually result from high-velocity missiles or
high, and mechanical shotguns fired at close range. Initial management is directed
ventilation is likely toward restoration of respiratory mechanics with early intubation
to be needed.
Observe patient. and mechanical ventilation.
The next priority is to address any underlying intrathoracic
Figure 2 Algorithm illustrates approach to management of flail injuries, which may range from mild pulmonary contusion to mas-
chest. sive hemorrhage in conjunction with severe lung or hollow viscus
injury. When associated intrathoracic injuries are present, the first
may benefit from internal fixation of the multiple rib fractures, step in the closure of the defect is to select an appropriate opera-
which restores chest wall stability and eliminates much of the frac- tive approach. Although the primary objective in this situation is
ture-related pain. In this procedure, the fractured ribs are exposed to provide excellent exposure for repair of what may be life-threat-
and a small orthopedic plate is affixed so as to stabilize the ribs and ening injuries, whenever possible, the thoracotomy should be per-
obtain compression osteosynthesis of each fracture site. To date, formed in such a way as to preserve the blood supply and muscle
internal fixation of rib fractures has not been widely studied in the mass of the chest wall adjacent to the defect.
United States, but reports involving a few carefully selected After definitive repair of intrathoracic injuries and debridement
patients suggest that it can provide excellent pain relief. It has also of devitalized chest wall tissue, the next step is to plan the closure.
been shown to improve tidal volume and pulmonary mechanics Such planning requires a degree of familiarity with current and
and reduce time spent on the ventilator.24,25 developing techniques and an understanding of pleural drainage,
respiratory mechanics, and techniques of tissue transfer.
PENETRATING Collaboration with plastic and thoracic surgeons is often helpful.
In most cases of penetrating thoracic trauma, the injury to the Most chest wall defects can be closed with viable autogenous tis-
chest wall is vastly overshadowed by the injury, or potential for sue, usually through rotation of local myocutaneous or myofascial
injury, to the intrathoracic structures. The notable exceptions to flaps of the pectoral muscle, the latissimus dorsi, or the rectus
this general rule are hemorrhage and open chest wounds. abdominis.
Figure 3 Pulmonary tractotomy is

useful for controlling hemorrhage
associated with deep through-and-
through injuries to the lungs.
Pulmonary Injuries Selective repair of hilar structures is usually impractical in this set-
Because of their size, the lungs are commonly injured in cases ting, and lobectomy or pneumonectomy is the salvage procedure
of thoracic trauma. Mortality from pulmonary lacerations is of choice.
directly proportional to the amount of blood lost. A 1,500 ml CONTUSIONS
hemothorax, regardless of causative mechanism, should always
prompt exploration. Pulmonary contusions are bruises to the lung that usually are
caused by blunt trauma to the chest but sometimes result from
LACERATIONS penetrating injury by high-velocity weapons. The contused seg-
Bleeding pulmonary lacerations can be oversewn, resected, or ment of the lung has a profound ventilation-perfusion mismatch,
explored via pulmonary tractotomy. Bleeding from small or shal- which produces an intrapulmonary right-to-left shunt and hypox-
low lacerations can be controlled with an over-and-over repair ia. The bruise also may serve later as a source of sepsis. The diag-
using a continuous monofilament suture. Bleeding from deeper nosis is usually evident on initial chest x-ray or CT, but the bruise
lacerations is controlled with resection or tractotomy. Most pul- often is not fully developed until 12 to 24 hours after injury.
monary resections for trauma should be stapled, nonanatomic Most pulmonary contusions that are not complicated by
resections. Mortality is proportional to the amount of lung tissue excessive attempts at resuscitation or by superinfection resolve
resected: with suture repair alone, mortality is 9%; with tractoto- over 3 to 5 days. Cardiovascular and, if necessary, ventilatory
my, 13%; with wedge resection, 30%; with lobectomy, 43%; and support must be provided. In general, pulmonary contusion is
with pneumonectomy, 50%.26,27 treated in much the same fashion as flail chest. Patients with rib
Tractotomy is especially useful for deep through-and-through fractures and painful chest wall excursions must be given suffi-
injuries. In this technique, the injury tract is opened with a linear sta- cient analgesic support to allow them to produce a cough force-
pler [see Figure 3] or between two aortic clamps. If clamps are used, ful enough to maintain pulmonary toilet. Intubated patients
the cut lung edges are oversewn and the tract left open.Tractotomy should undergo suctioning frequently. Patients with pulmonary
exposes bleeding vessels and air leaks inside the tract and permits contusions who require substantial volume resuscitation should
selective ligation. Occasionally, it exposes an injury to a major vas- be considered for pulmonary arterial catheter monitoring.
cular or airway structure that must be treated with a formal resec- Steroids are not indicated, because they have no effect on the
tion. Because of the risk of exanguination or excessive devitalization development or resolution of the contusion and because they set
of lung tissue, tractotomy is not indicated when the injury traverses the stage for subsequent infection. Diuretics and prophylactic
the hilum or when the entire thickness of a lobe will be cut. antibiotics are also unnecessary.
Central lung injuries often cause massive hemorrhage. In addi-
tion, they may be sources of pulmonary venous air emboli when
Tracheobronchial Injuries
both a major pulmonary vein and a large airway are disrupted. A
common scenario involves an intubated patient on positive pres- Although tracheobronchial injuries are often lethal, a high index
sure ventilation who exhibits sudden deterioration of CNS and of suspicion for the existence of the injury, a timely diagnosis, and
cardiac status. Emergency thoracotomy must be performed and appropriate intervention can improve the chances of a successful
the pulmonary hilum clamped. The diagnosis is confirmed by outcome. The reported incidence of tracheobronchial injury in
visualizing air in the epicardial coronary arteries. Aspiration of air blunt chest trauma patients ranges from 0.2% to 8%.28-30 More
from the left-side cardiac chambers and elevation of central blood than 80% of tracheobronchial ruptures occur within 2.5 cm of the
pressure are also useful maneuvers. Most central lung injuries are carina. Mainstem bronchi are injured in 86% of patients and dis-
associated with extensive parenchymal injury in gravely ill patients. tal bronchi in only 9.3%, whereas complex injuries are seen in 8%.
Knowledge of the anatomy of the trachea and the bronchial tree as abnormal migration of the tube tip and distention of the endo-
facilitates safe exposure and repair of these structures.The trachea tracheal tube balloon beyond the normal tracheal diameter.
is a tubular structure 10 to 13 cm long, with half of its length in the In only 30% of cases is a definitive diagnosis of tracheobronchial
neck and half in the thorax. The anterior two thirds of the trachea injury made within 24 hours. More often, the diagnosis is made
is protected by 18 to 22 U-shaped cartilages.The posterior wall of late, when pulmonary collapse and sepsis occur. As many as 10%
the trachea is membranous and in intimate contact with the esoph- of tracheobronchial tears give rise to no initial clinical or radiolog-
agus. The recurrent laryngeal nerve lies adjacent to the esophagus ic signs and are not recognized until months later, after stricture
and the trachea in the tracheoesophageal groove. At the level of the occurs. Immediate intubation of patients with multisystem trauma
fourth thoracic vertebra, the trachea ends and the mainstem can mask laryngeal or high cervical tracheal injuries and thereby
bronchi originate. The blood supply to the trachea is segmental delay the diagnosis. After tracheobronchial transection, the peri-
and approaches the trachea laterally. bronchial connective tissues sometimes remain intact and allow
When dissecting and mobilizing the trachea, one should avoid continued ventilation of the distal lung, in much the same way that
the lateral pedicles and mobilize only one tracheal ring circum- perfusion is maintained after traumatic aortic transection. If unrec-
ferentially so as to maintain an adequate vascular supply. One ognized, this injury heals with scarring and granulation tissue and
may resect a substantial length of the trachea (as much as 4 or 5 occasionally creates bronchial obstruction.
cm, or half) and still achieve a safe primary anastomosis. Because Concomitant injury is the rule rather than the exception, but the
the trachea is in contact with the esophagus along its entire pos- patterns of associated injury vary widely. Major vascular, cardiac,
terior length and is surrounded by vital structures (e.g., lungs, pulmonary, esophageal, bony thoracic, and neurologic injuries are
heart, and great vessels), associated injuries are common and common in tracheobronchial trauma and reflect the site, magni-
often fatal. tude, and mechanism of the trauma.The mechanism of injury may
Intrathoracic injury to the tracheobronchial tree is more com- alert the examiner to search for specific associated injuries. For
monly the result of blunt trauma but may also be caused by bullet example, transcervical and transmediastinal penetrating injuries
wounds. Blunt trauma may injure the trachea and the bronchi via pose a particular danger to the structures they traverse.The esoph-
several mechanisms, including direct blows, shear stress, and burst agus is the organ most frequently injured in conjunction with tra-
injury. Shear forces on the trachea cause damage at its relatively cheal trauma.31
fixed points—namely, the cricoid and the carina. Burst injury The diagnosis is typically suspected on the basis of the clinical
along the tracheobronchial tree often results in rapid anteroposte- history and the characteristic signs and symptoms [see Figure 4].
rior compression of the thorax. This compression causes a simul- The advent of spiral CT has led to renewed interest in the use of
taneous expansion in the lateral thoracic diameter, and the nega- this modality to evaluate tracheobronchial injury; however, there is,
tive intrapleural pressure stretches the lungs laterally along with the at present, no evidence that CT is adequate to exclude such injury
chest wall, thereby placing traction on the carina. When the plas- and render diagnostic bronchoscopy unnecessary. Indications for
ticity of the tracheobronchial tree is exceeded, the lungs are pulled bronchoscopy in this setting include a large pneumomediastinum,
apart and the bronchi avulsed. Closure of the glottis before impact a refractory pneumothorax, a large air leak, persistent atelectasis,
may convert the trachea into a rigid tube with increased intratra- and possibly marked subcutaneous emphysema.31 Bronchoscopy is
cheal pressure, and as a consequence, the impact may cause a lin- the most reliable means of establishing the diagnosis and determin-
ear tear or blowout of the membranous portion of the trachea or a ing the site, nature, and extent of the tracheobronchial disruption.
complex disruption of the trachea and the bronchi. Given the pro- Both rigid and flexible bronchoscopy have been employed in
tected nature of these structures, a high degree of energy transfer this setting; neither has been conclusively shown to be superior to
is usually required to injure them. the other. Rigid bronchoscopy must be performed with the patient
Various clinical presentations result after injury to the tracheo- under general anesthesia, and it requires a stable ligamentous and
bronchial tree, generally depending on the severity and the location bony cervical spine. On the other hand, it permits direct visualiza-
of the injury. In the neck, airway involvement may create severe tion and has the ability to provide ventilation. Flexible bron-
respiratory distress that causes death before emergency care can be choscopy may be performed without general anesthesia and allows
given. Alternatively, patients with cervical tracheal injuries may controlled insertion of a nasal or orotracheal tube while maintain-
present with stridor and severe respiratory distress or with hoarse- ing cervical stabilization; this maneuver may help prevent the need
ness, hemoptysis, or cervical subcutaneous emphysema. for emergency tracheostomy and the potential associated morbid-
The presentation of thoracic tracheobronchial injury depends ity. At the same time, the entire larynx and trachea can be visual-
on whether the injury is confined to the mediastinum or commu- ized with a flexible bronchoscope, as can the major lobar bronchi.
nicates with the pleural space. Thoracic tracheobronchial injuries Whichever type of scope is used, the signs and symptoms should
confined to the mediastinum usually present with a massive pneu- be correlated with the endoscopic findings.The most critical deter-
momediastinum. Pneumopericardium is occasionally described, minant seems to be the endoscopist’s level of experience and com-
but this description is usually mistaken, because air in the pericar- fort with the procedure. An experienced bronchoscopist can per-
dial sac is in fact rare. What is actually seen is air in the plane just form either technique with a high degree of sensitivity, specificity,
external to the pericardium, between it and the pleura. Injuries and accuracy.29 Often, the lesions are missed initially, or their
that do extend into the pleural space usually create an ipsilateral severity is underestimated, or they evolve into more obvious or
pneumothorax that may or may not be under tension. A pneu- severe lesions. For this reason, bronchoscopy should be liberally
mothorax that persists despite adequate placement of a thoracos- repeated as needed.
tomy tube and that leaks air continuously is suggestive of tracheo-
MANAGEMENT
bronchial injury and bronchopleural fistula. Dyspnea may actual-
ly worsen after insertion of the chest tube because of the loss of With tracheobronchial injuries, as with all injuries, airway man-
total volume via the tube. Several radiographic clues to possible agement is the first priority in treatment. If the patient is main-
airway injury may be observed with endotracheal intubation, such taining his or her own airway and is adequately ventilated, a cau-
Patient has suspected tracheobronchial injury

lost. Paralytic medications should generally be avoided in this set-
ting, for the same reason. Furthermore, bronchoscopy requires a
Injury may present as level of expertise that is not always immediately available in an
• Pneumothorax • Pneumomediastinum emergency situation. Urgent tracheostomy or cricothyrotomy, per-
• Subcutaneous emphysema • "Fallen lung" formed in the OR, is advocated by many as the safest and securest
Perform tube thoracostomy. way of obtaining airway control. If the trachea is completely tran-
sected, the distal trachea can usually be found in the superior
mediastinum and grasped for insertion of a cuffed tube. Early tra-
cheostomy may prevent the damage often caused by these hurried,
Atelectasis or lung
blind attempts at emergency airway control, but inevitably, a num-
Lungs reexpand
collapse persists, or ber of these tracheostomies will prove to have been unnecessary.
persistent or massive The approach taken to airway control must vary with the resources
air leak is noted and expertise available at each institution. One must also keep in
mind that even after the airway is secured, it may still be possible
Perform bronchoscopy
Condition Patient experiences (repeated, if necessary) to exacerbate the injury by means of aggressive ventilation with
resolves late clinical to identify and locate high airway pressures. Tube thoracostomies should be appropri-
deterioration, with injury.
Remove tube. lobar collapse or
ately placed at this time and connected to suction, even though
persistent pneumonia dyspnea may worsen.
Once the airway is controlled, there is time for orderly identifica-
tion of concurrent injuries, esophagoscopy, laryngoscopy, arteriog-
raphy, transport to definitive care areas, and, if necessary, celiotomy.
Determine whether injury is amenable to nonoperative Nonoperative
management. Criteria for nonoperative management
include On occasion, asymptomatic tracheobronchial tears are found
• Small lesion (< one third of circumference) incidentally in the course of bronchoscopy or other imaging pro-
• Well-opposed wound edges cedures. Nonoperative management is reserved for highly selected
• No tissue loss patients with unsuspected small injuries of this type. Lesions suit-
• No associated injuries able for observation must involve less than one third of the cir-
• No need for positive pressure ventilation cumference of the tracheobronchial tree. For patients to be candi-
dates for nonoperative care, their lungs should be fully reexpand-
ed with tube thoracostomy, and any air leaks should stop soon after
insertion of the tube.There must be no associated injuries and no
need for positive pressure ventilation. Prophylactic antibiotics,
Injury can be managed Injury must be managed
nonoperatively operatively
humidified oxygen, voice rest, frequent suctioning, and close
observation for sepsis and airway obstruction are required.
Treat with Treat with Small penetrating wounds with well-opposed edges and no evi-
• Humidified air • Voice rest • Debridement dence of loss or devitalization of tracheal tissue may be effectively
• Frequent suctioning • End-to-end anastomosis, treated with temporary endotracheal intubation.32 The cuff of the
• Prophylactic antibiotics without tension, with care taken
endotracheal tube should be inflated below the level of injury and
• PPIs • Close observation to preserve blood supply
Perform follow-up bronchoscopy.
left undisturbed for 24 to 48 hours while the wound seals. If a con-
Perform follow-up bronchoscopy. servatively managed patient’s clinical condition deteriorates, bron-
choscopy should be liberally repeated. Even small tears may pro-
Figure 4 Algorithm illustrates approach to management of duce substantial amounts of granulation tissue upon healing,
suspected tracheobronchial injury. which may necessitate late endobronchial excision.
Operative
tious noninterventional approach is probably the best initial choice Like emergency airway management, intraoperative airway man-
until further diagnostic workup is performed or other life-threat- agement requires close coordination with the anesthesiologist. After
ening injuries are stabilized. Careless handling or mishandling of the airway is initially secured, manipulation during the repair cre-
the airway (e.g., inadvertently placing an endotracheal tube ates additional challenges. A sterile anesthesia circuit and tube must
through a transected or ruptured airway and into soft tissue) can be available to pass off the table once control of the airway at the
be disastrous and may compound the injury. ED tracheostomies level of transection has been regained and the peritracheal con-
are difficult and may be dangerous, to say the least. nective tissue has been disrupted or entered for repair. If orotra-
How best to secure an airway in a patient with neck trauma and cheal intubation is performed, either a single-lumen or a double-
possible tracheal injury is a matter of debate. With blind endotra- lumen endotracheal tube may be used. For proximal levels of rup-
cheal intubation, the path of the tube distal to the larynx is ture, a long single-lumen tube may be passed beyond the area of
unknown, and it is possible to lose the lumen or create a false pas- injury [see Figure 1]; for distal injuries, the tube may be advanced
sage.With intubation over a flexible bronchoscope, the tube can be into the contralateral mainstem bronchus for single-lung ventila-
visualized as it passes beyond the site of injury, and some of the tion. Intubation over a flexible bronchoscope improves the safety
dangers of blind intubation are thereby mitigated; however, some and diagnostic capability of the procedure.
degree of sedation is usually required, and if the patient is overse- If a tracheostomy is performed, it should be placed two to three
dated, the airway that was being spontaneously protected may be rings caudal to any high tracheal or laryngeal injuries and should
be brought out through an incision separate from the surgical Tension may also be released with cervical flexion, which can be
repair wound.Tracheostomy proximal to an injury is probably not maintained postoperatively by securing the chin to the chest with
necessary to protect the suture lines after repair of the thoracic tra- a suture. Many investigators recommend performing the anasto-
chea or a major bronchus, and its prophylactic use is discouraged mosis with interrupted absorbable sutures; however, a continuous
for distal tracheobronchial injuries. Routine use of tracheostomy absorbable monofilament suture also offers a secure repair, is
may result in various complications, including pneumonia, medi- more readily visible during construction of the anastomosis, and
astinitis, wound infection, laryngeal and tracheal stenosis, and eliminates knots within the tracheal lumen.
postoperative dysphonia. The membranous portion may be repaired without tension and
In especially difficult cases, in which airway management is un- then brought together as repair of the cartilaginous portion is
satisfactory or the repair is complex, cardiopulmonary bypass or begun. Sutures may be placed around or through the cartilage
venovenous extracorporeal membrane oxygenation (ECMO) may but, in either case, must ensure approximation of mucosa to
be instituted. Both of these techniques require systemic anticoag- mucosa. Tying the suture knots on the outside of the lumen also
ulation, and their potential risks and benefits in multiply injured helps prevent suture granulomata and subsequent stricture. To
patients remain to be determined. prevent subsequent leakage and fistula formation, the suture line
Once the repair is complete, the endotracheal tube ideally should be reinforced with a patch of pericardium or a vascularized
should be removed immediately after the operation. Occasionally, pedicle from the pleura, an intercostal muscle, a strap muscle, or
there is a need for ongoing positive pressure ventilation, which may the omentum to protect the repair and assist bronchial healing.
require the surgeon to employ sophisticated techniques of critical For early repairs, the pleura is too flimsy to be suitable as rein-
care and ventilation, such as positioning of the endotracheal tube forcement. A vascularized pedicle of intercostal muscle offers
distal to the repair, dual-lung ventilation, high-frequency jet venti- both better protection and added healing potential. For this rea-
lation, and ECMO. Every effort must be made to improve lung son, the intercostal muscle should routinely be preserved during
compliance by providing good pulmonary toilet, appropriate fluid thoracotomy, along with the corresponding vein, artery, and
management, and aggressive treatment of pneumonia. nerve. This is accomplished by entering the chest through the
Intrathoracic tracheal, right bronchial, and proximal left main- bed of the rib; the rib itself may be either preserved or sacrificed.
stem bronchus injuries are best repaired through a right postero- An incision is made directly over the rib, and the periosteum is
lateral thoracotomy at the fourth or fifth intercostal space because stripped off. At the superior border of the rib, the incision is car-
this approach avoids the heart and the aortic arch. Complex or ried through the posterior layer of the periosteum to enter the
bilateral injuries are also approached through the right chest, for pleural space. The intercostal muscle is then divided from the
the same reason. Distal left bronchial injuries more than 3 cm ribs above and below and used as a flap to be wrapped around
from the carina are approached through a left posterolateral tho- and tacked to the trachea. In this manner, viable tissue is placed
racotomy in the fifth intercostal space. between the repair and the surrounding vital structures, and the
Optimal repair includes adequate debridement of devitalized blood supply in the area of the repair is increased, thus facilitat-
tissue (including cartilage) and primary end-to-end anastomosis ing healing [see Figure 5].
of the clean tracheal or bronchial ends. The anastomosis can be If diagnosis is delayed, repair should proceed as soon as the diag-
accomplished without tension by mobilizing the structures anteri- nosis is made or as soon as is practical after treatment of other life-
orly and posteriorly, thereby preserving the lateral blood supply. threatening injuries. Regardless of the length of the delay, recon-
Figure 5 Tracheal injury may be repaired by means of segmental resection, with the suture
line buttressed with an intercostal muscle flap.
struction of the tracheobronchial tree should be attempted if there Table 2 Diagnostic Measures for Evaluating
is no distal suppuration. Total bronchial disruption often leads to
Suspected Esophageal Injuries
complete occlusion and sterile atelectasis and may be amenable to
repair years later. The stenotic segment is resected and repaired in
Sensitivity Specificity Accuracy
much the same manner as an acute injury or a benign stenosis Diagnostic Measure (%) (%) (%)
would be. Incomplete bronchial obstruction ultimately leads to
suppuration and irreversible pulmonary parenchymal destruction. Assessment of clinical signs and
80 64 72
Bronchography and sputum culture are useful for determining symptoms
whether pulmonary resection (pneumonectomy or lobectomy) is
Contrast esophagography 80–100 94–100 90–95
necessary for salvage. On occasion, bronchial sleeve resection,
lobectomy, or pneumonectomy is urgently required for more Rigid esophagoscopy 67–100 89–95 86–94
extensive or distal injuries to lobar or segmental bronchi.
Although bronchial rupture can be treated successfully in either Flexible esophagoscopy 67–100 67–100 82–97
the acute or the delayed phase, early diagnosis and treatment min-
imize the risk of infection and resection and shorten hospital stay.
mediastinum, sepsis ensues, and the resulting mortality is high.
Between 60% and 80% of esophageal injuries give rise to clini-
Esophageal Injuries cal signs or symptoms, the sensitivity and specificity of which
Injury to the esophagus, though relatively rare, poses particular depend on the location of the injury, the size of the perforation, the
problems for the treating physician because of the complexity of degree of contamination, the length of time elapsed after injury,
the presentation, the workup, and the treatment options. Despite and the presence of associated injury. Odynophagia, dysphagia,
diagnostic and therapeutic advances, the morbidity and mortality hematemesis, oropharyngeal blood, cervical crepitus, pain and ten-
associated with esophageal injury remain high. Diagnosis and derness in the neck or chest, resistance to passive motion, dyspnea,
management of esophageal injuries evoke strong, and widely vary- hoarseness, bleeding, cough, and stridor are commonly noted.
ing, opinions from surgeons. Preoperative evaluation is still a sub- Fever, subcutaneous emphysema, abdominal tenderness, and
ject of debate, as is the question of mandatory surgical exploration mediastinal crunching sounds (Hamman sign) may be observed.
versus selective nonoperative management. Currently, most Pain is the most common presenting symptom (71% of patients),
esophageal injuries are iatrogenic or endoluminal; however, we will followed by fever (51%), dyspnea (24%), and crepitus (22%).34
concentrate here on injuries specifically related to external trau- Overall, the signs and symptoms associated with esophageal
ma—namely, penetrating injury and blunt esophageal rupture. injury are fairly nonspecific, and a high index of suspicion must be
Whereas the cervical esophagus is relatively unprotected from maintained to make the diagnosis. As noted (see above), con-
external trauma, the thoracic esophagus, being surrounded by the comitant injuries to structures surrounding the esophagus are
bony thorax, is well protected.The esophagus lies in close proxim- common. Of these, tracheal and vascular injuries are most fre-
ity to the heart, the great vessels, and the entire membranous por- quently seen, occurring in as many as two thirds of victims. The
tion of the trachea. Consequently, simultaneous injury to several of associated injuries also determine the symptoms seen in patients
these intrathoracic organs is common, which greatly increases asso- with esophageal trauma, the course the diagnostic evaluation takes,
ciated morbidity and mortality.The esophagus has no serosal cov- and the treatment options considered.
ering; rather, it is entirely surrounded by loose areolar connective Evaluation of potential penetrating trauma to the esophagus is
tissue, which makes suture placement less secure and increases the based on the trajectory and path of the missile. For penetrating
overall difficulty of surgical repair.The planes of the paraesophageal injuries near the organ, it is necessary to prove that the esophagus
and prevertebral spaces communicate freely with the mediastinum. is uninjured. Generally, this is done in one of two ways: (1) surgi-
As a result, spillage from the esophagus readily tracks into the cal exploration demonstrates a missile path inconsistent with
mediastinum, leading to mediastinitis, causing sepsis, and account- esophageal injury, or (2) direct examination of the esophagus
ing for much of the increased morbidity and mortality seen with reveals no injury. If neither option is feasible, proof is obtained
delayed diagnosis and treatment of esophageal injuries. through diagnostic testing. Plain x-rays, CT scans, and contrast
The exact incidence of injury of the esophagus caused by exter- esophagograms have all been used for this purpose, with varying
nal trauma is unknown, but such injury accounts for fewer than 1% sensitivity and specificity [see Table 2]. Endoscopy may add to the
of injuries for which patients are admitted to hospitals. Most esoph- diagnosis, but the results depend on the operator’s technique and
ageal injuries result from penetrating trauma. If surgical exploration experience, and there is a risk that it may exacerbate an esophageal
is performed for all penetrating cervical wounds that violate the tear or further injure an unstable cervical spine.
platysma, the esophagus is found to be injured approximately 12% In an otherwise asymptomatic patient who is awake, alert, and
of the time. Penetrating intrathoracic esophageal injuries are less able to cooperate, a simple contrast swallow is usually sufficient to
common, however, occurring in about 0.7% of all penetrating chest exclude injury. Injuries resulting from low-velocity projectiles and
wounds.33 Blunt esophageal trauma is relatively uncommon; it may stab wounds do not cause large tissue defects; for these injuries,
develop when the organ suffers a direct blow or when increased intra- barium gives superior anatomic detail and is the agent of choice.
luminal pressure against a closed glottis causes a burst-type injury. Injuries from large-caliber or high-velocity projectiles usually
Intrathoracic esophageal injuries tend to occur just proximal to cause more damage, and thus, the contrast agent tends to spread
the esophagogastric junction on the left side, where the esophagus more widely throughout the mediastinum during a diagnostic
is less well protected. The injury is thought to be the result of swallow. If contrast studies are indicated in this setting, a water-
increased transmission of intra-abdominal pressure to the stom- soluble agent may be used first. Such agents cause pulmonary
ach, as is seen in postemetic esophageal rupture (Boerhaave syn- damage when aspirated, however, and should not be used if tra-
drome). Gastric contents are widely and violently expelled into the cheoesophageal fistula is suspected.
For patients who are going to the OR for another reason (e.g., the thoracic esophagus from blunt trauma is so extremely unusual,
vascular repair or laparotomy), it may be most expedient to per- compared with the other causes of simple pneumomediastinum,36
form esophagoscopy simultaneously with the operation. If the that evaluation for esophageal injury is necessary only in the pres-
entire esophagus is well visualized and no injury is identified, no ence of other suggestive findings, such as pleural effusion, free air,
further evaluation is required. If the study is suboptimal for any and mediastinitis. In the absence of these suggestive signs and
reason, or if the possibility of an injury persists, a contrast study symptoms, pneumomediastinum associated with blunt trauma is
should be done as soon as the patient’s condition permits. much more likely to be from a distal small airway disruption or from
Regardless of the diagnostic studies obtained, evaluation must a bronchial injury, the evaluation of which should take precedence
be carried out expeditiously. Significant delays in management over evaluation of the esophagus.When esophageal or major airway
can increase the incidence of esophageal injury–related morbidity injury has been ruled out, pneumomediastinum should be treated
by as much as a factor of two.35 with observation alone. Chest tubes should be placed only if there
In cases of blunt trauma, determining when further study is is an associated hemothorax or pneumothorax.
needed is a vexing task. In general, whenever a patient has pneu-
MANAGEMENT
momediastinum that is extensive or is associated with any of the
symptoms of esophageal injury (e.g., odynophagia or blood in the Although injuries to the thoracic esophagus caused by external
esophagus), the esophagus should be evaluated. Simple pneumo- trauma are less common than those to the cervical esophagus,
mediastinum rarely warrants evaluation of the esophagus. Injury to they are more likely to be fatal.33,37 Trauma to the thoracic esoph-
Patient has transmediastinal penetrating injury
Assess hemodynamic status.
Patient is unstable Patient is stable
Attempt to control tension pneumothorax, cardiac

tamponade, or exsanguinating hemorrhage.
Patient remains unstable Patient becomes stable
Perform arteriography.
Arteriogram is negative Arteriogram is positive
Perform clinical assessment to determine Take to OR for repair of vascular

likelihood of esophageal injury. injury and exploration for other injuries.
Index of suspicion for Index of suspicion for

esophageal injury is high esophageal injury is low
Perform esophagography.
Esophagogram is positive Esophagogram is negative
Observe patient.
Take to OR.
Perform laryngoscopy, bronchoscopy, and esophagoscopy,
with or without operative repair as appropriate.
Figure 6 Algorithm illustrates approach to management of transmediastinal penetrating injury.

agus is almost exclusively caused by gunshot wounds; the location perforation of an already diseased esophagus. Risk factors associ-
of the organ within the chest protects it from most stab wounds. ated with an increased complication rate include shock, the need
Care of any associated injuries to surrounding structures (e.g., for urgent tracheostomy, and associated injuries (especially tra-
major airways and blood vessels) takes precedence in the manage- cheal disruption and paralysis from spinal cord injuries).
ment scheme; thus, by necessity, diagnosis and definitive therapy Esophageal anastomotic leakage is the most common compli-
of intrathoracic esophageal injuries are often delayed. cation associated with repair of perforations, occurring in 10% to
Guidelines have been formulated for the evaluation of transme- 28% of repairs.38 The causes are primarily technical and include
diastinal penetrating wounds [see Figure 6]. The signs and symp- inadequate debridement, devascularization, closure under ten-
toms of thoracic esophageal injury, besides being nonspecific, sion, and the presence of associated infection. As many as 50% of
often take several hours to develop. As with injuries to all other these leaks are asymptomatic; in this setting, they are usually asso-
areas of the esophagus, delays in diagnosis and therapy result in a ciated with prompt flow of oral contrast back into the esophageal
longer duration of contamination and a higher incidence of medi- or gastric lumen. Continued abstinence from oral intake, supple-
astinitis, sepsis, and death. mental parenteral nutrition, and antibiotic therapy usually suffice
Injuries to the distal third of the thoracic esophagus are most for successful treatment.
easily approached via the left chest. More proximal injuries are In patients who have sepsis and esophageal leakage after repair
best approached through the right chest or via a combination of of an esophageal perforation caused by external trauma, treatment
chest and cervical incisions. The incision should be made so as to should focus on wide local drainage and creation of a controlled
facilitate subsequent buttressing of the repair (e.g., with a pedicle fistula, which is usually best accomplished by resecting a segment
from an intercostal muscle or the latissimus dorsi). of a rib posteriorly at the level of the perforation, then packing the
Surgical repair entails local debridement, wide drainage, prima- wound open. Because there is usually no underlying esophageal or
ry repair of the perforation, and buttressing of the repair with a gastric pathologic condition and no forceful distribution of medi-
viable muscle flap. Primary repair can usually be accomplished astinal contamination, these fistulas generally heal well without
when the perforation is operated on within 24 hours of occurrence. resection, diversion, or replacement of the esophagus. Most of
Many investigators recommend two-layer repair of esophageal these patients also benefit from feeding jejunostomy tubes; healing
injuries; however, a secure single-layer repair performed with a con- time is generally measured in weeks.
tinuous absorbable monofilament suture (e.g., 3-0 polydioxanone)
allows excellent visualization of each bite and good mucosa-to-
mucosa approximation.There is no evidence that adding a second Thoracic Duct Injuries
layer adds any strength or security to the anastomosis. A number of Chylothorax after blunt or penetrating chest trauma is rare: only
different tissue flaps—free pericardium, pleura, intercostal muscle, case reports and small case series are found in the literature. Much
diaphragm, rhomboid muscle, lung, and gastric fundus (as in a of the management of this condition is extrapolated from man-
Thal patch)—have all been used, with varying success. Each of agement of iatrogenic thoracic duct injuries, which are much more
these flaps has its own set of advantages, but the use of any of them common. Most patients with traumatic chylothorax show evi-
(if viable) will yield an improved anastomotic outcome. dence of other axial injuries to the chest, especially spine frac-
Depending on the interval before exploration, the severity of the tures.39 The diagnosis is made by finding chylomicrons and high
injury, the degree of contamination, and the extent of the local levels of triglycerides in a typically large pleural effusion of milky
inflammatory response, primary repair may not be feasible. If this appearance. Drainage of as much as 1,000 ml/day is not unusual
is the case, there are several techniques that may be employed, and results in severe nutritional and immunologic derangements,
including esophageal diversion, total esophageal exclusion, which are the main causes of the high mortality associated with
esophagectomy, and T tube drainage. Most of the experience with this condition.
these delayed repairs has been acquired in patients who have per-
MANAGEMENT
forations caused by instrumentation or by emetogenic esophageal
rupture, neither of which is entirely analogous to the injuries seen Treatment usually begins with limiting oral intake of short- and
with external trauma. long-chain triglycerides, which cause increased flow of chyle. Diets
In general, even late-presenting esophageal perforations should high in medium-chain triglycerides must often be given enterally
be treated with an attempt at primary repair with autologous tis- because they are not palatable. Some clinicians recommend insti-
sue coverage. During the workup and surgical management, tuting total parenteral nutrition with complete abstinence from
esophageal patency must be ascertained. Primary esophageal oral intake. Administration of octreotide may also help decrease
lesions (e.g., strictures) must be corrected, or the repair is likely to chyle production.40 These modalities, in conjunction with ade-
fail. In the absence of distal obstruction, almost all late-presenting quate pleural drainage and lung expansion, are successful in
esophageal perforations heal after primary repair and tissue flap approximately 50% of cases after 2 to 6 weeks.
coverage. Generally speaking, techniques such as esophageal Operative strategies for managing thoracic duct injuries are gen-
exclusion, diversion, and resection should be needed only when erally undertaken only after conservative measures fail. Preopera-
perforation occurs in the setting of a primary esophageal patho- tively, patients are fed cream, with or without dyes such as Sudan
logic condition (e.g., cancer); esophageal perforation in this setting black, to increase chyle flow and enhance visualization of the site of
is rarely managed by trauma surgeons. injury.The thoracic duct is then ligated above and below the injury;
this may be perfomed by means of VATS on the hemithorax ipsi-
Complications lateral to the effusion.41 Fibrin glue and talc pleurodesis may be
Complications seen after esophageal repair include esophageal used as adjuncts to ligation. Because there are usually multiple
leakage and fistula, wound infection, mediastinitis, empyema, sep- areas of injury and because the thoracic duct is friable by nature,
sis, and pneumonia. Long-term complications (e.g., esophageal surgical treatment is not always successful. Continued nutritional
stricture) also occur, but they are more common after iatrogenic management and reoperation may be required.
Cardiac Injuries window should be considered when ultrasonographic findings are

The incidence of cardiac trauma continues to rise as a conse- equivocal or when ultrasonography is unavailable.This procedure
quence of growing urban violence, improved detection of cardiac is usually performed in the OR with the patient under general
injuries, and an increase in the percentage of patients with such anesthesia, often in combination with abdominal exploration.
injuries who arrive at trauma centers alive. Improved prehospital A subxiphoid pericardial window is performed through a 10 cm
transport, along with the continuing evolution of diagnostic, sur- vertical midline incision that is made over the xiphoid, slightly
gical, and anesthetic techniques, has contributed to an increase in favoring the epigastrium.The xiphoid is grasped with a clamp and
overall survival in this population. Although the overall mortality dissected away from the abdominal fascia and the diaphragmatic
associated with cardiac trauma remains high, survival rates of 50% fibers, and the substernal plane is accessed. As the inferior portion
to 95% are not uncommon in patients who arrive at the hospital of the sternum is being elevated, the prepericardial adipose tissue
with vital signs.42-45 is dissected to provide exposure of the acute margin of the peri-
cardium. The pericardium is then retracted inferiorly into the
PENETRATING wound and incised sharply. The presence of blood or clot within
Patients with penetrating cardiac injuries generally present in the pericardial sac indicates a positive result, necessitating imme-
one of three ways. In approximately 20% of patients, the injury is diate repair of the injury. A pericardial window can also be accom-
clinically silent, at least initially, and is subsequently diagnosed at plished during thoracoscopy of the left hemithorax [see 4:7 Video-
operation or on diagnostic imaging. In approximately 50%, there Assisted Thoracic Surgery], and examination of the pericardium can
is evidence of pericardial tamponade, including one or more of the be performed, though less reliably, during laparoscopy via a trans-
signs in Beck’s triad (hypotension, distended neck veins, and muf- diaphragmatic view.
fled heart sounds). In the remaining patients, hemorrhagic shock Some authorities advocate using pericardiocentesis to detect
develops after free bleeding from an atrial or ventricular wound cardiac injuries, especially where rapid access to the OR, trauma
into one or both hemithoraces. surgeons, and anesthesiologists is not available. Drawbacks to this
Diagnosis of penetrating injuries to the heart often requires a approach include the high rate of false positives and false negatives
high index of suspicion.The locations of entrance and exit wounds, and the potential for iatrogenic cardiac injuries. Furthermore,
the trajectory and path of the wounding object, and the locations pericardiocentesis is of limited use in treating tamponade because
of any retained missiles on radiographs are helpful in predicting blood within the pericardial sac often is clotted and is not amen-
heart injuries. Proximity wounds to the heart are defined as those able to removal through a needle.
that penetrate the chest wall in the area bounded superiorly by the
Management
clavicles, laterally by the midclavicular lines, and inferiorly by
the costal margins. Any crossing of the anterior mediastinum by Treatment of penetrating cardiac wounds depends on the
a missile or an instrument is also considered a proximity wound. urgency of the presentation. In patients who are in shock from
Because cardiac injuries are present in 15% to 20% of patients suspected cardiac injuries, the distinction between the two most
who present with proximity wounds, these injuries must be defin- likely causes, pericardial tamponade and free hemorrhage, is
itively excluded. important. If the patient exhibits distended neck veins and the
Physical examination is often unreliable in detecting pericardial characteristic plethoric, dusky facial expression, chest tubes
tamponade. It is rare for all three signs in Beck’s triad to be found; should immediately be placed bilaterally. If shock does not then
in fact, only about half of patients with tamponade show even two resolve, the diagnosis of tamponade should be made and a peri-
of the three. Moreover, detection of muffled heart sounds and dis- cardial window performed, either in the ED with local or no anes-
tended neck veins amid the commotion typical of the trauma bay thesia or in the OR as described (see above). If there is a suspicion
can be extremely difficult, especially when (as is often the case) the of free hemorrhage into one or both hemithoraces, which can usu-
patient is agitated or intoxicated. Accordingly, whenever tampon- ally be detected by means of physical examination and chest x-ray,
ade is suspected, additional diagnostic modalities should be the patient should be transported to the OR for definitive treat-
employed. ment. In patients who are in extremis from either causative con-
As more surgeons become familiar with the use of ultrasonog- dition or who go into cardiac arrest in the ED, an emergency left
raphy in the trauma setting, two-dimensional surface echocardiog- anterior thoracotomy should be performed.
raphy is gaining acceptance as a means of diagnosing cardiac In planning the surgical approach to the repair of cardiac injuries,
injuries. When performed by appropriately trained surgeons, this the location of the entrance and exit wounds, the path of the
modality detects blood within the pericardial sac with a sensitivi- wounding object, the type of wound created, the associated signs
ty of 96% to 100% and a specificity of 100%—results essentially and symptoms, and the level of suspicion for other thoracic viscer-
equivalent to those achieved with a pericardial window.46 When al injuries are important considerations. A median sternotomy is a
the requisite equipment is readily available, this test can be per- logical extension of a subxiphoid pericardial window and provides
formed in approximately 2 minutes. It is of vital importance that access to all four chambers of the heart. It is appropriate for most
the trauma surgeon who is attending to the patient perform and precordial stab wounds and some low-caliber gunshot wounds. Its
interpret the test: the results will be available sooner, the clinical main limitations are that it does not allow repair or cross-clamp-
correlation will be more accurate, and the information obtained ing of the descending aorta or examination or repair of the esoph-
will be more rapidly applied to treatment decisions.The main lim- agus and bronchi and that it provides limited exposure of the
itations of two-dimensional surface echocardiography are the high lower lobes of the lungs and the hemidiaphragms. A left thoracot-
cost of the equipment and the specialized training required. omy is appropriate for patients who may require cross-clamping of
Although cardiac ultrasonography has many advantages, the the thoracic aorta and for those with suspected cardiac injuries in
subxiphoid pericardial window remains the gold standard for conjunction with other complex thoracic visceral injuries. Only
diagnosis of cardiac injury. For otherwise stable patients with occasionally is a right thoracotomy required; this incision general-
proximity wounds or suggestive signs and symptoms, a pericardial ly does not provide adequate exposure of the heart.
Atrial wounds are generally amenable to early control by finger direct visualization of the heart at surgery or autopsy. For practical
pressure or by exclusion with a vascular clamp and simple over- purposes, the clinically significant sequelae of myocardial contu-
sewing. Right or left ventricular free wall injuries away from the sion are myocardial dysrhythmias and pump failure. Both of these
coronary arteries may be treated by applying digital pressure over sequelae must be treated, regardless of whether the diagnosis of
the entrance wound for hemostasis, then placing horizontal mat- blunt cardiac injury can be made. Guidelines have been proposed
tress sutures under the wound, reinforced with an epicardial con- that may facilitate the workup of this condition.48
tinuous suture along the site of injury. All left ventricular wounds As an initial test, a 12-lead ECG should be obtained whenever
should be repaired with felt-pledgetted or pericardial-pledgetted blunt cardiac injury is suspected. If the ECG is normal, no further
sutures. Many right ventricular stab wounds can be closed pri- workup is required. If there is an ECG abnormality that does not
marily without pledgets if the sutures are tied accurately. necessitate treatment (e.g., nonspecific ST-T wave changes), the
Injuries near coronary arteries must be closed without the coro- patient should undergo monitored observation for 12 hours, then
nary artery being incorporated within the suture. This can be be discharged if there are no dysrhythmias and the ECG is normal
accomplished by placing horizontal mattress sutures lateral and at that time. If there is a more serious ECG abnormality (e.g., dys-
deep to the coronary artery across the cardiac laceration. If the rhythmia, ST-segment elevation, or heart block), the patient should
sutures are tied with careful attention to the function of the undergo observation for at least 24 to 48 hours and may require
myocardium distal to the injury and equally careful attention to further testing and treatment, depending on the sequelae of the
the electrocardiogram, the laceration can be closed without coro- abnormality. In patients with hemodynamic instability and suspect-
nary artery occlusion and subsequent ischemia. ed blunt cardiac injury, echocardiography should be performed
An alternative method of repair of cardiac lacerations employs promptly. There is no role for cardiac enzyme analysis or cardiac
a skin stapler, which is effective in controlling hemorrhage from troponin assay in this setting.The latter test may detect myocardial
stab injuries and low-velocity gunshot wounds.47 The stapler can injury, but this information does not complement ECG and echo-
be used on all chambers of the heart, and in some instances, sta- cardiographic findings and has no clinical utility. Similarly, there is
ple repair can be quicker than suture repair. no role for nuclear medicine studies.
With all penetrating cardiac wounds, it is important to recognize
the possibility of associated intracardiac injuries. The surgeon Management
should palpate the heart along the pulmonary outflow tract for a Pump failure associated with cardiac contusion is usually the
thrill that would indicate a traumatic ventricular septal defect.This result of right heart failure, in that most hemodynamically sig-
diagnosis can be confirmed by performing co-oximetry on a sam- nificant cardiac contusions are caused by injury to the anterior
ple of blood aspirated from the pulmonary artery and the right atri- right ventricular free wall. Treatment of right heart failure from
um and demonstrating a step-up. Digital palpation through atrial cardiac contusion consists of inotropic support and reduction of
wounds should be routinely employed to identify atrioventricular right ventricular afterload. Dysrhythmias secondary to cardiac
valvular insufficiency or, occasionally, an atrial septal defect. Intra- contusion are treated in the same manner as dysrhythmias of any
operative surface echocardiography and transesophageal echocar- other etiology.
diography are also excellent at diagnosing intracardiac injuries, but The commonly repeated adage that cardiac contusion should
they are not readily available in the urgent trauma setting. be treated similarly to MI is incorrect.Therapy for MI is based on
Postoperatively, all patients with cardiac wounds should receive the premises that the patient is likely to have concomitant coro-
a thorough cardiovascular examination aimed at detecting mur- nary artery disease and that increased myocardial oxygen demand
murs or evidence of cardiac failure and should undergo echocar- may result in extension of the evolving infarct or the creation of an
diography if either of these is detected. Repair of intracardiac additional infarct. However, most young trauma patients have nor-
lesions usually can wait until the patient’s condition is stable and mal coronary arteries, and increased myocardial oxygen demand
cardiac catheterization has been performed, though some patients is unlikely to extend cardiac contusion unless the heart sustains an
experience such profound heart failure that immediate operative additional blow. Generally, the goal in resuscitation of injured pa-
repair, with cardiopulmonary bypass, must be performed. tients is to increase systemic oxygen delivery, which may increase
cardiac work. In addition, unlike patients with MI, patients with
BLUNT
myocardial contusion appear not to be at increased risk for cardiac
Blunt cardiac injuries range from disruption of myocardium, complications from general anesthesia and surgery.
septa, or valvular structures to cardiac contusion. Both cardiac dis- In the rare patient with cardiorrhexia who presents to the hos-
ruption (also known as cardiorrhexia) and cardiac contusion are pital with signs of life, the most common injury is right atrial per-
common; the former is seen most often in patients who die at the foration. Other lesions seen in patients with vital signs, in order of
scene, the latter in those who survive to reach the hospital. decreasing incidence, are left atrial perforation, right ventricular
Blunt cardiac injury typically involves a direct blow to the chest, perforation, atrial septal perforation, ventricular septal perforation,
usually sustained in a motor vehicle collision or a fall. Cardiac in- coronary artery thrombosis, and valvular insufficiency (most com-
juries generally are associated with sternal or rib fractures, though monly involving the tricuspid and mitral valves).42-45 Patients with
they may occur in the absence of any chest wall fracture; however, cardiac rupture generally present with signs of pericardial tam-
sternal fractures do not predict the presence of blunt cardiac ponade and require rapid decompression. Placement of an intra-
injury. The most common location of blunt cardiac injury is the aortic balloon pump is often an effective temporizing measure
anterior heart, which consists primarily of the right ventricle. A while preparations are made for definitive repair.
blow that causes the sternum to exert a direct impact on the myo- Patients with blunt cardiac trauma who lose vital signs in the
cardium may result in direct injury to myocardial cells, sometimes field or who go into cardiac arrest before arrival at the hospital
leading to cell death, mechanical dysfunction, or dysrhythmias. generally should not be subjected to ED thoracotomy, because vir-
The diagnosis of myocardial contusion is elusive. Many tests tually none of these patients can be saved. Patients admitted with
have been proposed, but none have proved definitive, except for vital signs after suffering blunt cardiac rupture, however, have
about a 50% chance of survival, and much of the mortality in

these patients is attributable to associated injuries.
Blunt Aortic Injuries

Traumatic rupture of the aorta may account for as many as
10% to 15% of all traffic fatalities, and the majority of such
injuries are fatal at the scene. Of those who survive the initial
injury, 50% die in the first 24 hours and 90% die within the first
month if the aorta is not repaired.Traumatic disruption of the tho-
racic aorta results from rapid deceleration and is produced by a
shearing effect caused by differences in the mobility of the aorta
above and below a point where the vessel is fixed. Most thoracic
aortic disruptions in survivors occur at the aortic isthmus just dis-
tal to the origin of the left subclavian artery, where the aorta is
fixed to a significant degree by the ligamentum arteriosum.
Autopsy series reveal that as many as 40% of aortic injuries in Figure 7 Shown is an injury to the descending thoracic aorta
nonsurvivors are not located at the isthmus, and the injuries tend (white arrow). A nasogastric tube can be seen in the esophagus,
to be complex.49 which is deviated to the right (black arrow).
Suspicion of an aortic injury is most often triggered by abnor-
mal findings on a chest x-ray in a patient with a high-speed mech-
anism of injury and multiple other injuries. Most patients show no aortic injury, it will be massive; lesser amounts of bleeding from a
signs or symptoms on physical examination, but some complain chest tube often derive from associated injuries. If intra-abdomi-
of interscapular pain or hoarseness, and some exhibit a difference nal bleeding is present, laparotomy is indicated before repair of the
in blood pressure or pulse fullness between the upper and lower torn thoracic aorta and before aortography. Similarly, in patients
extremities or between the right and left upper extremities. Ac- with intracranial hemorrhage that necessitates operative evacua-
cordingly, the diagnosis is usually made radiographically, often be- tion, craniotomy should take precedence over repair of the torn
ginning with the recognition of mediastinal hemorrhage on a thoracic aorta.
screening chest x-ray. While one is temporizing, stringent efforts must be made to
Numerous radiographic signs of a torn thoracic aorta have been prevent hypertension and reduce shear forces across the injury,
described, all of which are manifestations of hemorrhage within ideally by means of I.V. beta blockade. Esmolol, because of its
the mediastinum that alters or obliterates the shadows seen on a short half-life, is the best agent to use in these patients, who are at
normal chest radiograph. Mediastinal widening is the most fre- risk for sudden hypovolemic episodes of hypotension. The goals
quent indicator of mediastinal hematoma from a torn thoracic aorta. of medical therapy are a heart rate lower than 100 beats/min and
Other important signs are obscuration of the detail of the contour a systolic blood pressure of approximately 100 mm Hg (in young
of the aortic knob, opacification of the aortopulmonary window, and middle-aged patients) or 110 to 120 mm Hg (in elderly pa-
depression of the left mainstem bronchus, apical cap, deviation of tients).15 Nitroprusside may have to be given to achieve these
the nasogastric tube, and displacement of the esophagus to the goals, but it should not be used until after adequate beta block-
right. These signs may be present in any combination or may be ade is achieved, because it can increase intravascular shear forces
entirely absent. when used alone. During pharmacologic treatment of aortic
Currently, high-speed CT scanning with I.V. contrast is being injuries, pulmonary arterial catheter monitoring is essential to
liberally used for diagnosis of thoracic vascular injuries. prevent deleterious reductions in cardiac output and mixed ven-
Appropriately, this modality is employed in virtually all patients ous oxygen saturation. With careful delayed operative manage-
with abnormal chest x-rays and in many patients with normal x- ment of aortic injuries, the risk of rupture is low but is not com-
rays whose injury mechanisms include a high degree of energy pletely eliminated.15,52
transfer. CT findings that are diagnostic of aortic injury include Traditional repair techniques include exposure of the aorta and
mediastinal hematoma, periaortic hematoma, intraluminal irregu- arch through a left thoracotomy and direct repair or interposition
larity (intimal flap), acute coarctation, and abnormal aortic con- graft placement. Although excellent results have been obtained
tour [see Figure 7]. Depending on the experience of the interpret- with so-called clamp-and-sew techniques, most guidelines recom-
ing clinician, aortography may be eliminated in most of these mend use of some form of distal aortic perfusion (e.g., left atri-
patients before surgical repair; the sensitivity and specificity of CT al–distal aortic bypass or partial cardiopulmonary bypass with
in this setting approach 100%.15,50,51 Aortography should contin- femoral cannulation). Systemic heparinization is required for car-
ue to be used for equivocal cases or cases in which spiral CT is not diopulmonary bypass and has been shown to be safe with respect
available. to hemorrhagic complications.53,54 The aortic arch is clamped
between the common carotid and left subclavian arteries after
MANAGEMENT these vessels and the distal aorta have been controlled. An inter-
Essentially all aortic injuries associated with mediastinal position graft is required for most of these injuries, though 15% to
hematomas should be repaired. The timing of repair, however, is 20% can be treated with suture repair alone. With distal aortic
less urgent than the timing of certain associated maneuvers that perfusion, the risk of paraplegia is approximately 5% and is inde-
must be done, such as attainment of an adequate airway, control pendent of clamp time; without distal aortic perfusion, ischemic
of external or cavitary hemorrhage, and evacuation of intracranial times longer than 30 minutes are associated with an exponential
mass lesions. In general, if there is active bleeding from a blunt rise in the incidence of spinal cord injury.
Another potential advantage to using cardiopulmonary bypass Most penetrating wounds of the middle and distal segments of
is the ability to institute deep hypothermic circulatory arrest if the great vessels are amenable to lateral repair or end-to-end anas-
needed. This technique involves cooling to a core temperature tomosis; injuries involving greater tissue destruction, for which
lower than 20º C to induce cardiac standstill, turning off the grafts might be indicated, usually prove fatal before the patient
pump, and operating on the unclamped aorta in a relatively dry arrives at the hospital.The subclavian artery is a notable exception
field. Circulatory arrest can be safely maintained in this setting for to this general rule because the lack of elastic fibers in its tunica
approximately 30 to 45 min. This technique may be useful for media makes it extremely friable. End-to-end anastomosis of an
patients who have previously undergone thoracic aortic surgery or injured subclavian artery under any tension is doomed to failure.
who have complex tears involving the arch. Accordingly, many subclavian injuries should be repaired with an
An evolving modality for the treatment of aortic injury is endovas- interposition graft. Proximal injuries to the great vessels are best
cular stent grafting.The rationale for the insertion of a stent graft in repaired by exclusion and bypass grafting with prosthetic material
this population is that the aorta above and below the injury is usu- from the ascending aorta. Because bleeding is usually active, there
ally normal, which is not the case in the atherosclerotic population. is rarely enough time to arrange for cardiopulmonary bypass. In
Early results with this method of treatment are encouraging and are any case, cardiopulmonary bypass generally is not needed, except
in fact superior to those obtained with endovascular repair of aortic for rare cases of associated ascending or aortic arch injury.
aneurysms and dissections.55 If longer-term follow-up continues to
BLUNT
report acceptable outcomes, stent grafts will probably become stan-
dard therapy for uncomplicated aortic injuries. Blunt injuries of the great vessels are typically the result of high
speed and rapid deceleration. In postmortem examinations,
pedestrians struck by motor vehicles have the highest rate of great
Great Vessel Injuries vessel injuries. Patients with such injuries are rarely seen in the ED
Except for tears in the descending aorta, injuries to the thoracic with signs of life.56 Superior mediastinal hematoma is the most
great vessels, by any mechanism, are rarely seen in clinical prac- common finding during workup; its presence is an indication for
tice; the best descriptions come from wartime and autopsy series. further imaging with spiral CT or angiography. Besides vessel lac-
Indeed, postmortem studies reveal that patients with nonisthmus eration with hematoma, presentations of blunt thoracic great ves-
aortic and great vessel injuries rarely reach the hospital alive.56 As sel injury include dissection and thrombosis, which may be
many as 14% of patients have multiple great vessel injuries. asymptomatic if localized to the proximal segments. Central neu-
Diagnosis and management of these injuries covers a wide spec- rologic injury may also be present, especially with carotid dissec-
trum of possibilities, depending on mechanism of injury, present- tion. Associated stretch injury of the brachial plexus or the cervi-
ing features, and associated injuries. cal nerve roots is common with subclavian artery injuries.
PENETRATING Management
Penetrating thoracic great vessel injuries are usually obvious. Once the diagnosis is made, virtually all great vessel injuries
The presence of an entrance wound at the base of the neck or in should be treated surgically, with the possible exception of small
the chest should alert the clinician to this possibility. If the patient intimal defects that are found incidentally. Surgery is contraindi-
is in shock, urgent operation is required. If the patient’s condition cated, however, if neurologic injury is present, the injury is
stabilizes with resuscitation, an arteriogram should be performed deemed unsurvivable, or a common carotid dissection has ex-
to localize the injury. tended into the distal internal carotid artery. As with blunt aor-
tic injuries, the timing of surgery should be tailored to the treat-
Management ment priorities mandated by the associated injuries. When time
Exposure is most often obtained via a median sternotomy, with permits, proximal lesions are best managed with cardiopulmon-
or without neck extension as needed for innominate, right subcla- ary bypass and hypothermic circulatory arrest. Arranging for
vian, or carotid arterial injuries [see Table 1]. Exposure of the left sub- these techniques is mandatory with injuries involving the as-
clavian artery can be more difficult, even through a sternotomy with cending aorta and the arch.
a trap-door extension. For isolated injuries to the proximal subcla- Mediastinal blood seen on chest CT probably more often
vian artery, a fourth-interspace left posterolateral thoracotomy is derives from mediastinal venous injuries than from arterial injuries.
most useful. For injuries to the middle and distal thirds, supracla- These isolated venous injuries need not be repaired unless they are
vicular incisions or deltopectoral incisions—or, occasionally, a com- associated with cardiac tamponade or massive hemorrhage into a
bination thereof—are appropriate, provided that inflow control can pleural space, both of which are uncommon. An exception is injury
be achieved.When inflow control may not be achievable, as in cases to the intrapericardial venae cavae, which is usually associated with
involving injury at the thoracic outlet or the presence of a large tamponade. These injuries are caused by tearing of the mobile
hematoma, endovascular control of the proximal subclavian artery heart against the relatively fixed veins, particularly the inferior vena
by means of a balloon catheter placed percutaneously through the cava. In most cases, they can be repaired primarily. Associated
femoral artery may be necessary.There are also case reports describ- venous injuries are commonly encountered during exploration for
ing total endovascular management of subclavian injuries through great vessel arterial injury. If possible, they should be treated with
stent-graft placement.57 This technique may be valuable for unsta- lateral repair or patch venorrhaphy with pericardium or saphenous
ble patients who are already undergoing arteriography and for vein. However, ligation of these veins sometimes proves necessary
patients with multiple high-priority injuries. and is generally well tolerated.
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7 TRAUMA AND THERMAL INJURY 6 INJURIES TO LIVER, BILIARY TRACT, SPLEEN, AND DIAPHRAGM — 1
6 INJURIES TO THE LIVER, BILIARY

TRACT, SPLEEN, AND DIAPHRAGM
Jon M. Burch, M.D., F.A.C.S., and Ernest E. Moore, M.D., F.A.C.S.
Injuries to the Liver adrenal gland (which is vulnerable because it lies directly beneath
the peritoneal reflection) or the retrohepatic vena cava. When the
ASSESSMENT
ligaments have been divided, the right hemiliver can be rotated
The initial step in the management of penetrating abdominal medially into the surgical field. Mobilization of the left hemiliver
injuries and of blunt abdominal injuries in cases when nonopera- poses no unusual problems other than the risk of injury to the left
tive treatment is contraindicated or has failed is exploratory lapa- hepatic vein, the left inferior phrenic vein, and the retrohepatic
rotomy [see 7:9 Operative Exposure of Abdominal Injuries and Closure vena cava.
of the Abdomen]. If optimal exposure of the junction of the hepatic veins and the
Visualization of the right hemiliver [see Figure 1] is hindered by retrohepatic vena cava is necessary, the midline abdominal incision
the posterior attachments and by the right lower costal margin. can be extended by means of a median sternotomy.The pericardi-
Exposure of the right hemiliver is facilitated by elevating the right um and the diaphragm can then be divided toward the center of
costal margin with a large Richardson retractor. Further exposure the inferior vena cava. This combination of incisions provides
can be achieved with mobilization, which requires division of the superb exposure of the hepatic veins and the retrohepatic vena cava
right triangular and coronary ligaments [see Figure 2]. In dividing while avoiding injury to the phrenic nerves.
the superior coronary ligament, care must be taken not to injure Hepatic injuries are classified according to the grading system
the lateral wall of the right hepatic vein; in dividing the inferior developed by the American Association for the Surgery of Trauma
coronary ligament, care must be taken not to injure the right Committee on Organ Injury Scaling [see Table 1 and Figure 3].1 The
Right Hemiliver (Right Liver) Left Hemiliver (Left Liver)
Inferior Vena Cava Middle Hepatic Vein
Right Hepatic Vein

Left Hepatic Vein
1, 9
7
Falciform
Ligament
5
Portal Vein
6
Common
Hepatic Artery
Common
Bile Duct
Right Posterior Right Anterior Left Medial Left Lateral

Section Section Section Section
Figure 1 Shown are the anatomic divisions of the liver.

Inferior
Vena Cava Middle
Right
Hepatic Vein
Hepatic Vein
Right Triangular
Coronary
Ligament
Ligament
Left
Hepatic Vein
Left Triangular
Ligament
Left Branch of Portal Vein

Figure 2 Depicted are the
Falciform Ligament venous drainage and suspen-
sory attachments of the liver.
Right Branch Ligamentum
of Portal Vein Teres
Portal Vein
grading scale ranges from I to VI, with I representing superficial ma, and if the liver is not the highest priority, temporary control
lacerations and small subcapsular hematomas and VI representing of hepatic bleeding allows repair of other injuries without unnec-
avulsion of the liver from the vena cava. Isolated injuries that are essary blood loss. The most useful techniques for the temporary
not extensive (grades I to III) often require little or no treatment; control of hepatic hemorrhage are manual compression, perihe-
however, extensive parenchymal injuries and those involving the patic packing, and the Pringle maneuver.
juxtahepatic veins (grades IV and V) may require complex maneu- Periodic manual compression with the addition of laparotomy
vers for successful treatment, and hepatic avulsion (grade VI) is pads is useful in the treatment of complex hepatic injuries to pro-
lethal. vide time for resuscitation [see Figure 5].2-4 Hands and pads
Clamping of the hepatic pedicle—the Pringle maneuver—is should be positioned to realign the liver in its normal anatomic
helpful for evaluating grade IV and V hepatic injuries [see Figure 4]. position. Perihepatic packing with carefully placed laparotomy
This maneuver allows one to distinguish between hemorrhage pads is capable of controlling hemorrhage from almost all hepat-
from branches of the hepatic artery or the portal vein, which ceas- ic injuries.5-9 The right costal margin is elevated, and the pads are
es when the clamp is applied, and hemorrhage from the hepatic strategically placed over and around the bleeding site [see Figure
veins or the retrohepatic vena cava, which does not. When per- 6]. Additional pads may be placed between the liver and the
forming the Pringle maneuver, we prefer to tear open the lesser diaphragm and between the liver and the anterior chest wall until
omentum manually and place the clamp from the patient’s left the bleeding has been controlled.Ten to 15 pads may be required
side while guiding the posterior blade of the clamp through the to control the hemorrhage from an extensive right lobar injury.
foramen of Winslow with the aid of the left index finger. The Packing is not as effective for injuries to the left hemiliver, because
advantages of this approach are the avoidance of injury to the with the abdomen open, there is insufficient abdominal and tho-
structures within the hepatic pedicle, the assurance that the clamp racic wall anterior to the left hemiliver to provide adequate com-
will be properly placed the first time, and the inclusion of a replac- pression. Fortunately, hemorrhage from the left hemiliver can be
ing or accessory left hepatic artery between the blades of the controlled by dividing the left triangular and coronary ligaments
clamp. and compressing the hemiliver between the hands. Two compli-
cations may be encountered with the packing of hepatic injuries.
MANAGEMENT OF INJURIES
First, tight packing compresses the inferior vena cava, decreases
venous return, and reduces left ventricular filling; hypovolemic
Techniques for Temporary Control of Hemorrhage patients may not tolerate the resultant decrease in cardiac output.
Temporary control of hemorrhage is essential for two reasons. Second, perihepatic packing forces the right diaphragm superior-
First, during treatment of a major hepatic injury, ongoing hemor- ly and impairs its motion; this may lead to increased airway pres-
rhage may pose an immediate threat to the patient’s life, and tem- sures and decreased tidal volume. Careful consideration of the
porary control gives the anesthesiologist time to restore the circu- patient’s condition is necessary to determine whether the risk of
lating volume before further blood loss occurs. Second, multiple these complications outweighs the risk of additional blood loss.
bleeding sites are common with both blunt and penetrating trau- The Pringle maneuver is often used as an adjunct to packing
Table 1 AAST Organ Injury Scales for Liver, Biliary Tract, Diaphragm, and Spleen
Injured Structure AAST Grade Characteristics of Injury AIS-90 Score
Hematoma: subcapsular, nonexpanding, < 10% surface area 2

I
Laceration: capsular tear, nonbleeding, < 1 cm parenchymal depth 2
Hematoma: subcapsular, nonexpanding, 10%–50% surface area; intraparenchymal, 2

II nonexpanding, < 10 cm in diameter
Laceration: capsular tear, active bleeding, 1–3 cm parenchymal depth, < 10 cm in length 2
Hematoma: subcapsular, > 50% surface area, expanding; ruptured subcapsular hematoma with 3
III active bleeding; intraparenchymal, > 10 cm or expanding
Laceration: > 3 cm parenchymal depth 3
Liver*
Hematoma: ruptured intraparenchymal hematoma with active bleeding 4
IV
Laceration: parenchymal disruption involving 25%–75% of hepatic lobe or 1–3 Couinaud’s 4
segments within a single lobe
Laceration: parenchymal disruption involving > 75% of hepatic lobe or > 3 Couinaud’s segments 5
within a single lobe
V
Vascular: juxtahepatic venous injuries (i.e., injuries to retrohepatic vena cava or central major 5
hepatic veins)
VI Vascular: hepatic avulsion 5
Gallbladder contusion/hematoma 2
I
Portal triad contusion 2
Partial gallbladder avulsion from liver bed; cystic duct intact 2

II
Laceration or perforation of gallbladder 2
Complete gallbladder avulsion from liver bed 3

III
Extrahepatic biliary tree* Cystic duct laceration 3
Partial or complete right or left hepatic duct laceration 3

IV
Partial common hepatic duct or common bile duct laceration (< 50%) 3
> 50% transection of common hepatic duct or common bile duct 3–4
V Combined right and left hepatic duct injuries 3–4
Intraduodenal or intrapancreatic bile duct injuries 3–4
I Contusion 2
II Laceration < 2 cm 3
Diaphragm† III Laceration 2–10 cm 3
IV Laceration > 10 cm, with tissue loss < 25 cm2 3
V Laceration with tissue loss > 25 cm2 3
Hematoma: subcapsular, nonexpanding, < 10% surface area 2

I
Laceration: capsular tear, nonbleeding, < 1 cm parenchymal depth 2
Hematoma: subcapsular, nonexpanding, 10%–50% surface area; intraparenchymal, 2

nonexpanding, < 5 cm in diameter
II
Laceration: capsular tear, active bleeding, 1–3 cm parenchymal depth, not involving a trabecular 2
vessel
Hematoma: subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with 3
Spleen* active bleeding; intraparenchymal, > 5 cm or expanding
III
Laceration: > 3 cm parenchymal depth or involving trabecular vessels 3
Hematoma: ruptured intraparenchymal hematoma with active bleeding 4

IV Laceration: laceration involving segmental or hilar vessels producing major devascularization 4
(> 25% of spleen)
Laceration: completely shattered spleen 5

V
Vascular: hilar vascular injury that devascularizes spleen 5
*Advance one grade for multiple injuries, up to grade III.

†Advance one grade for bilateral injuries, up to grade III.
AAST—American Association for the Surgery of Trauma
Bleeding is coming from right upper quadrant
Take down falciform ligament.

Inspect and palpate liver.
Temporarily control bleeding with packing or Pringle
maneuver, as needed.
Make initial assessment of grade of liver injury.
Minor injury (grade I or II) Moderate to severe injury (grade III, IV, or V); Moderate to severe injury (grade III, IV, or V);
bleeding is controlled with Pringle maneuver bleeding is not controlled with Pringle maneuver
Apply topical agents.
Do not drain. Divide coronary and triangular ligaments and Divide coronary and triangular ligaments as needed to
open liver parenchyma as needed to expose injuries. gain exposure.
Close abdomen.
Apply topical agents to areas with minimal injury. Use topical agents and buttressed sutures as indicated.
For superficial injuries, ligate individual bleeding If bleeding persists, use packs, potentially as definitive
vessels or close parenchyma with sutures. treatment.
Bleeding is Bleeding continues Bleeding continues (mostly Bleeding is Bleeding continues

controlled (mostly low pressure high pressure before Pringle controlled
before Pringle maneuver) maneuver) Gain exposure as needed with
Close abdomen Close abdomen extension of midline celiotomy into
without drains. Suture bleeding vessels, Suture bleeding vessels, even without drains. median sternotomy.
even those deep in the those deep in the parenchyma. Remove packs in Control bleeding with intrahepatic
parenchyma. If necessary, ligate right 1 or 2 days. balloon tamponade, atriocaval
Pack abdomen if necessary. or left hepatic artery. shunt, or vascular isolation, as
Drain as indicated; close Drain as indicated; close necessary.
abdomen. abdomen. Repair injury to hepatic vein or
vena cava.
Drain as indicated; close abdomen.
Abdomen is not packed Abdomen is packed
Remove packs in 1 or 2 days.
Follow for postinjury complications (bleeding, abscess, hemobilia, etc.).

Evaluate and treat with arteriography, embolization, imaging, and drainage, as indicated.
Figure 3 Shown is an algorithm for the treatment of hepatic injuries.
for the temporary control of hemorrhage.3 Over the years, the or tear through the parenchyma if placed over an injured area. An
length of time for which surgeons believe a Pringle maneuver can alternative is the use of a liver clamp; however, the application of
be maintained without causing irreversible ischemic damage to such devices is hindered by the variability in the size and shape of
the liver has increased. Several authors have documented the the liver. We have not had consistent success with either of these
maintenance of a Pringle maneuver for longer than 1 hour in methods.
patients with complex injuries, without appreciable hepatic dam- Juxtahepatic venous injuries are technically challenging, diffi-
age.4,10 When a life-threatening hepatic injury is encountered on cult to control with packing, and often lethal. Complex procedures
entry into the abdomen, the Pringle maneuver should be per- may be required for temporary control of these large veins. Of
formed immediately and perihepatic packs placed. Persistent these procedures, the most important are hepatic vascular isola-
bleeding in the face of effective inflow occlusion implies that either tion with clamps, placement of the atriocaval shunt, and use of the
the retrohepatic vena cava or hepatic vein has been injured. Moore-Pilcher balloon.
Perihepatic packing is more likely to control bleeding from the Hepatic vascular isolation is accomplished by executing a
retrohepatic vena cava. Pringle maneuver, clamping the aorta at the diaphragm, and
Another technique for temporary control of hepatic hemor- clamping the suprarenal and suprahepatic vena cava.12 In patients
rhage is the application of a tourniquet or a liver clamp.11 Once the scheduled for elective procedures, this technique has enjoyed near-
bleeding hemiliver is mobilized, a 2.5 cm Penrose drain is wrapped ly uniform success, but in trauma patients, the results have been
around the liver near the anatomic division between the left disappointing. The relative ineffectiveness of hepatic vascular iso-
hemiliver and the right. The drain is stretched until hemorrhage lation with clamps in this setting is presumably due to the inabili-
ceases, and tension is maintained by clamping the drain. ty of a patient in shock to tolerate an acute reduction in left ven-
Unfortunately, tourniquets are difficult to use: they tend to slip off tricular filling pressure; on occasion, sudden death has occurred
rotated anteriorly to provide direct access to the posterior aspect

of the retrohepatic vena cava. Anterior injuries of the large veins
are repaired through an incision in the posterior aspect of the
retrohepatic vena cava.
The atriocaval shunt was designed to achieve hepatic vascular
isolation while still permitting some venous blood from below the
diaphragm to flow through the shunt into the right atrium.4 After
a few early successes, the initial enthusiasm for the atriocaval shunt
declined as high mortalities associated with its use began to be
reported.15-20 Surgeons’ lack of familiarity with the technique; the
manipulation of a cold, acidotic heart; and poor patient selection
have all contributed to the poor overall results.13 A variation on the
original atriocaval shunt has been described in which a 9 mm
endotracheal tube is substituted for the usual large chest tube [see
Figure 8].21 The balloon of the endotracheal tube makes it unnec-
essary to surround the suprarenal vena cava with an umbilical
tape. This minor change eliminates one of the most difficult
maneuvers required for the original shunt procedure: because
hemorrhage must be controlled by posterior pressure on the liver
during the insertion of the shunt, access to the suprarenal vena
cava is severely restricted, and thus, surrounding this vessel with
an umbilical tape is almost impossible. A side hole must be cut in
Figure 4 The Pringle maneuver controls arterial and portal vein the tube to allow blood to enter the right atrium. Care must be
hemorrhage from the liver. Any hemorrhage that continues must taken to avoid damage to the integral inflation channel for the
come from the hepatic veins. balloon.
An alternative to the atriocaval shunt is the Moore-Pilcher bal-
loon.21 This device is inserted through the femoral vein and
on placement of the venous clamps.13 If, however, a trauma advanced into the retrohepatic vena cava. When the balloon is
patient requiring hepatic vascular isolation has been maintained in properly positioned and inflated, it occludes the hepatic veins and
a relatively normal physiologic condition, it is reasonable to con- the vena cava, thus achieving vascular isolation.The catheter itself
sider this method. is hollow, and appropriately placed holes below the balloon permit
An alternative approach to exposure of the retrohepatic vena
cava and the hepatic veins has been developed in which vascular
isolation of the liver is achieved by means of clamping and the
suprahepatic vena cava is divided between vascular clamps [see
Figure 7].14 The liver and the suprahepatic vena cava are then
Figure 5 Manual compression of large hepatic injuries tem- Figure 6 Perihepatic packing is often effective in managing
porarily controls blood loss in hypovolemic patients until the cir- extensive parenchymal injuries. It has also been successfully
culating blood volume can be restored. employed for grade V juxtahepatic venous injuries.
Techniques for Definitive Management of Injuries

Techniques available for the definitive management of hepatic
Azygos Vein injuries range from manual compression to hepatic transplanta-
tion. Grade I or II lacerations of the hepatic parenchyma can gen-
erally be controlled with manual compression. If these injuries do
not respond to manual compression, they can often be controlled
with topical hemostatic measures.
The simplest of these measures is electrocauterization, which
can often control small bleeding vessels near the surface of the
liver (though the machine’s power output may have to be
increased). Bleeding from raw surfaces of the liver that does not
respond to the electrocautery may respond to the argon beam
coagulator. This device imparts less heat to the surrounding
hepatic tissue and creates a more consistent eschar, which
enhances hemostasis. Also useful in similar situations is micro-
crystalline collagen in the powdered form. The powder is placed
Inferior on a clean 10 × 10 cm sponge and applied directly to the oozing
Vena Cava surface, with pressure maintained on the sponge for 5 to 10 min-
utes. Thrombin can also be applied topically to minor bleeding
injuries by saturating either a gelatin foam sponge or a microcrys-
talline collagen pad and pressing it to the bleeding site.
In previous years, there was interest in the use of “bathtub” fi-
Adrenal Vein
Renal Vein
Figure 7 With hepatic vascular isolation accomplished, the
suprahepatic vena cava is divided between clamps, and the liver
and the suprahepatic vena cava are rotated anteriorly to afford
access to the posterior aspect of the retrohepatic vena cava.
blood to flow into the right atrium, in much the same way as the
atriocaval shunt. At present, the survival rate for patients with jux-
tahepatic venous injuries who are treated with this device is simi-
lar to that for patients treated with the atriocaval shunt.18
Surgeons who attempt hepatic vascular isolation should be
aware that none of these techniques provide complete hemostasis.
Drainage from the right adrenal vein and the inferior phrenic
veins and persistent hepatopetal flow resulting from unrecognized
replacing or accessory left hepatic arteries contribute to this prob-
lem. The relatively small volume of blood that continues to flow
after vascular isolation is readily removed by means of suction.
An adjunct to vascular isolation with clamps is venovenous
bypass. This technique provides vascular decompression for the
small bowel and maintains high cardiac filling pressures, which are
often necessary. Venovenous bypass is accomplished by placing a
catheter in the inferior vena cava via the femoral vein and a sec-
ond catheter in the superior mesenteric vein [see Figure 9].22 A
centrifugal pump withdraws blood from these veins and pumps it
into the superior vena cava through a third catheter placed in the Figure 8 Shown is a method of achieving hepatic vascular isola-
internal jugular vein. tion with a 9 mm endotracheal tube.
To Internal Jugular Vein
Suprahepatic
IVC Clamp
Pump
Figure 9 Shown is venove- Pringle
nous bypass. Catheters are Maneuver
placed into the inferior vena
cava (IVC) and the superior
mesenteric vein (SMV), and a
Suprarenal
centrifugal pump withdraws
IVC Clamp
blood from these veins and
pumps it into the superior
vena cava via a third catheter
placed into the internal jugu- To SMV via IMV
lar vein.
To IVC via Femoral Vein or

Greater Saphenous Vein
brin glue (made by mixing concentrated human fibrinogen with a Although some grade III and IV lacerations respond to topical
solution containing bovine thrombin and calcium) to treat hepat- measures, many do not. In these instances, one option is to suture
ic lacerations.23,24 This substance has now been rendered obsolete the hepatic parenchyma. Although this hemostatic technique has
by the commercial availability of numerous glues and sealants [see been maligned as a cause of hepatic necrosis, it still is frequently
Table 2]. used.3,4,10,17,26,27 Suturing of the hepatic parenchyma is often
Another relatively new hemostatic adjunct that can be highly employed to control persistently bleeding lacerations less than 3
useful in the setting of hepatic injury is recombinant activated fac- cm in depth; it is also an appropriate alternative for deeper lacer-
tor VII (NovoSeven; Novo Nordisk, Copenhagen), which works by ations if the patient cannot tolerate the further hemorrhage asso-
promoting coagulation at the lacerated edges of blood vessels. ciated with hepatotomy and selective ligation. If, however, the cap-
Many trauma surgeons have personally witnessed the abrupt ces- sule of the liver has been stripped away by the injury, this tech-
sation of hemorrhage when factor VII has been administered after nique is far less effective.
other materials have failed. Although this agent seems at times to The preferred suture material is 0 or 2-0 chromic catgut
have an almost magical effect, it does not always work, and it is attached to a large, blunt-tipped, curved needle; the large diame-
extremely expensive; furthermore, the only prospective study to ter prevents the suture from pulling through Glisson’s capsule. For
date that addressed the use of factor VII in trauma patients report- shallow lacerations, a simple continuous suture may be used to
ed only a modest decrease in total blood use and failed to demon- approximate the edges of the laceration. For deeper lacerations,
strate a survival advantage.25 For these reasons, many institutions, interrupted horizontal mattress sutures may be placed parallel to
including ours (University of Colorado Health Sciences Center), the edges.When tying sutures, one may be sure that adequate ten-
have created protocols for the use of factor VII. At our institution, sion has been achieved when hemorrhage ceases or the liver
for factor VII to be used, (1) the patient must be salvageable; (2) the blanches around the suture.
patient must have received at least 10 units of packed red blood Most sources of venous hemorrhage can be managed with
cells (PRBCs) plus clotting factors; (3) surgical control of hemor- parenchymal sutures. Even injuries to the retrohepatic vena cava
rhage must be achieved; and (4) the patient must still be experi- and the hepatic veins have been successfully tamponaded by clos-
encing diffuse hemorrhage.The usual dose is 60 to 90 µg/kg, which ing the hepatic parenchyma over the bleeding vessels.13,28 Venous
may be repeated once. It should be kept in mind that factor VII is hemorrhage caused by penetrating wounds traversing the central
not a substitute for fresh frozen plasma and platelets and that ade- portion of the liver may be managed by closing the entrance and
quate amounts of fibrin and platelets must be present for it to work. exit wounds with interrupted horizontal mattress sutures.
Table 2 Characteristics of Selected Commercially Available Tissue Glues and Sealants

Tisseel VH* FloSeal* CoSeal* BioGlue†
Human fibrinogen and throm-

Contents bin; calcium chloride; Bovine gelatin and thrombin Polyethylene glycol Glutaraldehyde; bovine
bovine aprotinin albumin
Method of
Cell-mediated inflammation
absorption Fibrinolysis (10–14 days) Hydrolysis (30 days) Not absorbed
(6 wk)
(time)
Physical Granular; conforms to irregular

properties Flexible and elastic surfaces Clear hydrogel; flexible and elastic Ridged and inelastic
Preparation
time 7–15 min 1–2 min 1–2 min 1–2 min
Tissue sealing and adher-

General ence; hemostasis in venous Hemostasis in wet fields up to ar- Tissue sealing in dry fields Tissue sealing in dry fields
applications oozing terial pressure
Sealing of small vessels and synthetic

Venous oozing; sealing of
Specific grafts; prevention of adhesion in pedi-
staple lines; decortication; Active bleeding Sealing of large vessels
applications atric cardiac surgical patients; sealing
pleurodesis
of large vessels
Means of Cannula; spray; minimally in- Cannula; minimally invasive Flexible cannula; spray; minimally inva-
Cannula
application vasive surgery surgery; 8 cm or 10 cm bulb tip sive surgery
Limiting factors Arterial pressure Does not seal Wet field Wet field, nerves
Set times 3 min 2 min 1 min 30 sec
Stability 4 hr 2 hr 2 hr —
*Baxter International, Deerfield, Illinois.
†CryoLife, Inc., Kennesaw, Georgia.
Although this measure may lead to the formation of intrahepatic because it does not stop hemorrhage from the portal and hepatic
hematomas that may then become infected, the risk is reasonable venous systems.33 Its primary role is in the management of deep
compared with the risks posed by an intracaval shunt or a deep injuries when application of the Pringle maneuver results in the ces-
hepatotomy. Still, suturing of the hepatic parenchyma is not always sation of arterial hemorrhage. If the bleeding from the wound stops
successful in controlling hemorrhage, particularly hemorrhage once the left or right hepatic artery is isolated and clamped, hepat-
from the larger branches of the hepatic artery. If it fails, one must ic arterial ligation is a reasonable alternative to deep hepa-
acknowledge the failure promptly and remove the sutures so that totomy. Generally, ligation of the right or left hepatic artery is well
the wound can be explored. tolerated; however, ligation of the proper hepatic artery (distal to the
Hepatotomy with selective ligation of bleeding vessels is an origin of the gastroduodenal artery) may produce hepatic necrosis.
important technique that is usually reserved for deep or transhe- An alternative to suturing the entrance and exit wounds of a
patic penetrating wounds. Most authorities prefer it to parenchy- transhepatic penetrating injury or to performing an extensive hepa-
mal suturing3,4,10,29,30; some even favor it over placement of an atri- totomy is the use of an intrahepatic balloon.34 These devices are
ocaval shunt for exposure and repair of juxtahepatic venous hand-crafted by the surgeon in the operating room. One method
injuries.20 The finger-fracture technique is used to extend the of fashioning such a device is to tie a 2.5 cm Penrose drain to a hol-
length and depth of a laceration or a missile tract until the bleed- low catheter [see Figure 11]. The balloon is then inserted into the
ing vessels can be identified and controlled [see Figure 10]. It bleeding wound and inflated with a soluble contrast agent. If the
should be remembered that considerable blood loss may be hemorrhage is controlled, a stopcock or clamp is used to occlude
incurred with the division of viable hepatic tissue in the pursuit of the catheter and maintain the inflation. (It should be noted that the
bleeding from deep penetrating wounds. As an alternative to finger balloon catheter may not be able to generate sufficient intra-
fracture, we have begun to use the LigaSure vessel sealing system parenchymal pressure to tamponade major arterial hemorrhage.)
(Valleylab, Boulder, Colorado) and have observed significant The balloon is left in the abdomen and removed at a subsequent
decreases in blood loss with this device. operation after 24 to 48 hours. The hemorrhage may recur when
An adjunct to parenchymal suturing or hepatotomy is the use of the balloon is deflated.
the omentum to fill large defects in the liver and to buttress hepat- Resectional debridement is indicated for peripheral portions of
ic sutures.The rationale for this use of the omentum is that it pro- nonviable hepatic parenchyma. Except in rare circumstances, the
vides an excellent source for macrophages and fills a potential dead amount of tissue removed should not exceed 25% of the liver.
space with viable tissue.31 In addition, the omentum can provide a Resectional debridement is performed by means of the finger-frac-
little extra support for parenchymal sutures, often enough to pre- ture technique and is appropriate for selected patients with grade
vent them from cutting through Glisson’s capsule. III to grade V lacerations. Because additional blood loss occurs
Hepatic arterial ligation may be appropriate for patients with during removal of nonviable tissue, this procedure should be
arterial hemorrhage from deep within the liver32; however, it plays reserved for patients who are in sound physiologic condition and
only a limited role in the overall treatment of hepatic injuries, can tolerate additional blood loss.
results; however, in the setting of trauma, the mortality associated

with this procedure exceeds 50% in most series.26,27,29,38-40
Consequently, hepatic resection is rarely performed in trauma
patients, having been largely replaced by perihepatic packing,
resectional debridement, and hepatotomy with selective ligation.
Nonetheless, there are two circumstances in which anatomic resec-
tion may still be a reasonable choice. The first is prompt resection
in patients with extensive injuries of the left lateral section of the
liver; because hemorrhage from the left hemiliver is easily con-
trolled with bimanual compression, the risk of uncontrolled blood
loss is not as high as it is with left or right anatomic hemihepatec-
tomies. The second is delayed anatomic hemihepatectomy in
patients whose hemorrhage has been controlled but whose left or
right hemiliver is nonviable as a result of ligation or thrombosis of
essential blood vessels. Because of the large mass of necrotic liver
tissue, there is a high risk of subsequent infection or persistent
hyperinflammation, setting the stage for the multiple organ dys-
function syndrome (MODS). The necrotic hemiliver should be
removed as soon as the patient’s condition permits.
Hepatic transplantation has been successful in several trauma
patients with devastating hepatic injuries who required total hepa-
tectomy.41-44 In each of these five patients, the mean anhepatic
period was approximately 24 hours. All five survived the trans-
plantation, though two died of disseminated viral infections within
2 months of the procedure.Two others were alive and well 16 and
17 months after the procedure; no follow-up was reported for the
Figure 10 Hepatotomy with selective ligation is an important
fifth patient. Hepatic transplantation represents the ultimate
technique for controlling hemorrhage from deep (usually pene-
trating) lacerations. This technique includes finger fracture to
expression of aggressive trauma care. All other injuries must be
extend the length and depth of the wound until vessels or ducts are well delineated (particularly injuries to the CNS), and the patient
encountered and controlled. must have an excellent chance of survival aside from the hepatic
injury. High cost and limited availability of donors restrict the per-
formance of hepatic transplantation for trauma, but it seems prob-
Perihepatic packing is the most significant advance in the treatable that this procedure will continue to be performed in extraor-
ment of hepatic injuries to occur in the past 25 years.The practice dinary circumstances.
of packing hepatic injuries is not a new one, but the concepts and
techniques associated with it have changed. In the past, liver lacer-
ations were packed with yards of gauze, and one end of the gauze
strip was brought out of the abdomen through a separate stab
wound35; the remainder of the gauze was then teased out of the
wound over a period of days. Unfortunately, this approach often
led to abdominal infection and failed to control the hemorrhage,
and as a result, it eventually fell from favor. The current approach
is not to place packing material in the laceration itself but rather to
place it over and around the injury to compress the wound by
compressing the liver between the anterior chest wall, the
diaphragm, and the retroperitoneum.5-9 The abdomen is closed,
and the patient is taken to the surgical intensive care unit for resus-
citation and correction of metabolic derangements. Within 24
hours, the patient is returned to the OR for removal of the packs.
Perihepatic packing is indicated for grade IV and V lacerations and
for less severe injuries in patients who have a coagulopathy caused
by associated injuries.
A technique that may be attempted if packing fails is to wrap the
injured portion of the liver with a fine porous material (e.g., poly-
glycolic acid mesh) after the injured hemiliver has been mobi-
lized.36,37 Using a continuous suture or a linear stapler, the surgeon
constructs a tight-fitting stocking that encloses the injured hemiliv-
er. Blood clots beneath the mesh, which results in tamponade of
the hepatic injury. Although this technique is intuitively attractive,
to date it has achieved only limited success.
The final alternative for patients with extensive injuries to one Figure 11 A handmade balloon from a Robinson catheter and a
hemiliver is anatomic hepatic resection. In elective circumstances, Penrose drain may effectively control hemorrhage from a trans-
anatomic hemihepatectomies can be performed with excellent hepatic penetrating wound.
Figure 12 (a) The first step in mobilizing the

spleen is to make an incision in the peritoneum
and the endoabdominal fascia, beginning at the
inferior pole and continuing posteriorly and
superiorly. (b) The correct plane of dissection is
between the pancreas and Gerota’s fascia.
Subcapsular Hematoma
recently, the use of large sump drains and closed suction drains
An uncommon but troublesome hepatic injury is subcapsular has become increasingly popular. Several prospective and retro-
hematoma, which arises when the parenchyma of the liver is dis- spective studies have demonstrated that the use of either Penrose
rupted by blunt trauma but Glisson’s capsule remains intact. or sump drains carries a higher risk of intra-abdominal infection
Subcapsular hematomas range in severity from minor blisters on than the use of either closed suction drains or no drains at all.45-47
the surface of the liver to ruptured central hematomas accompa- It is clear that if drains are to be used, closed suction devices are
nied by severe hemorrhage [see Table 1]. They may be recognized preferred. What remains unclear, however, is whether closed suc-
either at the time of the operation or in the course of CT scanning. tion drains are better or worse than no drains, particularly in view
Regardless of how the lesion is diagnosed, subsequent decision of the advent of percutaneous catheter drainage. Patients who are
making is often difficult. If a grade I or II subcapsular initially treated with perihepatic packing may also require
hematoma—that is, a hematoma involving less than 50% of the drainage; however, drainage is not indicated at the initial proce-
surface of the liver that is not expanding and is not ruptured—is dure, given that the patient will be returned to the OR within the
discovered during an exploratory laparotomy, it should be left next 48 hours.
alone. If the hematoma is explored, hepatotomy with selective li-
MORTALITY AND COMPLICATIONS
gation may be required to control bleeding vessels. Even if hepa-
totomy with ligation is effective, one must still contend with dif- Overall mortality for patients with hepatic injuries is approxi-
fuse hemorrhage from the large denuded surface, and packing mately 10%.The most common cause of death is exsanguination,
may also be required. A hematoma that is expanding during oper- followed by MODS and intracranial injury. Three generalizations
ation (grade III) may have to be explored. Such lesions are often may be made regarding the risk of death and complications: (1)
the result of uncontrolled arterial hemorrhage, and packing alone both increase in proportion to the injury grade and to the com-
may not be successful. An alternative strategy is to pack the liver plexity of repair; (2) hepatic injuries caused by blunt trauma carry
to control venous hemorrhage, close the abdomen, and transport a higher mortality than those caused by penetrating trauma; and
the patient to the interventional radiology suite for hepatic arteri- (3) infectious complications occur more often with penetrating
ography and embolization of the bleeding vessels. Ruptured trauma.48
grades III and IV hematomas are treated with exploration and Postoperative hemorrhage occurs in a small percentage of
selective ligation, with or without packing. patients with hepatic injuries. The source may be either a coagu-
lopathy or a missed vascular injury (usually to an artery). In most
Perihepatic Drainage instances of persistent postoperative hemorrhage, the patient is
For years, all hepatic injuries were drained via Penrose drains best served by being returned to the OR. Arteriography with
brought out laterally or through the bed of the resected 12th rib; embolization may be considered in selected patients. If coagula-
tion studies indicate that a coagulopathy is the likely cause of post- and Malignant Biliary Tract Disease].54-57 Treatment of injuries to
operative hemorrhage, there is little to be gained by reoperation the left or right hepatic duct is even more difficult—so much so
until the coagulopathy is corrected. that we question whether repair should even be attempted under
Perihepatic infections occur in fewer than 5% of patients with emergency conditions. If only one hepatic duct is injured, a rea-
significant hepatic injuries. They develop more often in patients sonable approach is to ligate it and deal with any infections or atro-
with penetrating injuries than in patients with blunt injuries, pre- phy of the hemiliver rather than to attempt repair.58 If both ducts
sumably because of the greater frequency of enteric contamina- are injured, each should be intubated with a small catheter brought
tion. An elevated temperature and a higher than normal white through the abdominal wall. Once the patient has recovered suffi-
blood cell count after postoperative day 3 or 4 should prompt a ciently, delayed repair is performed under elective conditions.
search for intra-abdominal infection. In the absence of pneumonia, Injuries to the intrapancreatic portion of the CBD are treated by
an infected line, or urinary tract infection, an abdominal CT scan dividing the duct at the superior border of the pancreas, ligating
with intravenous and upper gastrointestinal contrast should be the distal portion, and performing a Roux-en-Y choledochoje-
obtained. Many perihepatic infections can be treated with CT- junostomy.
guided drainage; however, infected hematomas and infected The Roux-en-Y choledochojejunostomy is done in a single layer
necrotic liver tissue cannot be expected to respond to percuta- with interrupted 5-0 absorbable monofilament sutures.To prevent
neous drainage. Right 12th rib resection remains an excellent ischemia and possible stricture, no circumferential dissection of the
approach for posterior infections and provides superior drainage in duct is performed. A round patch of approximately the same diam-
refractory cases. eter as the CBD is removed from the seromuscular layer of the
Bilomas are loculated collections of bile that may or may not be small bowel, but the mucosa and submucosa are only perforated,
infected. If a biloma is infected, it is essentially an abscess and not resected. The posterior row of sutures is placed first, with full-
should be treated as such; if it is sterile, it will eventually be thickness bites taken through both the duct and the small bowel.
resorbed. Biliary ascites is caused by disruption of a major bile The anterior row is then completed. Finally, three or four 3-0
duct. Reoperation after the establishment of appropriate drainage polypropylene sutures are placed to secure the small bowel around
is the prudent course. Even if the source of the leaking bile can be the anastomosis to the connective tissue of the porta hepatis. The
identified, primary repair of the injured duct is unlikely to be suc- only purpose for these sutures is to spare the fragile anastomosis
cessful. It is best to wait until a firm fistulous communication is any potential tension. No T tubes or stents are employed. Closed
established with adequate drainage. suction drainage is added in the case of injuries to the intrapancre-
Biliary fistulas occur in approximately 3% of patients with major atic portion of the duct or at the surgeon’s discretion.
hepatic injuries.40 They are usually of little consequence and gen- Injuries to the gallbladder [see Table 1] are treated by means of
erally close without specific treatment. In rare instances, a fistulous either lateral repair with absorbable sutures or cholecystectomy [see
communication with intrathoracic structures forms in patients 5:21 Cholecystectomy and Common Bile Duct Exploration]; the deci-
with associated diaphragmatic injuries, resulting in a bronchobil- sion between the two approaches depends on which is easier in a
iary or pleurobiliary fistula. Because of the pressure differential given situation. Cholecystostomy is rarely, if ever, indicated.
between the biliary tract and the thoracic cavity, most of these fis-
tulas must be closed operatively; however, we know of one pleuro-
biliary fistula that closed spontaneously after endoscopic sphinc- Injuries to the Spleen
terotomy and stent placement. Splenic injuries [see Table 1] are treated operatively by means of
Hemorrhage from hepatic injuries is often treated without iden- splenic repair (splenorrhaphy), partial splenectomy, or resection,
tifying and controlling each bleeding vessel individually, and arter- depending on the extent of the injury and the condition of the
ial pseudoaneurysms may develop as a consequence. As the patient.57,58 The continued enthusiasm for nonoperative manage-
pseudoaneurysm enlarges, it may rupture into the parenchyma of ment of splenic injuries is driven, in part, by concern about the rare
the liver, into a bile duct, or into an adjacent branch of the portal but often fatal complication known as overwhelming postsplenec-
vein. Rupture into a bile duct results in hemobilia, which is char- tomy infection (OPSI). OPSI is caused by encapsulated bacteria
acterized by intermittent episodes of right upper quadrant pain, (e.g., Streptococcus pneumoniae, Haemophilus influenzae, and
upper GI hemorrhage, and jaundice; rupture into a portal vein Neisseria meningitidis) and is very resistant to treatment: mortality
may result in portal vein hypertension with bleeding varices. Both may exceed 50%. OPSI occurs most often in young children and
of these complications are exceedingly rare and are best managed immunocompromised adults and is uncommon in otherwise
with hepatic arteriography and embolization. healthy adults. For this reason, splenic salvage is attempted more
vigorously in pediatric patients than in adult ones [see Discussion,
Nonoperative Management of Blunt Hepatic and Splenic Injuries,
Injuries to the Bile Ducts and Gallbladder below].
Injuries to the extrahepatic bile ducts [see Table 1] can be caused To ensure safe removal or repair, the spleen should be mobilized
by either penetrating or blunt trauma; however, they are rare in to the point where it can be brought to the surface of the abdom-
either case.49-53 inal wall without tension. To this end, the soft tissue attachments
The diagnosis is usually made by noting the accumulation of between the spleen and the splenic flexure of the colon must be
bile in the upper quadrant during laparotomy for treatment of divided. Next, an incision is made in the peritoneum and the
associated injuries.Treatment of common bile duct (CBD) injuries endoabdominal fascia, beginning at the inferior pole, 1 to 2 cm lat-
after external trauma is complicated by the small size and thin wall eral to the posterior peritoneal reflection of the spleen, and con-
of the normal duct, which render primary repair almost impossi- tinuing posteriorly and superiorly until the esophagus is encoun-
ble except when the laceration is small and there is no tissue loss. tered [see Figure 12a]. Care must be taken not to pull on the spleen,
When there is tissue loss or the laceration is larger than 25% to so that it will not tear at the posterior peritoneal reflection, causing
50% of the diameter of the duct, the best treatment option is a significant hemorrhage. Instead, the spleen should be rotated
Roux-en-Y choledochojejunostomy [see 5:22 Procedures for Benign counterclockwise, with posterior pressure applied to expose the
peritoneal reflection. It is often helpful to rotate the operating table

20° to the patient’s right so that the weight of the abdominal vis-
cera facilitates their retraction. A plane is thus established between
the spleen and pancreas and Gerota’s fascia that can be extended
to the aorta [see Figure 12b]. With this step, mobilization is com-
plete, and the spleen can be repaired or removed without any need
to struggle to achieve adequate exposure.
Splenectomy [see 5:25 Splenectomy] is the usual treatment for
hilar injuries or a pulverized splenic parenchyma. It is also indi-
cated for lesser splenic injuries in patients who have multiple
abdominal injuries and a coagulopathy, and it is frequently neces-
sary in patients in whom splenic salvage attempts have failed.
Partial splenectomy is suitable for patients in whom only a portion
of the spleen (usually the superior or inferior half) has been
destroyed. Once the damaged portion has been removed, the same
methods used to control hemorrhage from hepatic parenchyma
can be used to control hemorrhage from splenic parenchyma [see
Figure 13]. When horizontal mattress sutures are placed across a
raw edge, gentle compression of the parenchyma by an assistant
facilitates hemostasis; when the sutures are tied and compression
Figure 13 Methods for controlling hemorrhage from the splenic
is released, the spleen will expand slightly and tighten the sutures
parenchyma are similar to those for controlling hemorrhage from
further. Drains are never used after completion of the repair or the hepatic parenchyma. Shown are interrupted mattress sutures
resection. across a raw edge of the spleen.
If splenectomy is performed, vaccines effective against the
encapsulated bacteria are administered. The pneumococcal vac-
cine is routinely given, and vaccines effective against H. influenzae through an abdominal incision. Because of the concave shape of
and N. meningitidis should also be given if available. the diaphragm and the overlying anterior ribs, anterior diaphrag-
matic injuries may be difficult to suture. Repair is greatly facilitat-
ed by using a long Allis clamp to grasp part of the injury and evert
Injuries to the Diaphragm the diaphragm. Lacerations are repaired with continuous No. 1
In cases of blunt trauma to the diaphragm, the injury is on the monofilament nonabsorbable sutures. Occasionally, with large
left side 75% of the time, presumably because the liver diffuses avulsions or gunshot wounds accompanied by extensive tissue loss,
some of the energy on the right side. With both blunt and pene- polypropylene mesh is required to bridge the defect.
trating injuries [see Table 1], the diagnosis is suggested by an abnor- The explosive growth of laparoscopic procedures has led to the
mality of the diaphragmatic shadow on chest x-ray. Many of these application of this technology for both diagnostic and therapeutic
abnormalities are subtle, particularly with penetrating injuries, and purposes in trauma patients. In a number of patients with low
further diagnostic evaluation may be warranted.The typical injury anterior thoracic stab wounds who otherwise were not candidates
from blunt trauma is a tear in the central tendon; often, the tear is for a laparotomy, small diaphragmatic lacerations have been iden-
quite large. Regardless of the cause, acute injuries are repaired tified and repaired with laparoscopy and stapling.
Discussion
Nonoperative Treatment of Blunt Hepatic and Splenic
Morrison’s pouch, the left upper quadrant, or the pelvis, which
Injury
suggests a hemoperitoneum.This observation prompts a CT scan
Only a few years ago, blunt and penetrating hepatic and splenic of the abdomen, which establishes the presence or absence of
injuries were managed in a similar fashion on the basis of a posi- injuries to the liver or the spleen and, to some degree, serves as a
tive diagnostic peritoneal lavage or the probability of peritoneal means of grading the severity of organ injury. Patients may be
penetration: a laparotomy was performed, and the injured organs observed either in the SICU or on the ward, depending on the
were identified and treated. Currently, although penetrating apparent severity of the parenchymal injury on the CT scan, the
abdominal injuries are still treated in the same way, nearly all chil- presence and extent of any associated injuries, and the overall
dren and 50% to 80% of adults with blunt hepatic and splenic hemodynamic status.69,70
injuries are treated without laparotomy.59-68 This remarkable The primary requirement for nonoperative therapy is hemody-
change was made possible by the development of the high-speed namic stability.63-72 To confirm stability, frequent assessment of
helical CT scanner, the replacement of diagnostic peritoneal vital signs and monitoring of the hematocrit are necessary.
lavage by ultrasonography, and the growth of interventional Continued hemorrhage occurs in 1% to 4% of patients.65,66,68-73
radiology. Hypotension may develop, usually within the first 24 hours after
The diagnosis of blunt abdominal trauma is suspected on the hepatic injury but sometimes several days later, especially when
basis of the mechanism of injury and the presence of associated splenic injury is present.71,72 It is often an indication that opera-
injuries (e.g., right or left lower rib fractures). Ultrasonographic tive intervention is necessary. A persistently falling hematocrit
examination of the abdomen may reveal a fluid stripe in should be treated with PRBC transfusions. If the hematocrit con-
tinues to fall after two or three units of PRBCs, embolization of missed abdominal injuries, parenchymal infarction, infection, and
the liver in the interventional radiology suite should be consid- bile leakage (a complication associated solely with hepatic
ered.66 Overall, nonoperative treatment obviates laparotomy in injuries).59,62-64 Aseptic infarcts, infected hematomas, and bile col-
more than 95% of cases.59-65 lections are suspected on the basis of a clinical picture suggestive of
Out of concern over the risk of delayed hemorrhage or other infection and confirmed by CT-guided aspiration. Aseptic infarc-
complications, follow-up CT scans have often been recommend- tion usually does not necessitate operative intervention. Fluid col-
ed; unfortunately, there is no consensus as to when or even lections are drained, with the method depending on the viscosity of
whether they should be obtained. Given that patients with grade I the fluid: CT-guided drainage may be effective in treating thin col-
or II hepatic or splenic injuries rarely show progression of the lections, but operative intervention is required for thicker collec-
lesion or other complications on routine follow-up CT scans, it is tions, those with solid components, and those for which percuta-
reasonable to omit such scans if patients’ hematocrits remain sta- neous drainage was attempted without success. Extrahepatic bile
ble and they are otherwise well. Patients with more extensive collections should be treated with percutaneous drainage under
injuries often have a less predictable course, and CT scanning CT guidance. Most biliary fistulas close spontaneously; endoscop-
may be necessary to evaluate possible complications. Routine ic stent placement may hasten closure in recalcitrant cases.74
scanning before discharge, however, is unwarranted. On the other Intrahepatic collections of blood and bile are managed expectant-
hand, patients who participate in vigorous or contact sports ly. Complete absorption of large intrahepatic collections may take
should have CT documentation of virtually complete healing several months. If a collection becomes infected, CT-guided aspi-
before resuming those activities. ration is performed and drainage obtained as described.
A more convenient and less expensive alternative to follow-up Missed enteric and retroperitoneal injuries are another cause of
CT scanning is ultrasonographic monitoring of lesions. failed nonoperative treatment. Such injuries are present in 1%
Ultrasonographic monitoring is particularly useful for following to 4% of patients in whom nonoperative treatment is attempt-
up splenic injuries; however, it may not be useful for following up ed.59,61-64 High-quality images and expert interpretation minimize
hepatic injuries, because the technology currently available is inca- the number of missed injuries on CT scans but cannot eliminate
pable of reliably imaging the entire liver. them entirely. Therefore, patients must be watched carefully for
Other complications of nonoperative therapy for blunt hepatic the development of peritoneal irritation and other signs of intra-
and splenic injuries occur in 2% to 5% of patients; these include abdominal pathology.
References
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Predicting hepatic-related morbidity associated 63. Pachter HL, Hofstetter ST: The current status of
Acknowledgments
with nonoperative management of complex nonoperative management of adult blunt hepatic
blunt hepatic injuries: a multicenter trial. Arch injuries. Am J Surg 169:442, 1995 Figure 1 Tom Moore.
Surg (in press) 64. Croce MA, Fabian TC, Menke PG, et al: Figures 2, 7, and 9 Thom Graves.
49. Jurkovich GJ, Hoyt DB, Moore FA, et al: Portal Nonoperative management of blunt hepatic trau- Figure 3 Marcia Kammerer.
triad injuries: a multi-institutional study. J ma is the treatment of choice for hemodynami- Figures 4 through 6, 8, and 10 through 13 Susan
Trauma 39:426, 1995. cally stable patients. Ann Surg 221:744, 1995 Brust, C.M.I.
50. Noyes LD, Doyle DJ, McSwain NE: Septic com- 65. Boone DC, Federle M, Billiar TR, et al: Table 2 Information provided by Baxter International,
plications associated with the use of peritoneal Evolution of management of major hepatic trau- Deerfield, Illinois.
7 TRAUMA AND THERMAL INJURY 7 INJURIES TO THE STOMACH, SMALL BOWEL, COLON, AND RECTUM — 1
7 INJURIES TO THE STOMACH, SMALL

BOWEL, COLON, AND RECTUM
Jordan A.Weinberg, M.D., F.R.C.S.C., and Timothy C. Fabian, M.D., F.A.C.S
Hollow viscus injury is most commonly the result of penetrating Helical (spiral) computed tomography is currently the imaging
abdominal trauma. It is relatively infrequent in the setting of blunt modality of choice in stable patients who have undergone blunt
trauma: in one multi-institutional analysis, only 1.2% of blunt abdominal trauma. Our experience indicates that it is useful for
trauma admissions were associated with a hollow viscus injury.1 identifying blunt hollow viscus injury. In a review of over 8,000
Initial resuscitation of the patient with abdominal trauma is CT scans performed to evaluate cases of blunt abdominal trauma,
described in detail elsewhere [see 7:1 Initial Management of Life- we found that the number of abnormal radiologic findings sug-
Threatening Trauma].The diagnosis of hollow viscus injury remains gesting blunt injury to the bowel, the mesentery, or both [see Table
a challenge in abdominal trauma patients, and subsequent evalu- 1] was correlated with the true presence of injury.5 A CT scan
ation is determined by the mechanism of injury. Regardless of the demonstrating a solitary abnormality was associated with a true
specific injury mechanism, however, the principles of operative positive rate of 36%, whereas a scan demonstrating more than one
management are the same. abnormality was associated with a true positive rate of 83%.
Unexplained intraperitoneal fluid (i.e., fluid appearing in the
absence of solid-organ injury) was the most common radiograph-
Determination of Need for Operation ic finding associated with blunt bowel or mesenteric injury, but it
often proved to be a false positive finding [see Table 1].
BLUNT TRAUMA
On the basis of this experience, we developed an algorithm for
Hollow viscus injury after blunt trauma, though uncommon, can the evaluation of blunt hollow viscus injury in patients with unre-
have serious consequences if the diagnosis is missed or delayed. liable clinical examination results [see Figure 1]. If CT scanning
In a multi-institutional study of 198 patients with blunt small bowel demonstrates no suspicious findings, the patient is observed. No
injury, delay of as little as 8 hours in making the diagnosis resulted further diagnostic workup of hollow viscus injury is performed,
in increased morbidity and mortality.2 Mortality increased in paral- and the duration of the observation period depends on the relia-
lel with time to operative intervention (< 8 hours to operation, 2% bility of the clinical examination. It is worth noting that the 2003
mortality; 8 to 16 hours, 9%; 16 to 25 hours, 17%; > 24 hours, multi-institutional review of 2,457 cases carried out by the Eastern
31%), as did the complication rate. Association for the Surgery of Trauma (EAST) reported a 13%
Particular consideration should be given to lap- and shoulder- incidence of blunt small bowel injury in patients with an initial
restraint injuries, which may be associated with an increased risk negative CT scan. These results indicate that caution should be
of hollow viscus injury.The so-called seat-belt sign (i.e., ecchymo- exercised in dismissing the presence of hollow viscus injury on the
sis of the abdominal wall secondary to the compressive force of the basis of a negative scan.3 This concern is echoed by our own insti-
lap belt) is associated with a more than doubled relative risk of
small bowel injury.3 Flexion-distraction fractures of the spine
(Chance fractures) are also associated with lap-belt use, and the
presence of such fractures should raise the index of suspicion for
associated hollow viscus injury. Table 1—Incidence of Findings Suggestive of Blunt
Clinical examination often indicates the need for exploratory Mesenteric and Bowel Injury in True Positive and
laparotomy. Abdominal tenderness after blunt torso trauma is fre- False Positive CT Scans6
quently associated with significant intra-abdominal pathology, but
the reliability of the examination may be compromised by dis- Incidence
tracting chest or long bone injury, closed head injury, spinal cord
injury, or intoxication. In such scenarios, additional diagnostic True Positive CT False Positive CT
Finding Scans (%)
Scans (%)
tests are necessary.
Ultrasonography is routinely performed early in the evaluation Unexplained intraperitoneal fluid 74 79
of blunt abdominal trauma. It is highly specific and moderately
sensitive in identifying intra-abdominal fluid, the presence of Pneumoperitoneum 28 2
which in a hemodynamically unstable patient is an indication for Bowel wall thickening 30 8
laparotomy (in that it strongly suggests the presence of significant
intra-abdominal hemorrhage).4 Ultrasonography does not, how- Mesenteric fat stranding 9 4
ever, reliably distinguish solid-organ injury from hollow viscus Mesenteric hematoma 19 19
injury—a distinction that is critical for determining subsequent
management (i.e., operative versus nonoperative) in a hemody- Extravasation of luminal content 4 0
namically stable patient. Diagnostic peritoneal lavage (DPL) may Extravasation of vascular content 9 0
help differentiate one type of injury from the other (see below).
algorithms that rely on diagnostic tests, serial abdominal exami-

Patient has experienced blunt abdominal
nation, or some combination of the two. When the peritoneum
trauma and is hemodynamically stable
has obviously been penetrated (as with omental or bowel evis-
Obtain CT scan. ceration), we perform a laparotomy to evaluate the entire peri-
toneal cavity for organ injury.When it is unclear whether the peri-
toneum has been penetrated, we proceed with a definitive evalu-
ation to rule out peritoneal violation. Anterior wounds (i.e., those
anterior to the midaxillary line) are evaluated for fascial penetra-
No findings suggestive One abnormal Multiple abnormal tion by means of local wound exploration. In the emergency
of hollow viscus injury finding is noted findings are noted department (ED), with sterile technique and local anesthesia, the
are noted wound is sharply extended to allow retraction of the subcuta-
Perform DPL. Perform exploratory neous tissue and visualization of the anterior fascia. If fascial pen-
Observe patient. laparotomy.
etration is evident, laparoscopy is performed in the operating
room to look for peritoneal penetration; if peritoneal penetration
is confirmed, a laparotomy is then done. In cooperative patients
who have no history of abdominal surgery, it is often possible to
DPL yields negative DPL yields positive perform diagnostic laparoscopy with local anesthesia in the ED
results results by establishing pneumoperitoneum through a 5 mm trocar (e.g.,
Optiview; Ethicon Endo-Surgery, Cincinnati, Ohio) and main-
Observe patient. Perform exploratory
laparotomy. taining a relatively low (7 mm Hg) intra-abdominal pressure to
allow visualization of the peritoneum while maintaining patient
comfort.
Figure 1 Algorithm outlines the evaluation of blunt injury to a
Several centers have reported favorable experiences with expec-
hollow viscus.
tant management of anterior stab wounds.7,8 Patients without evi-
dence of peritonitis are admitted and monitored with serial phys-
tutional experience, in which the incidence of injury in patients ical examinations. As noted (see above), we prefer to determine
with an initial negative CT scan was 12%.5 the presence of peritoneal penetration at the time of presentation.
If CT demonstrates a solitary suspicious finding, DPL is per- The rationale for this approach is to avoid any delay in diagnosis
formed for further evaluation. If DPL yields positive results (white of hollow viscus injury and to allow early discharge of patients
blood cell [WBC] count > 500 cells/mm3, alkaline phosphatase with no peritoneal violation. Various centers have described both
level > 10 IU/L, or amylase level > 20 IU/L), exploratory laparot- DPL and CT criteria for excluding peritoneal penetration.9,10
omy is performed. It must be kept in mind, however, that DPL Wounds to the lower back or the flank (posterior to the midax-
results may be falsely negative or equivocal in the early period illary line), which carry a lower risk of intra-abdominal injury, are
after trauma.6 This phenomenon may be attributable to a time lag evaluated with CT, augmented by intravenous, oral, and rectal
between the intestinal perforation and the subsequent develop- contrast studies. CT scanning has proved to be a reliable means
ment of intraperitoneal leukocytosis. If a high degree of suspicion not only of identifying posterior intraperitoneal violation but also
of hollow viscus injury remains even after a negative DPL result, of evaluating injury to retroperitoneal structures.11
DPL may be repeated. Alternatively, exploratory laparotomy may
be performed.The choice between the two options is largely based
on the individual surgeon’s clinical judgment. Operative Management of Injuries at Specific Sites
If CT demonstrates multiple abnormalities, DPL is omitted When hollow viscus injury is suspected, antibiotics with broad-
from the workup and exploratory laparotomy is performed. spectrum aerobic and anaerobic coverage should be administered
before the skin incision. If injury is confirmed, the antibiotics
PENETRATING TRAUMA should be continued for a 24-hour period. The EAST Practice
Management Guidelines Workgroup has reviewed the available
Gunshot Wounds evidence regarding perioperative antibiotic use in the trauma set-
Gunshot wounds to the abdomen generally necessitate explor- ting.12 Data from prospective studies clearly indicate that pro-
atory laparotomy, given the high incidence of intra-abdominal longing antibiotic administration beyond 24 hours provides no
injury.The exception to this rule is the case of a tangential wound additional protection against surgical site infection (SSI).
that is believed to be traversing the soft tissues of the abdominal Abdominal exploration is generally performed through a mid-
wall without entering the peritoneal cavity. In this scenario, we line incision that is sufficiently extensive to permit evaluation of
usually perform laparoscopy to look for peritoneal penetration. If the entire peritoneal cavity. Once initial control of any significant
the peritoneum has been violated, a laparotomy is done to permit bleeding has been obtained, the next step is to control any con-
systematic evaluation of the peritoneal cavity. If the peritoneum tamination from spilled GI contents. Babcock clamps are useful
has not been violated, the operation may be terminated and the for temporarily controlling contamination from bowel perfora-
patient discharged after recovery from anesthesia, provided that tions without causing injury to the bowel wall. Inspection com-
there are no other extra-abdominal injuries necessitating hospital mences in a systematic fashion, with any holes in the bowel con-
admission. trolled as they are found. In the setting of penetrating injury, when
an odd number of hollow viscus perforations are encountered, a
Stab Wounds diligent search for an additional perforation is essential. An odd
Stab wounds to the abdomen are associated with a lower inci- number of perforations implies that one of the wounds is tangen-
dence of intra-abdominal injury than gunshot wounds are. Ac- tial (or that the projectile is intraluminal); this is a diagnosis of
cordingly, there has been a shift toward selective management exclusion.
Patient presents with gastric injury
Treat injury according to grade [see Table 2].
Injury is amenable to primary Injury is not amenable to Injury is associated with complete
repair (grade I, II, or III) primary repair (grade IV) devascularization or destruction
(grade V)
Partial thickness: treat with hemostasis Treatment depends on
and seromuscular closure. associated injuries. Perform near-total or total gastrectomy
Full thickness: treat with hemostasis with Roux-en-Y reconstruction.
and closure in two layers.
Patient has no associated Patient has associated injuries

injuries to duodenum, pancreas, to duodenum or pancreas
Figure 2 Algorithm outlines or esophagus
the treatment of gastric injury. Treat with distal gastrectomy
Treat with distal gastrectomy and and gastrojejunostomy.
gastroduodenostomy.
INJURIES TO THE STOMACH

gastric devascularization and often are associated with major vas-
Intraoperative evaluation of the stomach begins with full visual- cular injury as a consequence of the proximity of the major vessels
ization of the anterior gastric surface from the pylorus to the and the force necessary to cause such a significant injury. Patients
esophagogastric junction. Proximal exposure is facilitated by incis- with grade IV or V injuries often do not survive long enough to
ing the triangular ligament and retracting the left lateral section of undergo laparotomy, and consequently, these extensive gastric
the liver to the patient’s right.The posterior aspect of the stomach wounds are rarely encountered. Grade IV injuries can usually be
is assessed by opening the gastrocolic ligament, which provides managed by means of a partial gastrectomy. Restoration of gastric
access to the lesser sac. Care must be taken to avoid injuring the outflow is accomplished with either a gastroduodenostomy or a
vascular arcade of the greater curvature.While the stomach is ele- gastrojejunostomy; the choice is dictated by the extent of the resec-
vated superiorly, the transverse colon is retracted inferiorly to tion and the presence or absence of an associated duodenal or
expose the posterior gastric wall. Frequently, light adhesions pancreatic injury. In the exceedingly rare event of complete gastric
between the posterior gastric wall and the retroperitoneum overly- devascularization or destruction, a total gastrectomy is required;
ing the pancreas must be freed to provide full exposure. Altern- we have yet to encounter such a situation. Occasionally, recon-
atively, the greater omentum may be detached from its avascular struction of intestinal continuity after resection should not be per-
attachment to the transverse colon to afford access to the lesser formed at the initial operation. Such a damage-control approach
sac. Care must be taken to avoid placing excess tension on the is indicated in the presence of the triad of acidosis, hypothermia,
greater curvature of the stomach and the short gastric vessels so as and coagulopathy.
not to cause iatrogenic injury to the spleen.The greater and lesser In fasting patients, the stomach harbors low numbers of bacte-
curvatures should be closely inspected because the omental attach- ria because of its low pH. In trauma victims, however, who, it
ments may obscure an underlying gastric wound. Such inspection seems, often arrive with full stomachs, a more neutral pH and a
is particularly important in the setting of a small-caliber missile higher bacterial count can be expected. If a gastric perforation
wound: the perforation can be remarkably small, and the serosal with significant contamination is encountered, secondary or
tissue damage in such cases is often subtle. delayed primary skin closure should be performed in view of the
Treatment of a gastric injury is dictated by its severity [see Figure increased risk of SSI; this is particularly true when significant
2], which is classified according to the grading system developed hemorrhage or associated injury is present, in which case the rate
by the American Association for the Surgery of Trauma (AAST) of intra-abdominal abscess formation may be as high as 24%.13
[see Table 2]. Intramural hematomas (grade I) are managed by
INJURIES TO THE SMALL INTESTINE
means of unroofing and evacuation, followed by seromuscular clo-
sure with interrupted sutures. The great majority of gastric perfo- Injury to the small intestine is evaluated intraoperatively by
rations are amenable to primary repair (grades II and III). In view “running the bowel”: the small bowel and its mesentery are in-
of the propensity of the richly vascularized gastric wall to bleed at spected in a systematic and comprehensive fashion from the liga-
the site of injury, a two-layer technique is recommended to achieve ment of Treitz caudad to the ileocecal valve. As active mesenteric
adequate hemostasis. When the wound involves the pylorus, con- bleeding is encountered, it is controlled by isolation and individ-
version to pyloroplasty to prevent stenosis is often beneficial. ual ligation of the bleeding vessels rather than by mass ligation of
Suture repair of wounds at the cardioesophageal junction is rein- the mesentery, which may produce ischemia. Likewise, as bowel
forced by gastric fundoplication. perforations are found, temporary control measures are rapidly
Some extensive wounds are not amenable to primary repair initiated in an effort to prevent excessive or ongoing soilage. Once
(grades IV and V). Such injuries include significant tissue loss or all bowel injuries are accounted for, the decision must be made
Table 2—AAST Organ Injury Scales for Stomach, Small Intestine, Colon, and Rectum
Injured Structure AAST Grade* Characteristics of Injury AIS-90 Score
I Intramural hematoma < 3 cm; partial-thickness laceration 2
II Intramural hematoma ≥ 3 cm; small (< 3 cm) laceration 2
Stomach III Large (> 3 cm) laceration 3
IV Large laceration involving vessels on greater or lesser curvature 3
V Extensive (> 50%) rupture; stomach devascularized 4
I Contusion or hematoma without devascularization; partial-thickness laceration 2
II Small (< 50% of circumference) laceration 3
III Large (≥ 50% of circumference) laceration without transection 3

Small bowel
IV Transection 4
V Transection with segmental tissue loss; devascularized segment 4
I Contusion or hematoma; partial-thickness laceration 2
Colon III Large (≥ 50% of circumference) laceration 3
IV Transection 4
V Transection with tissue loss; devascularized segment 4
I Contusion or hematoma; partial-thickness laceration 2

Rectosigmoid and
III Large (≥ 50% of circumference) laceration 4
rectum
IV Full-thickness laceration with perineal extension 5
V Devascularized segment 5

AIS-90—Abbreviated Injury Score, 1990 version AAST—American Association for the Surgery of Trauma
whether to perform primary repair, resection of the injured seg- dence of vascular compromise, bowel resection and anastomosis
ment, or some combination of the two. Primary repair of multiple are indicated.
injuries preserves bowel length and is generally preferred. At the Determination of intestinal viability begins with assessment of
discretion of the operating surgeon, resection of a segment con- the bowel’s appearance. Adjunctive measures, such as the use of a
taining multiple injuries may be performed to expedite the opera- handheld Doppler device or fluorescein infusion with Wood lamp
tion, provided that the amount of bowel to be resected is small illumination, may facilitate assessment of perfusion in segments
enough that its loss would have only a negligible effect on diges- where viability is questionable. We generally prefer to use a hand-
tive function. held Doppler device because it is easy to use and is available at
Management of each individual wound is determined by its short notice in the OR. A probe applied directly to the antimesen-
severity according to the AAST grading system [see Figure 3 and teric side of the bowel wall effectively detects the presence of arte-
Table 2]. Small partial-thickness injuries (grade I) are managed by rial flow, which reliably demonstrates viability.
reapproximating the seromuscular layers with interrupted sutures. Small bowel anastomoses are usually handsewn in one or two
Small full-thickness wounds (grade II) are repaired with limited layers, though stapling devices may also be employed [see 5:29
debridement and closure. Closure is performed in either one or Intestinal Anastomosis]. The choice of technique depends largely
two layers (we prefer a single-layer closure), and transverse closure on surgeon preference. One multicenter retrospective study sug-
is preferred to avoid luminal narrowing. Larger full-thickness gested that in the setting of trauma, stapled anastomoses had a
wounds (grade III) may be repaired primarily if luminal narrow- higher complication rate than sutured anastomoses did14: overall,
ing can be avoided; otherwise, resection and anastomosis should 13% of stapled anastomoses were associated with an intra-abdom-
be performed. Extensive wounds and wounds associated with inal postoperative complication, compared with 5% of sutured
devascularization (grades IV and V) are treated with resection and anastomoses. Because this study did not separate small intestinal
anastomosis. When mesenteric injury is encountered in the ab- anastomoses from colonic anastomoses, it is unclear to what
sence of bowel injury, the associated bowel must be closely extent the results apply specifically to small bowel anastomoses. It
assessed for evidence of vascular compromise. If the bowel appears is likely, however, that bowel edema contributes to staple line fail-
viable, the rent in the mesentery should be reapproximated after ure. If bowel edema is evident or anticipated, it may be prudent to
bleeding is controlled to prevent an internal hernia. If there is evi- perform a sutured anastomosis.
Patient presents with small bowel injury
Treat injury according to grade [see Table 2].
Patient has partial-thickness Patient has small full-thickness Patient has large full-thickness Patient has extensive wound or
injury (grade I) injury (grade II) injury (grade II) segmental devascularization
(grade IV or V)
Repair with hemostasis Repair with limited debridement
and seromuscular closure. and closure in one or two layers. Repair with resection and primary
anastomosis.
Primary closure will not Primary closure will

Figure 3 Algorithm outlines the treat- narrow lumen narrow lumen
ment of small bowel injury.
Repair with limited debridement Repair with resection and
and closure in one or two layers. primary anastomosis.
INJURIES TO THE COLON

pletely transect the colon (grade IV) or involve tissue loss and
In World War II, colostomy was mandatory for penetrating devascularized segments (grade V). Optimal management of such
colon trauma because of the significant morbidity associated with wounds is less certain than optimal management of nondestruc-
anastomotic suture line dehiscence.15 In the ensuing years, experi- tive wounds. Data from randomized and prospective trials demon-
ence with primary repair of penetrating colonic injuries in civilian strate that resection and primary anastomosis can be performed
settings suggested that primary repair could be performed safely safely.22-25 It should be kept in mind, however, that these results are
and perhaps, in select cases, with less morbidity than colosto- derived from a relatively small number of reported cases.The ret-
my.16,17 This suggestion was confirmed in the late 1970s by a ran- rospective data indicate a higher incidence of suture line failure
domized, prospective study that demonstrated significantly lower and a significant incidence of associated mortality, suggesting that
rates of intra-abdominal infection in patients treated with primary resection and primary anastomosis may not be the optimal treat-
repair than in those treated with colostomy.18 In that early trial, ment for all colonic wounds.20
high-risk patients (i.e., those with shock, hemorrhage, associated A 1994 report from our institution (University of Tennessee)
injuries, delayed presentation, significant peritoneal soilage, de- concluded that patients with destructive colonic injuries who had
structive wounds of the colon, or loss of abdominal wall integrity) comorbid medical conditions or transfusion requirements greater
were excluded from randomization and treated with colostomy.
Currently, there is less concern for such risk factors, and primary
repair is gaining wider acceptance.19
To direct management decisions, it is helpful to categorize pen-
etrating colonic injuries as either nondestructive or destructive [see Patient presents with colon injury
Figure 4].20,21 Although blunt colonic injuries are considerably less
common, we manage them in a similar fashion.
Nondestructive colonic injuries are defined as wounds that
involve less than 50% of the bowel wall without devascularization.
Such wounds account for approximately 80% of colon wounds Wound is nondestructive Wound is destructive
and are amenable to primary suture repair with limited amounts
Partial thickness: perform Look for risk factors:
of debridement. Sufficient data have been accumulated over the seromuscular closure. intraoperative transfusion > 6 U,
past 30 years to support primary repair as standard treatment for Full thickness: repair with underlying comorbid condition,
nondestructive colon wounds in the absence of peritonitis, regard- primary closure. delayed operation, shock.
less of associated injuries or comorbid conditions. Evaluation of
the available prospective and retrospective data indicates that the
suture line failure rate for primary repair is approximately 1%,
which is less than the rate generally reported for elective colon and No risk factors are Risk factors are
rectal surgery. Mortality associated with suture line failure in this present present
setting is uncommon.The favorable morbidity and mortality pro-
files, along with the inherent benefits of avoiding colostomy, sup- Repair with resection Perform resection with
and primary anastomosis. end colostomy
port primary repair as standard therapy for nondestructive
or
wounds. Partial-thickness lacerations (grade I) are repaired with
Perform resection and
inverting seromuscular sutures. Full-thickness lacerations (grade primary anastomosis
II) may be closed in one or two layers. Figure 4 Algorithm outlines the with proximal diversion.
Destructive colonic injuries are defined as wounds that com- treatment of colon injury.
Patient presents with rectal injury
Location of wound is Location of wound is extraperitoneal

intraperitoneal
Manage as colon injury

[see Figure 4].
Solitary gunshot wound suggests Wound is in upper two thirds Wound is in lower one third
presence of associated of rectum of rectum
extraperitoneal wound. Strongly
consider fecal diversion and
Repair with primary closure
presacral drainage [see Figure 6].
or resection and anastomosis.
Perform proximal diversion.
Wound is accessible Wound is inaccessible
Repair with primary closure. Perform proximal diversion

Figure 5 Algorithm outlines the treatment of rectosigmoid or Perform proximal diversion. and presacral drainage
rectal injury. [see Figure 6].
than 6 units of blood were at significantly higher risk for suture line use results in a large deserosalization injury to the cecum and
breakdown when the wounds were managed with resection and ascending colon or to the sigmoid colon. In such cases, the serosa
primary anastomosis.26 Other reported risk factors that may direct may be reapproximated with interrupted silk sutures in an accor-
the surgeon toward fecal diversion include a Penetrating Abdom- dion-type fashion, provided that the lumen is not significantly
inal Trauma Index (PATI) score greater than 25, shock, and a compromised by the imbrication of the submucosa. It is likely that
delayed operation.27 It is our practice to manage these patients as subclinical luminal narrowing occurs frequently after such repairs,
high-risk patients and perform fecal diversion. Diversion may be of which we rarely see sequelae. If significant luminal narrowing is
accomplished by means of either loop colostomy (with an open or anticipated or the serosal disruption is extensive enough to pre-
closed distal stoma) or end colostomy (with a mucous fistula or clo- clude reapproximation, resection of the injured segment with pri-
sure of the rectal stump) [see 5:30 Intestinal Stomas]. The diversion mary anastomosis is indicated.
technique is dictated both by surgeon preference and by the nature
INJURIES TO THE RECTUM
of the colonic injury. In most civilian clinical practices, destructive
wounds account for approximately 20% of all colon wounds Recognition of rectal injuries requires diagnostic vigilance. All
encountered. Between 50% and 75% of destructive wounds do not patients with a penetrating wound to the pelvis, perineum, buttock,
have risk factors that prompt diversion. Thus, the overall diversion or upper thigh should be evaluated for rectal injury. Digital exam-
rate ranges from 5% to 10%. In our experience over the past sev- ination for the presence of rectal blood is mandatory, but the
eral years, 90% to 95% of all colon wounds have been managed absence of blood does not definitively rule out injury. Rigid proc-
with primary repair or resection and anastomosis. toscopy should be performed whenever there is any suspicion of
The potential risk of postoperative SSI associated with colonic rectal injury.
injury should be considered at the time of initial laparotomy. It is our practice to classify rectal injuries according to anatom-
Retained bullets or other projectiles that have penetrated the colon ic criteria, which then dictate management [see Figure 5].33 The
or rectum may act as nidi for abscess formation and should be anterior and lateral sidewalls of the upper two thirds of the rectum
removed when it is technically feasible to do so. Approximately 10% are serosalized; injuries in this region are classified as intraperi-
of these retained missiles result in soft tissue infection or toneal and are managed in the same manner as colonic injuries [see
osteomyelitis.28 Delayed primary or secondary skin closure is Figure 4]. The upper two thirds of the rectum posteriorly and the
recommended. lower one third of the rectum circumferentially are not serosalized;
If colostomy is performed, it will eventually have to be closed in injuries in these regions are classified as extraperitoneal.
most cases.The mortality associated with colostomy closure is low, Extraperitoneal wounds in the upper two thirds are usually
but the reported morbidity has varied considerably, ranging from amenable to exploration and suture repair. Fecal diversion is also
5% to 25% in single-institution studies.29-31 We typically perform performed as an adjunctive measure and may be accomplished
closure 2 to 3 months after hospital discharge to allow time for the with either loop or end colostomy [see 5:30 Intestinal Stomas]. In
resolution of the dense inflammatory adhesions that may form after select cases in which the wound is primarily intraperitoneal with
laparotomy. Before closure, a contrast enema is obtained to con- minimal extraperitoneal involvement, diversion may be omitted.
firm that no distal strictures or fistulas are present. Some surgeons Extraperitoneal wounds to the lower third of the rectum are
maintain that early closure (within 2 weeks) is as safe as the tradi- usually explored and repaired, provided that the wound is easily
tional late closure (3 months), with a shorter operating time and accessible without risk to the associated neurovascular and geni-
less intraoperative blood loss, and suggest that it may also allow tourinary structures. Fecal diversion is recommended. Wounds
colostomy closure during the patient’s initial hospitalization.32 To that are difficult to reach are not explored and instead are managed
date, however, this practice has not garnered wide enthusiasm. with proximal fecal diversion and presacral drainage. Presacral
Occasionally, blunt abdominal trauma associated with lap-belt drainage is performed with the patient in the lithotomy position
[see Figure 6]. A curvilinear incision is made in the skin between the and, in many cases, a patient who is unstable as a result of associ-
coccyx and the anus, and blunt dissection is employed to gain ated injuries. Although a solitary proximal rectal gunshot wound
entry into the presacral space. Generally, we place one or two may truly be tangential (or the projectile may be intraluminal), an
Penrose drains into this space and gradually withdraw them be- associated distal extraperitoneal wound is often present. After pri-
tween postoperative days 5 and 7. mary repair of the proximal wound, fecal diversion and presacral
Whether presacral drainage is necessary is controversial. There drainage should be performed, as with inaccessible extraperitoneal
is published prospective evidence to suggest that presacral drain- rectal injuries.
age does not lessen morbidity34; however, this study did not make Distal rectal washout was initially advocated on the basis of
a distinction between accessible and inaccessible extraperitoneal experience gained during the Vietnam War.35 In the majority of
wounds. Our view is that for inaccessible extraperitoneal wounds, civilian studies since then, however, distal rectal washout has had
presacral drainage is required to prevent retroperitoneal abscess no significant effect on morbidity.33,36-38 It may be useful in cases
formation, which results from fecal contamination of a relatively of severe wound contamination or fecal impaction, but in general,
closed space and can produce significant morbidity in the form of it does not seem to be an important adjunct to the management of
retroperitoneal infection that may also track downward into the rectal injuries.Typically, distal rectal washout involves lavage of the
thighs. Accessible extraperitoneal wounds that are explored and rectum distal to the injury with 3 to 6 L of irrigant via an irrigation
repaired become effectively intraperitonealized; thus, presacral tube placed into the distal limb of a loop colostomy. The irrigant
drainage is not required for these injuries. may be normal saline, a genitourinary irrigant, or an antiseptic
As emphasized (see above), a tangential gunshot wound is a solution. Digital rectal dilatation is performed to facilitate drainage
diagnosis of exclusion.This point is of particular importance when of the irrigant. Care should be taken to protect the midline wound
the wound involves the rectum, because mobilization and visual- with a polyethylene or similar barrier to reduce the risk of wound
ization may be limited by a narrow pelvis, a fat-laden mesorectum, contamination during the washout.
Figure 6 Presacral drainage is provided through a curved

incision midway between the anus and the tip of the coccyx.
With blunt dissection, two fingers are inserted between the
rectum and the hollow of the sacrum. Penrose drains are
inserted and sutured to the skin.
References
1. Watts DD, Fakhry SM: Incidence of hollow viscus the EAST Practice Management Guidelines Work 26. Stewart RM, Fabian TC, Croce MA, et al: Is resec-
injury in blunt trauma: an analysis from 275,557 Group. J Trauma 48:508, 2000 tion with primary anastomosis following destruc-
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2. Fakhry SM, Brownstein M, Watts DD, et al: Rela- abscess and the synergistic effect of hemorrhage 27. Cornwell EE 3rd, Velmahos GC, Berne TV, et al:
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3. Current diagnostic approaches lack sensitivity in 15. Office of the Surgeon General. Circular Letter No. to the colon: the missile is an adjuvant for abscess.
the diagnosis of perforated blunt small bowel injury: 178. October 23, 1943 J Trauma 31:1088, 1991
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16. Axelrod AJ, Hanley PH: Treatment of perforating 29. Crass RA, Salbi F, Trunkey DD: Colostomy clo-
EAST multi-institutional HVI trial. EAST Multi-
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Institutional Hollow Viscus Injury Research Group.
South Med J 60:811, 1967 J Trauma 27:1237, 1987
J Trauma 54:2956, 2003
17. Woodhall JP, Ochsner A: The management of per- 30. Pachter HL, Hoballah JJ, Corcoran TA, et al: The
4. Rozycki GS, Ballard RB, Feliciano DV, et al:
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Surgeon-performed ultrasound for the assessment
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diagnostic peritoneal lavage. Surgery 91:656, 1982 trating colon injuries requiring resection: diversion pective randomized trial. Surgery 118:815, 1995
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Kurek S Jr, Ed. Eastern Association for the Surgery penetrating rectal injuries. J Trauma 45:656, 1998
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20:1101, 1996 35. Lavenson GS, Cohen A: Management of rectal
21. Miller PR, Fabian TC, Croce MA, et al: Improving injuries. Am J Surg 122:226, 1971
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22. Gonzalez RP, Falimirski ME, Holevar MR: Fur-
10. Shanmuganathan K, Mirvis SE, Chiu WC, et al: 37. Thomas DD, Levison MA, Dykstra BJ, et al:
Penetrating torso trauma: triple-contrast helical ther evaluation of colostomy in penetrating colon
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Acknowledgment
Practice management guidelines for prophylactic with intracolonic bypass vs. ostomy. Dis Colon
antibiotic use in penetrating abdominal trauma: Rectum 35:957, 1992 Figure 6 Susan Brust, C.M.I.
7 TRAUMA AND THERMAL INJURY 8 Injuries to the Duodenum and Pancreas — 1
8 INJURIES TO THE PANCREAS AND

DUODENUM
Gregory J. Jurkovich, M.D., F.A.C.S.
Pancreatic and duodenal injuries continue to challenge trauma not require immediate laparotomy for hemorrhage or bowel perfo-
surgeons.The relative rarity of these unforgiving injuries, the diffi- ration, establishing the presence of pancreatic injury is a consider-
culty of diagnosing them in a timely manner, and the high mor- able challenge, made more difficult by the knowledge that a missed
bidity and mortality associated with them justify the anxiety they pancreatic duct injury has dire consequences for the patient.7-10
evoke. Because of the deep, central, and retroperitoneal location of There are isolated reports of patients with complete duct tran-
the pancreas and much of the duodenum, trauma to these organs section who remain asymptomatic for weeks, months, or even years
is infrequent; however, this relatively protected anatomic location after the initial injury.5,7,8,11 More commonly, however, patients
also is the reason for the diagnostic difficulty and contributes to with pancreatic duct injuries that were initially missed manifest an
the high morbidity and mortality. Mortality for pancreatic trauma abdominal crisis within a few days after the injury.12-14 The reasons
ranges from 9% to 34%. Duodenal injuries are similarly lethal, why physical signs and symptoms may not develop promptly are
with mortality ranging from 6% to 25%. Complications after duo- related to the retroperitoneal location of the pancreas, the inactivi-
denal or pancreatic injuries are alarmingly frequent, occurring in ty of pancreatic enzymes after an isolated injury, and the decreased
30% to 60% of patients.1,2 If these injuries are recognized early, secretion of pancreatic fluid after trauma. Early identification of a
treatment is straightforward, and morbidity and mortality are low; subtle pancreatic injury therefore depends on a high index of sus-
if they are recognized late, they typically follow a protracted, diffi- picion, a carefully planned approach, and close observation.
cult clinical course, often ending in a devastating outcome. A high index of suspicion is warranted in any patient who has
sustained a direct high-energy blow to the epigastrium—for exam-
ple, from a crushed steering wheel (in an adult) or a bicycle or tri-
Injuries to the Pancreas cycle handlebar (in a child).15,16 The energy of impact causes the
retroperitoneal structures to be crushed against the spine, and the
DIAGNOSIS
pancreas is typically transected at this point. The presence of soft
The two most important determinants of outcome after pancre- tissue contusion in the upper abdomen or disruption of the lower
atic injury are (1) the status of the main pancreatic duct and (2) the ribs or costal cartilages should suggest possible pancreatic injury.
time interval between initial trauma and definitive management of Epigastric pain that is out of proportion to the abdominal exami-
a duct injury. These determinants were probably first recognized nation findings is often another clue to a retroperitoneal injury.
and emphasized in 1962 by Baker and associates.3 Two subsequent Although the highest concentration of amylase in the human
reviews of pancreatic trauma cases at the University of Louisville body is in the pancreas, hyperamylasemia is not a reliable indicator
confirmed the importance of determining pancreatic duct status. of pancreatic trauma. In one series, only 8% of hyperamylasemic
The first found that resection of distal duct injuries, as opposed to patients with blunt abdominal trauma had pancreatic duct injuries.17
drainage alone, significantly lowered postoperative morbidity and As many as 40% of patients with pancreatic injuries may initially
mortality.4 The second confirmed this observation by noting that have normal serum amylase levels.18,19 In addition, there is evi-
pancreatic resection distal to the site of duct injury caused mortal- dence that isolated brain injury can cause elevated amylase20 or
ity at the University to decrease from 19% to 3%.5 Experience at lipase levels21 through a central mechanism that remains to be clar-
my institution (University of Washington School of Medicine) sup- ified. Nonetheless, the presence of hyperamylasemia should raise
ported this finding, in that accurate determination of the status of the index of suspicion for pancreatic injury.The time between pan-
the pancreatic duct with intraoperative pancreatography was found creatic duct injury and serum amylase determination may be criti-
to reduce the complication rate from 55% to 15%.6 cal. In a report of 73 patients with documented blunt injury to the
Unfortunately, the cross-sectional body-imaging techniques pancreas, serum amylase levels were elevated in 61 patients (84%)
currently employed in multiply injured patients (e.g., abdominal and normal in 12 (16%).22 Patients with elevated serum amylase
computed tomography) are not sensitive enough for accurate levels were assayed 7 ± 1.5 hours after injury, whereas those with
assessment of duct status, and operation for direct inspection car- normal levels were assayed 1.3 ± 0.2 hours after injury.The inves-
ries its own morbidity. Thus, the main challenge in addressing tigators concluded that determination of serum amylase levels
potential pancreatic trauma is to make an early determination of within 3 hours after injury did not yield diagnostic results.
whether or not a pancreatic duct injury has occurred. Review of the available data suggests that the sensitivity of
Which diagnostic techniques are most useful in a patient with a serum amylase level determination in detecting blunt pancreatic
possible pancreatic injury depends on the mechanism of injury, the trauma ranges from 48% to 85% and that the specificity ranges
presence or absence of other indications for early laparotomy, and from 0% to 81%.1 The negative predictive value of the serum amy-
the time that has elapsed since the initial abdominal insult lase level after blunt trauma is about 95%.18,19,23 The sensitivity
occurred. If the patient has a clear indication for laparotomy, there and the positive predictive value may be increased if the serum
is little or no need for preoperative evaluation directed at identify- amylase level is obtained more than 3 hours after injury.The con-
ing a possible pancreatic injury, because the diagnosis of such clusion to be drawn is that 95% of blunt abdominal trauma pa-
injury must be made intraoperatively. If, however, the patient does tients with normal amylase levels will not have a pancreatic injury.
Intraoperative Evaluation
An elevated amylase level in serum or peritoneal lavage effluent
does not necessarily confirm the presence of a pancreatic injury, Careful inspection of the pancreas and classification of injuries
but it does mandate further evaluation. [see Management, Classification of Pancreatic Injuries, below] are
Blunt abdominal trauma patients with hyperamylasemia in often complicated by the extent and severity of associated injuries
whom the results of abdominal examination are reliable and benign and occasionally hindered by the reluctance of the surgeon to
are carefully observed, and the amylase level is measured again mobilize retroperitoneal structures. Clues suggesting pancreatic
after several hours. Persistent elevation of serum amylase levels or injury include the injury mechanisms described (see above), the
the development of abdominal symptoms is an indication for fur- presence of an upper abdominal wall contusion or abrasion, and
ther evaluation, which may include abdominal CT, endoscopic concomitant lower thoracic spine fractures. The presence of an
retrograde cholangiopancreatography (ERCP), or surgical explo- upper abdominal central retroperitoneal hematoma, edema around
ration. If the abdominal examination initially yields equivocal or the pancreatic gland and the lesser sac, and retroperitoneal bile
unreliable results in a hemodynamically stable patient with hyper- staining mandate thorough pancreatic inspection.
amylasemia, a dual-contrast (i.e., intravenous and oral) abdom- Inspection of the pancreas requires complete exposure of the
inal CT scan should be done as part of the initial evaluation. If gland. First, the lesser sac is opened through the gastrocolic liga-
abdominal symptoms subsequently develop or the amylase level ment just outside the gastroepiploic vessels. This exposure is car-
does not return to normal, directed evaluation of the pancreas by ried far to the patient’s left, fully opening the lesser sac and free-
means of repeat abdominal CT, ERCP, or surgical exploration is ing the transverse colon. The transverse colon is then retracted
warranted. downward and the stomach upward and anteriorly [see Figure 1].
Overall, abdominal CT is reported to be 70% to 80% sensitive Frequently, there are a few adhesions between the posterior stom-
and specific for diagnosing pancreatic injury, though its accuracy ach and the anterior surface of the pancreas that must be incised.
is largely dependent on the experience of the interpreter, the qual- Next, a complete Kocher maneuver is performed to provide
ity of the scanner, and the time elapsed since injury.24-26 Charac- adequate visualization of the pancreatic head and the uncinate
teristic CT findings associated with pancreatic injury include direct process. In addition, mobilization of the hepatic flexure of the
visualization of a parenchymal fracture, an intrapancreatic hema- colon (a frequently overlooked maneuver) greatly facilitates visu-
toma, fluid in the lesser sac, fluid separating the splenic vein and alization and bimanual examination of the head and neck of the
the pancreatic body, a thickened left anterior renal fascia, and a re- pancreas. Inspection of the pancreatic tail requires exposure of the
troperitoneal hematoma or fluid collection. These findings often splenic hilum. If the injury involves the tail, the peritoneal attach-
are subtle and rarely are all present in one patient.27 If the patient ments lateral to the spleen and colon are divided, and the colon,
is examined immediately after injury, some of the CT signs of the spleen, and the body and tail of the pancreas are then mobi-
pancreatic injury may not yet be apparent, which may be part of lized forward and medially by creating a plane between the kidney
the explanation for the false negative CT scans reported in as many and the pancreas with blunt finger dissection.This maneuver per-
as 40% of patients with significant pancreatic injuries.28 This pos- mits bimanual palpation of the pancreas and inspection of its pos-
sibility is not sufficient grounds for delaying CT evaluation, but it terior surface.
is an argument for repeating CT if symptoms persist. Injuries to the major pancreatic duct occur in perhaps 15% to
ERCP has no role in the acute evaluation of hemodynamically 20% of cases of pancreatic trauma. At my institution, of 193 pa-
unstable patients, but numerous reports over the past decade have tients with pancreatic injuries managed over a period of 15 years,
indicated that it can be useful in the diagnosis and management only 27 (14%) had grade III injuries, and 10 (5%) had grade IV
of pancreatic trauma. Currently, ERCP is the best available or V injuries.2 Studies from the 1970s and 1980s observed that
modality for imaging the pancreatic duct and its divisions, but it penetrating trauma was more likely to cause pancreatic duct in-
usually involves anesthesia, and it is not readily or widely available. jury than blunt trauma was,40,41 but subsequent reviews did not
For the most part, ERCP has been used in the setting of a late or confirm these observations.2,42
missed diagnosis of pancreatic duct injury, occasionally with The majority of pancreatic duct injuries, regardless of mecha-
transductal stenting to manage the injury, particularly in chil- nism, can be diagnosed through careful inspection of the injury
dren.29-33 Appropriate application of ERCP is an evolving issue tract after adequate exposure. All penetrating wounds should be
that will continue to foster investigations, but any application will traced from the entry point through the surrounding tissue to the
continue to be based on the principle of timely diagnosis, recog- exit point or the end of the tract. If the pancreas was damaged by
nition, and management of pancreatic duct injury.4,34 If ERCP is a knife or a bullet, it is necessary to determine the integrity of the
done early and shows intact pancreatic ducts (including the sec- major pancreatic duct.With most penetrating wounds to the mar-
ondary and tertiary radicles) without any extravasation, nonoper- gins of the gland, the pancreas can be inspected directly and duct
ative therapy is permissible if no associated injuries are present.35 integrity confirmed. With penetrating wounds to the head, neck,
The difficulties in this management scheme are determining or central portion of the pancreas, however, further evaluation is
which patients should undergo ERCP and getting the ERCP often required. Occasionally, intravenous injection of 1 to 2 µg of
accomplished promptly.36,37 cholecystokinin pancreozymin (CCK-PZ) may stimulate pancre-
Magnetic resonance imaging has emerged as a potentially valu- atic secretions enough to allow an otherwise unrecognized major
able technique for evaluation of the pancreatic duct.38,39 Although pancreatic duct injury to be identified.The remaining few injuries
to date, magnetic resonance pancreatography (MRP) has primar- may necessitate the use of more elaborate investigative tech-
ily been employed in elective settings, it has also been employed niques, including intraoperative pancreatography (see below).
as a noninvasive alternative method of determining the status of Minor blunt contusions or lacerations of the pancreatic sub-
the main pancreatic duct in patients with pancreatic injuries. Early stance usually do not necessitate further evaluation of the pancre-
reports suggest that MRP is unreliable early after injury but is use- atic duct and can be effectively managed with closed suction
ful for delayed diagnosis and management.10 Further study of its drainage. The presence of an intact pancreatic capsule, however,
sensitivity and specificity in this setting appears warranted. does not necessarily rule out complete division of the pancreatic
Figure 1 Illustrated is the appearance of a contusion to the body of the pancreas overlying the vertebral
column, as seen from the lesser sac (a). The pancreas is mobilized to determine whether a fracture is
present and to assess the likelihood of a duct injury. This exposure is best accomplished by dissecting
along the inferior border of the gland, dividing the inferior mesenteric vein if necessary, and reflecting
the pancreas superiorly (b).
duct, and on rare occasions, a blunt impact on the pancreas can soluble contrast material under fluoroscopic guidance. It typically
result in transection of the major duct without complete transec- yields clear images of the biliary tree, and in one study, it success-
tion of the gland.5 Under these circumstances, establishing the sta- fully visualized the pancreatic duct in 64% of the patients (7/11).2
tus of the major duct system is an essential step in determining Contracture of the sphincter of Oddi from I.V. morphine admin-
therapy and in anticipating late morbidity and mortality. In one istration may enhance the likelihood of pancreatic duct visualiza-
study, routine performance of intraoperative pancreatography tion. A cholecystectomy is not necessary after this procedure.
when proximal pancreatic duct injury was suspected reduced
MANAGEMENT
postoperative morbidity from 55% to 15%.6
Intraoperative imaging of the pancreatic duct can be performed
with ERCP, direct open ampullary cannulation, or needle cholan- Classification of Pancreatic Injuries
giopancreatography. Intraoperative ERCP is cumbersome and Classification of pancreatic injuries is based on the status of the
often difficult to coordinate during an emergency operation, but it pancreatic duct and the site of injury relative to the neck of the
has been used in this setting.43 Duodenotomy and direct pancreas. Several different classification systems have been devised
ampullary cannulation—or even transection of the tail of the pan- to catalogue pancreatic injuries.39,44,45 At present, the most widely
creas and distal duct cannulation—have been employed in the used system is the one devised by the American Association for the
past, but as a consequence of advances in perioperative imaging, Surgery of Trauma (AAST) [see Table 1], which addresses the key
improvements in exposure and direct visualization of the pancreas, issues of parenchymal disruption and major pancreatic duct status
and effective use of wide closed suction drainage and postopera- by focusing on the anatomic location of the injury for the more
tive ERCP, these very invasive diagnostic methods of imaging the severe (grade III to V) injuries.46
pancreatic duct have largely been abandoned.44 Needle cholecys- The management alternatives for proximal pancreatic duct
tocholangiopancreatography remains a useful intraoperative injuries differ from those for distal duct and parenchymal injuries
adjunct in the evaluation of the pancreatic duct. This technique [see Figure 2]. For parenchymal contusions or lacerations with min-
involves cannulating the gallbladder with an 18-gauge angio- imal or no parenchymal tissue loss and no duct injury (grade I or
catheter and injecting 30 to 75 ml of three-quarter–strength water- II), the only treatment required is external drainage. For combined
Table 1—AAST Organ Injury Scales for Pancreas and Duodenum
Injured Structure AAST Grade* Characteristics of Injury AIS-90 Score
I Small hematoma without duct injury; superficial laceration without duct injury 2
II Large hematoma without duct injury or tissue loss; major laceration without duct injury or tissue loss 2; 3
Pancreas III Distal transection or parenchymal laceration with duct injury 3
IV Proximal† transection or parenchymal laceration involving ampulla 4
V Massive disruption of pancreatic head 5
I Single-segment hematoma; partial-thickness laceration without perforation 2; 3
II Multiple-segment hematoma; small (< 50% of circumference) laceration 2; 4
Duodenum Large laceration (50%–75% of circumference of segment D2 or 50%–100% of circumference of 4

III
segment D1, D3, or D4)
IV Very large (75%–100%) laceration of segment D2; rupture of ampulla or distal CBD 5
V Massive duodenopancreatic injury; devascularization of duodenum 5

†
Proximal pancreas is to the patient’s right of the superior mesenteric vein.
AAST—American Association for the Surgery of Trauma AIS-90—Abbreviated Injury Score, 1990 version CBD—common bile duct
duodenal and pancreatic head injuries that include the major duct Creation of a needle-catheter jejunostomy or a small-feeding-
or the ampulla, the required treatment is a combined pancreatico- tube jejunostomy at the time of the initial celiotomy should be
duodenectomy (Whipple procedure). The difficult decisions in considered for all patients with grade III to V pancreatic injuries.
managing pancreatic trauma involve patients with parenchymal This measure allows early postoperative enteral nutrition and
disruption and major duct injury. By focusing on the anatomic avoids committing patients who cannot tolerate oral or gastric
location of duct and parenchymal injury (proximal versus distal), feedings to total parenteral nutrition (TPN). Surgically placed
the AAST classification provides a useful management guide. feeding tubes are, however, associated with some degree of mor-
bidity. In a study from my institution, feeding jejunostomies had a
Grades I and II: Contusions and Lacerations without major complication rate of 4% in severely injured patients.53
Duct Injury Needle-catheter jejunostomies were associated with fewer compli-
Minor pancreatic contusions, hematomas, and capsular lacera- cations than Witzel-tube jejunostomies—hence my preference for
tions (grade I) account for about 50% of all pancreatic injuries; lac- the smaller-caliber feeding tube.
erations of the pancreatic parenchyma without major duct disrup-
tion or tissue loss (grade II) account for an additional 25%. These Grade III: Distal Transection or Distal Parenchymal
injuries are treated with hemostasis and adequate external Injury with Duct Disruption
drainage.47 No attempt should be made to repair capsular lacera- The anatomic distinction between the proximal and the distal
tions, because closure may result in a pancreatic pseudocyst, pancreas is generally defined by the superior mesenteric vessels
whereas a controlled pancreatic fistula is usually self-limiting. Soft passing behind the pancreas at the junction of the pancreatic head
closed suction drains (Jackson–Pratt) are preferred to Penrose and body. In the gland itself, there is no true anatomic distinction
drains or sump drains because intra-abdominal abscess formation between the head, the body, and the tail, but dividing the organ into
is less likely, effluent is more reliably collected, and the skin ex- these three parts is useful for estimating residual pancreatic endo-
coriation at the exit site is significantly less with closed suction crine and exocrine function. A 1994 study found that a distal pan-
drains.15,48,49 Drains are removed when the amylase concentrations creatic resection at the portal vein removed an average of 56% of
in the drains are lower than the serum concentration, which gener- the gland by weight (range, 36% to 69%).54 Because most blunt-
ally occurs within 24 to 48 hours. An international consensus trauma pancreatic injuries occur at the spine, which is just to the
group has defined pancreatic fistula as the persistence of any mea- patient’s left of the portal vein as it crosses behind the pancreas, a
surable volume of drain output on or after postoperative day 3 with distal pancreatectomy in this circumstance involves resecting, on
an amylase content higher than three times the serum amylase con- average, 56% of the gland. A resection at the common bile duct
tent.50 This group has also defined three grades of pancreatic fistu- (CBD), on the other hand, removes an average of 89% of the gland
la complications [see Complications, below]. Drains are generally (range, 64% to 95%). Although there have been reports of normal
left in situ until there is no evidence of pancreatic leakage. endocrine and exocrine function after a 90% pancreatectomy, every
Nutrition should be provided via the oral or gastric route as possible effort should be made to leave at least 20% of the pan-
soon as possible. In patients with severe pancreatic injuries, how- creatic tissue in situ to minimize postoperative complications.55,56
ever, prolonged gastric ileus or pancreatic complications may pre- Distal parenchymal transection, particularly if it involves dis-
clude standard gastric feeding. Because most tube-feeding formu- ruption of the main pancreatic duct, is best treated by means of
las are high in fat and increase pancreatic effluent volume and distal pancreatectomy [see Figure 3]. If there is any concern regard-
amylase concentration, elemental diets, which have a lower fat ing the status of the remaining proximal main pancreatic duct,
content and a higher pH and tend to be less stimulating to the intraoperative pancreatography should be performed through the
pancreas, are preferred.51,52 open end of the proximal duct. If the remaining proximal duct is
Grade IV: Proximal Transection or Parenchymal

normal, the transected duct should be identified and closed with
Injury with Probable Duct Disruption
a direct U stitch ligature using nonabsorbable monofilament
suture material.57 The parenchyma may be closed with a large (4.8 Injuries to the pancreatic head represent the most challenging
mm) TA-55 stapler57,58; however, I find that this crushes the resid- management dilemmas.The key steps in immediate management,
ual pancreas excessively, and I prefer to place mattress sutures in order of importance, are (1) to control bleeding, (2) to halt con-
through the full thickness of the pancreatic gland from the anteri- tamination, and (3) to define the anatomy of the injury. Only
or to the posterior capsule to minimize leakage from the transect- when these steps have been carried out is effective management
ed parenchyma. Although most surgeons prefer nonabsorbable possible.
suture material for pancreatic stump closure, one report found In particular, it is essential that the surgeon define the anatomy
that complication rates were lower when absorbable polyglycolic of the pancreatic duct in patients who have sustained proximal
acid sutures were employed.34 A small omental patch may be used pancreatic injuries. This can usually be accomplished through
to buttress the surface, and a drain should be left near the tran- local inspection and exploration of the defect to determine the sta-
section line. tus of the duct.61 If local exploration fails to determine the status
Concerns about the possibility of overwhelming postsplenec- of the main pancreatic duct, intraoperative pancreatography (see
tomy infection (OPSI) and subphrenic abscess formation after above) is strongly recommended. The only exception to this
splenectomy have prompted several authors to consider distal approach involves hemodynamically unstable patients with
pancreatectomy without splenectomy. The technical challenge in hypothermia, acidosis, and coagulopathy, for whom simple dam-
pancreatectomy with splenic salvage is how to isolate the pancre- age-control surgery is advised.
atic branch vessels off the splenic vein and artery and ligate them Some experienced surgeons have expressed reservations about
without causing injury to the splenic hilum and thrombosis of the making a duodenotomy to perform pancreatography. In many
splenic vein. Generous mobilization of the entire pancreatic gland cases (64%, according to experience at my institution), needle
and the spleen is a prerequisite. On average, there are 22 tribu- cholecystocholangiopancreatography can image the pancreatic
taries of the splenic vein and seven branches of the splenic artery duct along with the distal CBD.2 If this technique proves unsuc-
that must be ligated.59 One report suggested that this maneuver cessful, the best approach consists of wide external drainage with
would increase operating time by an average of 50 minutes (range, several closed suction drains in conjunction with planned early
37 to 80 minutes).60 Another reported splenic salvage in 21 (64%) postoperative ERCP or MRP. If postoperative ERCP confirms the
of the 33 patients who underwent distal pancreatic resection.13 presence of major proximal pancreatic duct injury, pancreatic
The increased operating time and the potential blood loss associ- duct stenting may be considered as an alternative to near-total
ated with pancreatectomy without splenectomy must be balanced pancreatectomy. A growing body of experience suggests that pan-
against the slight risk of OPSI. In my view, the balance favors creatic duct stenting is a promising approach30,32,33; however, at
splenic salvage only when the patient is hemodynamically stable least one report has found it to yield discouraging results, citing
and normothermic and when the pancreatic injury is isolated or long-term stricture development and acute sepsis as particular
occurs with only minor associated injuries. problems.10
Patient has possible pancreatic injury
History of high-energy direct blow to epigastrium

is suggestive.
Obtain serum amylase levels.
Perform CT with I.V. contrast (repeated if necessary).
If pancreatic trauma is likely, perform laparotomy for
inspection of pancreas and grading of injury.
Grade I or II Grade III Grade V
Treat with unroofing, careful inspection Perform distal pancreatectomy, with or without Perform pancreaticoduodenectomy
to confirm absence of duct injury, and splenic salvage. (Splenic salvage is particularly (Whipple procedure).
drainage. worth considering in children.)
Grade IV
Unstable patient: treat with hemostasis and drainage, with

postoperative ERCP to define duct anatomy and allow duct
Figure 2 Algorithm outlines the treatment of stenting if indicated.
pancreatic injury.131 Stable patient: divide pancreas completely, oversew proximal
stump, and perform Roux-en-Y anastomosis of distal pancreatic
remnant to jejunal limb.
Consider adding pyloric exclusion.
Figure 3 Illustrated is distal

pancreatectomy with salvage of
the spleen (a) and without
splenic salvage (b).
If the proximal pancreatic duct is injured but the ampulla and A review of 399 patients with pancreatic injuries from four sepa-
the duodenum are spared (a rare scenario), two options are avail- rate published reports revealed that only two (0.5%) patients
able. The first option is extended distal pancreatectomy, resulting underwent Roux-en-Y drainage of the distal segment of a tran-
in subtotal removal of the gland. The proximal residual gland sected pancreatic gland.13,34,62,63 A report from the University of
should drain into the duodenum in a normal fashion if the duct is Tennessee at Memphis is compelling for its findings regarding the
intact.Wide external drainage of the residual pancreatic duct sur- effectiveness of drainage alone, without extended pancreatectomy,
face must be provided. I do not add pyloric exclusion or duodenal particularly for proximal pancreatic gland injuries in which the
defunctionalization or diverticularization [see Combined Pancreatic- duct status is unclear.13 A total of 37 patients with proximal pan-
Duodenal Injuries, below] to this procedure, though others advo- creatic duct injuries were managed with closed suction drainage
cate the use of such techniques in this circumstance.51,61 If it appears alone, and the fistula and abscess rate was a modest 13.5%. Be-
that the residual proximal pancreatic tissue may be inadequate to cause pancreatography was not performed in these patients, the
provide endocrine or exocrine function, the second option may be status of the pancreatic duct was not defined. Thus, it remains
applied, which is to preserve the pancreatic tail distal to the injury unclear whether this technique is truly effective in the presence of
by performing a Roux-en-Y pancreaticojejunostomy [see Figure 4]. a major pancreatic duct injury.
This technique involves division of the pancreas at the site of In cases of incomplete pancreatic parenchymal transection,
injury, debridement of injured parenchyma, secure closure of the some surgeons have employed an end-to-side jejunopancreatic
proximal duct and the parenchyma, and anastomosis of the open anastomosis. This technique is not recommended, because of the
end of the divided distal pancreas to the Roux-en-Y jejunal limb. difficulty of ensuring the integrity of the anastomosis and because
of the potential for a high-output pancreatic fistula resulting from denal injury. Most of the immediate mortality in patients with
the posterior pancreatic wound. A report from Emory University combined pancreatic and duodenal injuries is attributable to
illustrated the high complication rate associated with this dated major vascular injury in the vicinity of the head of the pancreas.
technique: of the seven patients in whom the technique was used Provided that immediate control of hemorrhage and adequate
(out of a total of 283 patients), five (71%) had fistulas and three resuscitation can be achieved, the Whipple procedure [see 5:24
(43%) died.49 Pancreatic Procedures] remains the preferred option in the select
Again, provisions should be made for early enteral nutritional group of patients who have unreconstructable injuries to the
support in all patients with major pancreatic duct injuries. A mea- ampulla or the proximal pancreatic duct or who have massive
sure of foresight in placing a jejunal feeding tube at the time of the destruction of both the duodenum and the pancreatic head. In
initial celiotomy will be amply rewarded by the institution of a these patients, pancreaticoduodenectomy is essentially the com-
simplified and advantageous enteral nutrition regimen.64 Ele- pletion of surgical debridement of devitalized tissue. For patients
mental or short-chain polypeptide feeding formulas are particular- with hemodynamic instability, hypothermia, coagulopathy, and
ly useful in this situation. These formulas may be delivered via a acidosis, a staged operative approach (i.e., damage-control surgery)
needle-catheter jejunostomy, which is the approach I prefer.52,53 is advocated. First, hemorrhage is controlled; next, bowel and bac-
terial contamination are managed; and finally, the anatomy of the
Combined Pancreatic-Duodenal Injuries injury is identified.The patient is then resuscitated in the ICU and
Severe combined injuries to the pancreatic head and the duo- returned to the operating room for definitive reconstruction and
denum are, fortunately, rare. In one study, only 48 (3%) of 1,404 anastomoses when stabilized (generally, 24 to 48 hours later).
patients with pancreatic duct injuries reported between 1981 and Because of the large number of possible combinations of
1990 underwent pancreaticoduodenectomy.65 These combined injuries to the pancreas and the duodenum, no single therapeutic
injuries are most commonly caused by penetrating trauma and approach is appropriate for all patients. In a review of 129 cases of
occur in association with multiple other intra-abdominal injuries. combined pancreatic-duodenal injuries, 24% of the patients were
In fact, the associated injuries are the primary cause of mortality, treated with simple repair and drainage, 50% underwent repair
a fact that again underscores the importance of hemorrhage con- and pyloric exclusion, and only 10% required a Whipple proce-
trol and contamination control in dealing with pancreatic or duo- dure.61 The best treatment option for a given patient is determined
Figure 4 If a patient has a grade IV

injury to the pancreatic head and there
is concern regarding whether the prox-
imal residual gland would have ade-
quate endocrine and exocrine function
if the distal gland is resected in an
extended distal pancreatectomy, an
option is to preserve the uninjured
portion of the distal gland. This is done
by dividing the pancreas at the site of
the injury and performing a Roux-en-Y
pancreaticojejunostomy to allow the
distal pancreas to drain into the
jejunal limb.
weeks to 2 months, the pylorus opens and the gastrojejunostomy

functionally closes. One group has described a technical method
of controlling the release of the pyloric exclusion knot and there-
by timing the opening of the pyloric occlusion.69 Marginal ulcera-
tion at the gastrojejunostomy site has been reported in 5% to 33%
of patients in whom a vagotomy was not performed.67,68,70,71
Pyloric exclusion is generally reserved for severe combined pan-
creatic head and duodenal injuries for which a Whipple procedure
is not required. Few surgeons advocate pyloric exclusion for iso-
lated pancreatic duct injuries.
In patients who have sustained massive injuries of the proximal
duodenum and the head of the pancreas, destruction of the
ampulla and the proximal pancreatic duct or the distal CBD may
preclude reconstruction. In addition, because the head of the pan-
creas and the duodenum share an arterial supply, it is essentially
impossible to resect one structure entirely without making the
other ischemic. In this situation, a pancreaticoduodenectomy [see
5:24 Pancreatic Procedures] is required. Between 1961 and 1994,
184 Whipple procedures for trauma were reported; there were 26
operative deaths and 39 delayed deaths, for a 65% overall survival
rate.65 Subsequent experience, however, suggests that with appro-
priate selection criteria, pancreaticoduodenectomy for trauma can
be performed with morbidity and mortality comparable to those
of pancreaticoduodenectomy for cancer.72-74
Nonoperative Management in Children
Major pancreatic duct injury is rare in children, occurring in
only 0.12% of children with blunt abdominal trauma.75 Most
Figure 5 Duodenal diverticularization consists of antrectomy pediatric pancreatic injuries are grade I or II injuries, which do not
with gastrojejunostomy, tube duodenostomy, vagotomy, and
peripancreatic drainage.
by the integrity of the distal CBD and the ampulla, as well as by

the severity of the duodenal injury. For this reason, every patient
with a combined pancreatic-duodenal injury should undergo cho-
langiography, pancreatography, and evaluation of the ampulla. If
the CBD and the ampulla are intact (as they are in the majority of
cases), the duodenum may be closed primarily and the pancreatic
duct injury treated as described (see above). If the status of the
pancreatic duct cannot be determined intraoperatively, wide exter-
nal drainage of the pancreatic head with closed suction drains,
rather than total pancreatectomy, should be performed, followed
by early postoperative ERCP or MRP.
In cases of severe injury to the duodenum, it may be advisable
to divert gastric contents away from the duodenal repair. One
technique for accomplishing this diversion is duodenal diverticu-
larization, which employs primary closure of the duodenal wound,
antrectomy, vagotomy, end-to-side gastrojejunostomy, drainage of
the CBD with a T tube, and lateral tube duodenostomy [see Figure
5].The goals are (1) complete diversion of both gastric and biliary
contents away from the duodenal injury, (2) provision of enteral
nutrition via the gastrojejunostomy, and (3) conversion of a poten-
tial uncontrolled lateral duodenal fistula to a controlled fistula.
A less formidable and less destructive alternative technique for
diversion of gastric contents is pyloric exclusion, which does not
employ antrectomy, biliary diversion, or vagotomy [see Figure
6].51,66-68 This procedure is performed through a gastrotomy and
involves grasping the pylorus with a Babcock clamp, suturing the Figure 6 Pyloric exclusion consists of closure of the pylorus
pylorus closed with absorbable size 0 polyglycolic acid or polygly- from within the stomach, followed by gastrojejunostomy. The pro-
conate, and constructing a loop gastrojejunostomy. Gastric flow is cedure eliminates discharge of gastric acid into the duodenum,
then diverted away from the duodenum for several weeks while the thus minimizing the stimulation of pancreatic secretion and
duodenal and pancreatic duct injuries heal. After a period of 2 reducing morbidity if there is breakdown of a repair.
involve major pancreatic duct injury. Accordingly, several authors ed by careful inspection of the pancreas and accurate determina-
have advocated managing all blunt pediatric pancreatic injuries tion of the status of the main pancreatic duct.9
nonoperatively with bowel rest, serial abdominal CT scans to
watch for pseudocyst formation, and percutaneous drainage as Fistula
required.76-79 However, this approach is generally associated with Postoperative pancreatic fistula has been defined as any measur-
a high morbidity and a prolonged hospital course and therefore able drain output with an amylase level higher than three times the
may not be justified, given the good recovery reported after distal serum level.50 It is the most common complication after pancreatic
pancreatectomy with splenic salvage.80 Pseudocysts develop in duct injury, occurring in 7% to 20% of patients (and in 26% to 35%
40% to 100% of children with major duct injury,78,81,82 and recur- of patients with combined pancreatic-duodenal injury).2,13,40,88,89
rent episodes of pancreatitis may arise long after the time of Direct suture closure of the main pancreatic duct may help mini-
injury.16,83 ERCP with proximal stenting of duct injuries may be a mize this complication; fibrin sealants appear to be ineffective.90
useful adjunct to care in these patients, but it requires a skilled The vast majority of pancreatic fistulas are minor (drain output
pediatric endoscopist. < 200 ml/day) and spontaneously resolve within 2 weeks after
A report from Toronto detailed the management of 35 children injury, given adequate external drainage. In a multicenter review
with pancreatic trauma over a 10-year period.78 In 23, the injury of distal pancreatectomy for trauma, the postoperative fistula rate
was diagnosed early (< 24 hours), whereas in the remaining 12, was 14% (10/71), and fistulas closed spontaneously in 89% (8/9)
the diagnosis was initially missed. In all, 28 of the 35 were man- of survivors within 6 to 54 days.63 Extirpation of a residual pan-
aged nonoperatively. A subsequent report provided a more de- creatic sequestrum was required to facilitate fistula closure in one
tailed examination of 10 patients from this group who had pan- patient. By way of comparison, a subsequent study reported a
creatic duct transections.79 Pseudocysts developed in 44% and 3.3% fistula rate after elective distal pancreatectomy for chronic
were managed in all cases with percutaneous drainage. Atrophy of pancreatitis.55
the distal pancreatic remnant developed in 75%, but there was no High-output fistulas (drain output > 700 ml/day) are rare.
evidence of endocrine or exocrine dysfunction. A report from Generally, either more extended external drainage or surgical
Japan found that pseudocysts developed in five out of five children intervention is required for resolution. If a high-output fistula does
with pancreatic duct injuries that were managed nonoperatively.82 not progressively decrease in volume or persists for longer than 10
The data suggest that pediatric pancreatic injuries can be success- days, ERCP is indicated to help establish the cause of the persis-
fully managed nonoperatively but also that there is a high inci- tent fistula and guide further therapy. Nutritional support must be
dence of pseudocyst formation necessitating further hospitaliza- provided throughout this period. At this point, as noted [see
tion and interventions and that atrophy of the distal remnant is Management, Grade IV: Proximal Transection or Parenchymal
common. Several pediatric surgeons have argued for the benefits Injury with Probable Duct Disruption, above], the surgeon’s fore-
of distal pancreatectomy in terms of shortening hospital stay and sight in placing a feeding jejunostomy at the time of the initial
minimizing intervention.29,80,84 trauma laparotomy is rewarded. Elemental feeding formulas cause
Nonoperative management of adults with blunt pancreatic less pancreatic stimulation than standard enteral formulas and
injuries has been less well studied. In one report, patients with should therefore be tried before the patient is committed to
grade I and II injuries (confirmed by laparotomy) had a higher TPN.52 The somatostatin analogue octreotide acetate has shown
morbidity with external drainage than with exploration without promise in treating prolonged high-output pancreatic fistulas but
drainage.85 Selection bias might have affected these results, how- only when any infection has been eradicated and when pancreat-
ever, in that less severe injuries might not have been drained. ic duct obstruction or stricture is absent.91
Proponents of nonoperative management of grade I and II injuries The use of octreotide as an adjuvant to standard fistula man-
have advocated early ERCP to identify the presence of any pan- agement probably reduces fistula output, but whether it hastens
creatic duct injuries that would necessitate surgical interven- fistula closure remains to be proved.92 Somatostatin analogues do
tion.86,87 Proximal stenting of the pancreatic duct has been suc- appear to prevent postoperative complications and fistula forma-
cessful in isolated case reports of duct injuries in adults.33 Further tion in patients undergoing elective pancreatic resection. However,
study is indicated before any recommendations can be made nonrandomized studies addressing the efficacy of somatostatin
regarding nonoperative management of pancreatic duct injury in analogues in pancreatic trauma patients have yielded conflicting
adults. For the present, I continue to advocate operative manage- results.93,94 Moreover, in the trials demonstrating reductions in
ment for known or suspected pancreatic duct injury. postoperative complications with octreotide use in elective pan-
creatic resection, octreotide administration was initiated in the
COMPLICATIONS
preoperative period—a time frame that is not applicable to the
The complication rate after pancreatic injury remains uncom- trauma setting. The octreotide dosage typically starts at 50 µg sub-
fortably high. Between 20% and 40% of patients who undergo cutaneously every 12 hours but may rise as high as 1,000 µg/day.
surgical intervention for a pancreatic duct injury have a compli- Although octreotide has been included in TPN solutions, this
cated postoperative course, and the rate is even higher if both the practice remains controversial and is not recommended by the
pancreatic head and the duodenum were injured.1 The risk of 1997 package insert, because of the formation of glycosyl octre-
complications is directly and independently related to the injury otide conjugates that may reduce the efficacy of the agent.95 The
grade on the AAST scale and to the presence or absence of an major potential side effects are unpredictable changes in serum
associated bowel injury.2 Although most of the complications of glucose levels, pain at the injection site, and various nonspecific
pancreatic duct injury are either self-limiting or treatable, there is GI complaints.
a significant risk of sepsis and multiple organ dysfunction syn-
drome (MODS), which are responsible for nearly 30% of deaths Abscess
resulting from pancreatic trauma. In some series, as many as one The incidence of abscess formation after pancreatic trauma
half of the postoperative complications could have been prevent- ranges from 10% to 25%, depending on the number and type of
associated injuries present. Early operative or percutaneous deficiency (diet-controlled hyperglycemia after 80% pancreatecto-
decompression or evacuation is critical, though even with these my) was documented, and no instances of exocrine insufficiency
measures, the mortality in this group of patients remains about were observed.63 In another study, no cases of pancreatic insuffi-
25%.61,96 In most cases, the abscesses are subfascial or peripan- ciency were reported after resection of as much as 90% of the pan-
creatic; true pancreatic abscesses are unusual and generally result creas.88 By way of contrast, patients with chronic pancreatitis who
from inadequate debridement of dead tissue or inadequate initial undergo distal pancreatectomy have an incidence of diabetes rang-
drainage.40,63,89,97 True pancreatic abscesses often are not ing from 15% (with 0% to 33% of the gland resected) to 64%
amenable or responsive to percutaneous drainage and must be (with 50% to 75% of the gland resected).55
treated with prompt surgical debridement and drainage. Per-
cutaneous decompression may be helpful in distinguishing abs-
cesses from pseudocysts (see below). Injuries to the Duodenum
Duodenal injuries are uncommon. A 6-year statewide review in
Pancreatitis Pennsylvania found the incidence of blunt duodenal injury to be
Transient abdominal pain and a rise in the serum amylase con- only 0.2% (206 of 103,864 trauma registry entries), and only 30
centration, signaling pancreatitis, may be anticipated in 8% to of the patients had full-thickness duodenal injuries.100 About 75%
18% of postoperative patients.5,63,98 This type of pancreatitis is of the patients in published reports of duodenal injury sustained
treated with nasogastric decompression, bowel rest, and nutrition- penetrating rather than blunt trauma; however, this figure may pri-
al support and can be expected to resolve spontaneously. A much marily reflect the experience of urban trauma centers.101 Blunt
less common but far more deadly complication is hemorrhagic duodenal injuries are the result of a direct blow to the epigastrium,
pancreatitis.The first sign of this complication may be bloody pan- which in adults is usually the result of a steering-wheel injury to an
creatic drainage or a fall in the serum hemoglobin concentration, unrestrained driver and in children is usually the result of a direct
with the patient rapidly becoming desperately ill. It is fortunate blow from a bicycle handlebar or similar device. It is well known
that this complication occurs in fewer than 2% of operative pan- that the insidious nature of many blunt duodenal injuries makes
creatic trauma patients: mortality may approach 80%, and there is the initial diagnosis difficult unless a high index of suspicion is
no effective treatment.40,56 maintained. Nevertheless, delays in the diagnosis of duodenal
trauma continue to plague trauma surgeons and seriously com-
Secondary Hemorrhage promise patient care.102
Postoperative hemorrhage necessitating blood transfusion may
DIAGNOSIS
occur in 5% to 10% of pancreatic trauma patients, particularly
when external drainage after pancreatic debridement was inade- The radiologic signs of duodenal injury on the initial plain
quate or when intra-abdominal infection has developed.98,99 abdominal or upright chest radiograph are often quite subtle. Mild
Generally, reoperation is required to control secondary hemor- spine scoliosis or obliteration of the right psoas muscle may be vis-
rhage, though angiographic embolization may be an effective ible, in addition to retroperitoneal air, which is often difficult to
alternative. distinguish from the overlying transverse colon. An early suspicion
of retroperitoneal duodenal rupture is best confirmed or excluded
Pseudocysts by means of either an abdominal CT scan, with both oral and I.V.
Blunt pancreatic injuries that were missed or were intentionally contrast, or an upper GI series, first with a water-soluble contrast
managed nonoperatively often result in the formation of a pseudo- agent and then with barium if the initial examination yields nega-
cyst; in one report, 22 pseudocysts developed in 42 blunt pancre- tive results. The findings must be interpreted with a high index of
atic trauma patients managed nonoperatively.8 The status of the suspicion for injury, and any uncertainty in interpretation is ade-
pancreatic duct is the key determinant of how a pancreatic quate justification for operative exploration.
pseudocyst is treated. If the pancreatic duct is intact, percutaneous Even with careful examination, false negative results are known
drainage of the pseudocyst is likely to be effective. If the pseudo- to occur.103 In one study of the accuracy of CT in diagnosing duo-
cyst is secondary to major disruption of the duct, however, percu- denal and other small bowel injuries, only 10 (59%) of 17 scans
taneous drainage will not provide definitive therapy but will con- were prospectively (i.e., preoperatively) interpreted as suggestive
vert the pseudocyst to a chronic fistula. ERCP should therefore of bowel injury, but 15 (88%) of 17 were suggestive when evalu-
precede any attempt at percutaneous drainage. If pancreatic duct ated retrospectively.104 The investigators emphasized that using
stenosis or injury is demonstrated, the treatment options are (1) CT to diagnose blunt bowel rupture requires careful inspection
reexploration and partial resection of the gland, (2) internal Roux- and technique to detect the often subtle findings. Abdominal CT
en-Y drainage of the distal gland, and (3) endoscopic transpapil- findings suggestive of duodenal injury may be difficult to confirm
lary stenting of the pancreatic duct.32 There is some evidence to with duodenography.105 In a series of 96 patients with CT findings
suggest that surgical decompression will be required if the pseudo- suggestive of duodenal injury, duodenography had a sensitivity of
cyst is larger than 10 cm.82 54% and a specificity of 98%. For injuries necessitating operative
repair, the sensitivity was only 25%, with a 25% false negative rate.
Exocrine and Endocrine Insufficiency In another study, 83% of patients in whom diagnosis of blunt duo-
Exocrine and endocrine insufficiency are unusual after pancre- denal injury was delayed had subtle CT findings (e.g., pneu-
atic trauma. Animal and human studies suggest that a residuum as moperitoneum, unexplained fluid, and unusual bowel morpholo-
small as 10% to 20% of the normal pancreatic tissue mass is ade- gy) that were dismissed.106 The authors emphasized the point that
quate for pancreatic function.6 The implication is that any resec- subtle findings of duodenal injury on abdominal CT should be an
tion distal to the mesenteric vessels should leave an adequate indication for laparotomy.
amount of functioning pancreatic tissue. In a multicenter study of Diagnostic peritoneal lavage (DPL) is unreliable in detecting
74 cases of distal pancreatic resection, only one case of endocrine isolated duodenal and other retroperitoneal injuries. Nevertheless,
Table 2 Factors Determining Severity of Duodenal Injury108

Degree of Injury
Factor Severe
Mild
Means of Injury Stab Blunt force or missile
Size of Injury ≤ 75% of circumference > 75% of circumference
Location of injury in duodenum D3, D4 D1, D2
Interval between injury and repair ≤ 24 hr > 24 hr
Adjacent injury to CBD Absent Present
it is often helpful, in that approximately 40% of patients with a mary duodenal repair or no duodenal procedure at all.Twenty-six
duodenal injury have associated intra-abdominal injuries that will of the 56 patients with grade III to V injuries were treated with
result in a positive DPL result.The presence of amylase or bile in more complex duodenal treatment strategies, including pyloric
the lavage effluent is a more specific indicator of possible duode- exclusion, duodenoduodenostomy, duodenojejunostomy, and
nal injury. Serum amylase levels are nondiagnostic as well, but if pancreaticoduodenectomy.
they are found to be elevated, additional investigation (via CT or
celiotomy) for possible pancreatic or duodenal injury is warrant- Duodenal Hematoma
ed. At celiotomy, the presence of any central upper abdominal Duodenal hematoma is generally considered a consequence of
retroperitoneal hematoma, bile staining, or air mandates visual- childhood play or child abuse. In one report, 50% of cases of duo-
ization and thorough examination of the duodenum. The techni- denal hematoma in children were attributable to child abuse.110
cal details of exposure of the entire duodenum and pancreas are However, this condition can occur in adults as well. Nearly one
well described elsewhere.107 third of patients present with obstruction of insidious onset at least
48 hours after injury, presumably resulting from a fluid shift into
MANAGEMENT
the hyperosmotic duodenal hematoma. Generally speaking, duo-
denal hematoma is a nonsurgical injury, in that the best results are
Classification of Duodenal Injury obtained with conservative or nonsurgical management.111 It may
Treatment of duodenal trauma is determined by the severity be diagnosed by means of either contrast-enhanced CT or an
of the injury and the likelihood of postrepair complications. upper GI study. The initial contrast examination should be done
Approximately 70% to 80% of duodenal wounds can safely be with a water-soluble agent (e.g., meglumine diatrizoate), followed
repaired primarily; approximately 20% to 30% call for more com- by a barium study to provide the greater detail needed for detec-
plex procedures. A 1980 review of 247 patients treated for duo- tion of the so-called coiled-spring or stacked-coin sign. This find-
denal trauma catalogued factors that determined whether a duo- ing is characteristic of intramural duodenal hematoma, but it is
denal wound could be primarily repaired.108 In the 228 patients present in only about one quarter of patients with hematomas.
who survived longer than 72 hours, the overall duodenal fistula Although initial treatment is nonoperative, care must be taken
rate was 7%, and the mortality was 10.5%. The investigators iden- to exclude associated injuries, with particular attention paid to
tified five factors that, in their view, correlated most significantly the potential for pancreatic injuries, which occur in 20% of
with the severity of duodenal injury and subsequent morbidity patients.111 Continuous nasogastric suction should be employed
and mortality [see Table 2].To these five factors should be added a and TPN initiated. If signs of obstruction do not spontaneously
sixth—namely, the presence of a pancreatic injury, which is a sig- abate, the patient should be reevaluated with upper GI contrast
nificant predictor of late morbidity and mortality. These factors, studies at 5- to 7-day intervals. Ultrasonography may also be
both individually and in different combinations, have been used to employed to follow a resolving duodenal hematoma.112
develop a variety of duodenal injury classification systems. One Percutaneous drainage of an unresolving duodenal hematoma has
such system is simply to divide injuries into two categories, mild been reported,113,114 but the usual recommendation is to perform
and severe. In the study already mentioned,108 the investigators operative exploration and evacuation of the hematoma after 2
reported a 0% mortality and a 2% duodenal fistula rate in patients weeks of conservative therapy to rule out stricture, duodenal per-
with mild duodenal trauma, compared with a 6% mortality and a foration, or injury to the head of the pancreas as factors that might
10% fistula rate in those with severe duodenal trauma. In gener- be contributing to the obstruction.115 In a review of six cases of
al, primary repair is satisfactory for mild duodenal injuries with- duodenal and jejunal hematoma resulting from blunt trauma, the
out associated pancreatic injuries. More complex treatment strate- hematomas resolved with nonoperative management in five cases;
gies may be required for more severe duodenal injuries. the average hospital stay was 16 days (range, 10 to 23 days), and
A more contemporary classification system is that developed by the average duration of TPN was 9 days (range, 4 to 16 days). In
the AAST, in which duodenal injuries are graded from I to V in the sixth case, upper GI series showed evidence of complete bowel
order of increasing severity [see Table 1 and Figure 7].46 In a multi- obstruction, which failed to resolve after 18 days of conservative
center review of 164 duodenal trauma patients to whom the management. Laparotomy revealed jejunal and colonic strictures
AAST classification scheme was applied, there were 38 grade I, 70 with fibrosis, which were successfully resected.116
grade II, 48 grade III, 4 grade IV, and 4 grade V injuries. Primary If a duodenal hematoma is incidentally found at celiotomy,
repair was the sole treatment in 71% (117) of all cases.109 Ninety a thorough inspection must be done to exclude perforation.
of the 108 patients with grade I or II injuries underwent either pri- Inspection necessitates an extended Kocher maneuver, which usu-
Patient has possible duodenal injury
History of direct blow to epigastrium is suggestive.

Obtain serum amylase levels and WBC count.
Perform abdominal x-ray and contrast studies.
If duodenal trauma is likely, perform laparotomy for
inspection of duodenum and grading of injury.
Grade I or II hematoma Grade III
If hematoma is detected at laparotomy, Attempt primary suture closure as first option, with
treat with evacuation. concomitant pyloric exclusion.
If hematoma is detected by nonoperative If primary repair is technically not feasible, treat as follows:
means, observe patient, and support with Injury proximal to ampulla: perform antrectomy plus
NG suction and TPN. gastrojejunostomy and stump closure.
Injury distal to ampulla: perform Roux-en-Y
duodenojejunostomy to proximal end of duodenal injury,
with oversewing of distal duodenum.
Grade I or II laceration Grade IV or V
Perform primary suture closure in one or two layers. Management options are as follows:
Consider pyloric exclusion or buttressing only • Pancreaticoduodenectomy
if there is associated pancreatic injury.
• Reimplantation of ampulla or distal CBD into duodenum
or Roux-en-Y jejunal limb
• Reconstruction with hepaticojejunostomies
• Delayed reconstruction.
Pancreaticoduodenectomy is mandatory for grade V injuries.
Figure 7 Algorithm outlines the treatment of duodenal injury.132
ally successfully drains the subserosal hematoma. It is unclear whether most commonly accomplished by means of pyloric exclusion [see
the serosa of the duodenum should intentionally be incised along its Figure 6].68 This technique, probably first described by Summers
extent to evacuate the hematoma or whether doing so would actu- in 1904 as an adjunct to the treatment of duodenal wounds,119 is
ally increase the likelihood of turning a partial duodenal wall tear less disruptive than true duodenal diverticularization [see Figure
into a complete perforation. Because an extended period of gastric 5].66,120 To date, no prospective, randomized trial has proved that
decompression will probably be required, a feeding jejunostomy gastric diversion is truly beneficial in the setting of duodenal trau-
should be placed. ma, but several reports have supported the use of pyloric exclusion
and gastrojejunostomy in cases of severe duodenal injury71,121 or in
Duodenal Laceration and Transection cases of delayed diagnosis of injury.67 Potential benefits notwith-
For complete transection of the duodenum, primary repair is standing, the additional operating time and the extra anastomosis
appropriate if there is little tissue loss, if the ampulla is not in- required with gastric diversion suggest that this approach should
volved, and if the mucosal edges can be debrided and closed with- be employed with a good deal of selectivity. Marginal ulceration is
out tension. If adequate mobilization for a tension-free repair is a well-described complication of gastric diversion and has prompt-
impossible or if the injury is very near the ampulla and mobiliza- ed some surgeons to add truncal vagotomy to the procedure. Most
tion might result in injury to the CBD, the most reasonable option surgeons, however, do not perform vagotomy with gastric diver-
is a Roux-en-Y jejunal limb anastomosis to the proximal duodenal sion, because nearly all of the pyloric closures open within a few
injury with oversewing of the distal injury. Mucosal jejunal patch weeks, regardless of the type of suture material used, and the occa-
repair is rarely, if ever, employed; it was not used in any of the 164 sional marginal ulcer can be medically managed in the interim.
patients in the multicenter trial previously cited,109 in which only An alternative or addition to gastric diversion is duodenal
five patients (3%) underwent repair with duodenoduodenostomy decompression via retrograde jejunostomy. In a study of 237
or duodenojejunostomy. Pancreaticoduodenectomy is only requir- patients with a variety of duodenal injuries treated by means of ret-
ed for duodenal injuries if there is uncontrollable pancreatic hem- rograde jejunostomy tube drainage, the fistula rate was lower than
orrhage or if duodenal injuries exist in combination with distal 0.5%, whereas the incidence of duodenal complications was
CBD or pancreatic duct injuries. 19.3% when decompression was not performed.122 Retrograde
Several techniques may be applied to help protect a tenuous duodenodenal drainage is preferred to lateral duodenostomy.
duodenal repair. One option is buttressing the repair with omen- Direct drainage with a tube through the suture line results in a
tum (my preference) or a serosal patch from a loop of jejunum. high (23%) rate of dehiscence or fistula. In a 1984 review of the
This approach seems intuitively logical, though its benefits are literature on penetrating duodenal trauma and tube duodenosto-
unproven.117,118 Another option is diversion of gastric contents, my,123 there was an overall mortality of 19.4% and a fistula rate of
11.8% when decompression was not performed, compared with a Early death from a duodenal injury, particularly a penetrating
9% mortality and a 2.3% fistula rate when it was. The authors injury, is usually attributable to exsanguination from associated
concluded that tube drainage should be performed either via the vascular, hepatic, or splenic trauma.4,128 The proximity of the duo-
stomach or via a retrograde jejunostomy, noting that these meth- denum to other vital structures and the high-energy transfer
ods were associated with a lower fistula rate and a lower overall mechanisms involved make isolated duodenal injuries uncom-
mortality than lateral tube duodenostomy was. Nonetheless, there mon, though certainly not unheard of. Most late deaths from duo-
has been no prospective, randomized analysis of the efficacy of denal trauma are attributable to infection and MODS. In as many
tube duodenal drainage techniques, and not all surgeons support as one third of patients who survive the first 48 hours after duo-
the use of decompression in this setting. denal injury, a complication related to the injury eventually devel-
Mortality directly related to the duodenal injury is the result ops. Common complications include anastomotic breakdown, fis-
of duodenal dehiscence, uncontrolled sepsis, and subsequent tula, intra-abdominal abscess, pneumonia, bloodstream infection,
MODS. Given the known lethal nature of duodenal dehiscence and organ failure. Late deaths typically occur from 1 to 2 weeks or
and duodenal fistula, the operating surgeon may well be strongly more after the initial duodenal injury; about one third of them are
tempted to add pyloric exclusion, anastomosis buttressing, and directly attributable to the injury itself.108,125
duodenostomy to the repair of grade III or IV duodenal injuries. The length of time between injury and definitive treatment
Concomitant pancreatic injury should be included as a high-risk has a substantial effect on the development of late complications
confounder that might warrant the addition of pyloric exclusion and subsequent mortality. In one study, 10 patients were identi-
to the duodenal repair. In a report of 40 patients with penetrating fied in whom the diagnosis of duodenal injury was delayed for
duodenal injuries, 14 patients had combined pancreatic-duodenal more than 24 hours; four of the 10 died, and three of the 10 had
wounds. Five of these 14 were treated with primary duodenal duodenal fistulas.129 In a classic report from 1975, the remark-
repair alone, and two of the five had duodenal leaks. Three of the able importance (and frequency) of delays in the diagnosis of
14 underwent pyloric exclusion in addition to primary repair, and duodenal injury was strikingly demonstrated.130 Diagnosis was
none of them had duodenal leaks.124 delayed by more than 12 hours in 53% of the patients in this
report and by more than 24 hours in 28%. In patients whose
DETERMINANTS OF OUTCOME
diagnosis was delayed for more than 24 hours, mortality was
Large series published toward the end of the 20th century doc- 40%; in those who underwent surgery within 24 hours of injury,
umented an average mortality of 18% in patients with duodenal mortality was 11%. These observations were subsequently con-
injuries, but the mortalities cited in individual reports showed firmed by other studies. In one study, two of the four blunt duo-
great variability, ranging from 6% to 29%.1,71,117,125 Mortality denal trauma patients with delayed diagnoses died, and the
directly related to duodenal injury is much lower—generally, 2% other two had duodenal fistulas.108 In another study, 100% of
to 5%—and is primarily the result of complications, dehiscence, the deaths directly attributable to duodenal injury occurred in
sepsis, and MODS.42,108,109,117,121,122,126,127 Morbidity after duode- patients with delayed diagnoses.102
nal injury ranges from 30% to 63%; however, in only about one The implication of these observations is that the first priority in
third of cases is morbidity directly related to the duodenal injury managing duodenal trauma, as in managing pancreatic trauma,
itself.108,117,125 To a large extent, the variability in morbidity and should be control of hemorrhage. The second priority should be
mortality statistics can be explained by differences in the mecha- limiting bacterial contamination from associated colon or other
nism of injury, the nature and severity of associated injuries (if bowel injury, with the aim of preventing late infections. As a rule,
present), and the time between initial injury and diagnosis. For if a duodenal injury has occurred, it will be apparent intraopera-
example, a review of 100 consecutive penetrating duodenal tively; thus, the next priority should be a diligent search for poten-
injuries documented a mortality of 25%,117 compared with a mor- tial pancreatic injury, with an emphasis on assessing the status of
tality of 12% to 14% for blunt injuries.102,108 the pancreatic duct.1,6
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118. McInnis WD, Aust JB, Cruz AB, et al: Traumatic Acknowledgments
103. Sherck J, Oakes D: Intestinal injuries missed by injuries of the duodenum: a comparison of 1
computed tomography. J Trauma 30:1, 1990 degrees closure and the jejunal patch. J Trauma Figures 1, 3, and 6 Carol Donner.
104. Mirvis S, Gens D, Shanmuganathan K: Rupture 15:847, 1975 Figures 4 and 5 Susan Brust, C.M.I.
7 TRAUMA AND THERMAL INJURY 9 ABDOMINAL EXPOSURE AND CLOSURE — 1
9 OPERATIVE EXPOSURE OF
ABDOMINAL INJURIES AND
CLOSURE OF THE ABDOMEN
Erwin R.Thal, M.D., F.A.C.S., and Terence O’Keeffe, M.B., Ch.B., F.R.C.S.Ed.
Over the past two decades, the advent of nonoperative manage- All areas of the body that are not included in the skin prepara-
ment techniques for many solid-organ injuries has led to a signifi- tion should be covered so as to prevent excessive heat loss, and
cant shift in the care of patients who have sustained abdominal warming devices should be placed if available. Sterile draping
trauma. The ever-improving accuracy of diagnostic modalities should be placed so as to allow access to all potential injuries. If
(computed tomography in particular) has also contributed to this the patient is in extremis and in danger of expiring, however,
shift.1-4 Today, fewer patients require operative intervention for patient preparation should be limited to a rapid skin cleansing and
treatment of abdominal injuries.Those who do require such inter- surgery should commence immediately.
vention make up a select group who continue to pose a significant
challenge to surgeons. In our view, these patients are best managed
by following a standardized operative approach, the aim of which is Incision and Initial Exploration
to diagnose, prioritize, and treat the injuries in an expeditious fash-
CHOICE OF INCISION
ion so that the patient is not kept in the operating room any longer
than necessary [see Figure 1]. Such an approach optimizes patient A midline celiotomy is the incision of choice. Its advantages are
care by minimizing the risk of missed injuries and ensuring a rapid that it allows rapid and easy access to the abdominal cavity, with
and efficient response by the members of the surgical team. good exposure of the majority of the intra-abdominal organs and
Naturally, every patient’s care should be individualized as neces- structures, and that it can be extended into a median sternotomy if
sary. In general, however, a standardized operative approach, com- necessary. Its main disadvantage is that it may not provide adequate
plemented by a solid knowledge of a variety of exposures and tech- exposure of injuries in the deep recesses of the upper quadrants.
niques, should allow the surgeon to deal with virtually any abdom- Patients with previous midline incisions pose a challenge to the
inal injury. In this chapter, we outline our recommended approach surgeon. If at all possible, an attempt should be made to enter the
to operative intervention in patients with abdominal trauma. abdomen above or below the previous incision, in an area less like-
ly to have adhesions. If this is not possible, an alternative incision,
such as a chevron (bilateral subcostal) incision, should be consid-
Patient Preparation ered. A chevron incision provides entry into the abdomen while
The key to success in this setting is advance preparation aimed avoiding any viscera that are adherent to the undersurface of the
at covering all eventualities. Such preparation involves both the previous laparotomy scar. However, this incision takes more time,
environment and the patient. The room should be warmed to does not provide ideal exposure, and is associated with a higher
ensure that the patient does not lose too much heat and become morbidity; accordingly, it should be considered only when the cir-
hypothermic. The instruments should be open on the back table, cumstances are dire. Paramedian, subcostal, retroperitoneal, and
and specific instruments should be available when specific injuries flank incisions are not recommended, for much the same reasons.
are anticipated (e.g., a vascular set should be available when a vas-
INITIAL EXPLORATION
cular injury is suspected). A sufficient number of laparotomy pads
should be on hand, and a retracting device with which the surgi- Once the peritoneal cavity has been entered, initial exploration
cal team is familiar should be employed. Cell saver systems and proceeds in an orderly fashion so as to minimize hemorrhage and
rapid infusion systems can be useful adjuncts; if desired and avail- contamination, prevent iatrogenic injury, and facilitate the expedi-
able, they should be requested in advance.5 tious identification of injuries. The intestines are eviscerated, and
Patient preparation begins with the insertion of a nasogastric or gross blood is rapidly evacuated. Laparotomy pads are then rapid-
orogastric tube and a Foley catheter. Invasive monitoring lines ly placed in all four quadrants to pack the abdomen; the right
may have to be placed, and resuscitation should continue as the upper quadrant is packed first, then the left upper quadrant, and
patient is being prepared. A broad-spectrum antibiotic should be finally the lower two quadrants. Care should be taken not to tear
administered intravenously before the initial incision is made. the falciform ligament or the fibrous capsule of the liver during
When the patient is correctly positioned on the operating table, this maneuver. Blood pressure may drop when the abdomen is
skin preparation should extend from the sternal notch superiorly decompressed. Anesthesia should be given the opportunity to
to include the anterior thorax.Thus, no further preparation will be catch up with resuscitation efforts at this point.
required if a thoracic injury is identified or vascular control in the Once hemodynamic stability has been achieved, the intraperi-
thorax is necessary. Thoracostomy, if required, can also be per- toneal portion of the exploration is begun. In cases of blunt trau-
formed without the drapes being changed. Inferiorly, skin prepa- ma, the temporary packs (except for those around the solid vis-
ration should extend to the upper anterior thighs so that the prox- cera) may now be carefully removed and any remaining blood
imal saphenous veins are available if a vascular reconstruction is evacuated. In cases of penetrating trauma, it is often easier initial-
required and so that distal vascular control can be achieved with- ly to address the site of ongoing hemorrhage via a direct approach.
out undue delay. Vascular injuries are controlled manually until proximal and distal
Patient has sustained abdominal trauma for which

operative exposure is warranted
Prepare abdomen, as well as chest and upper thighs.

Perform midline celiotomy.
Only hemorrhage is present Hemorrhage and contamination are Only contamination is present
present
Pack abdomen. Control contamination.
Control bleeding and contamination.
Allow anesthesia to catch up.
Allow anesthesia to catch up if necessary.
Bleeding persists Bleeding ceases
Reevaluate patient and continue

efforts to control bleeding.
Treat any coagulopathies.
Perform systematic evaluation of abdomen.
Bleeding persists Bleeding ceases No additional exposure Additional exposure is

is required required
Pack abdomen.
Perform Kocher maneuver.
Perform left or right medial
visceral rotation, as indicated.
Patient is physiologically unstable Patient is physiologically stable
Perform definitive repair of injuries.

Close abdomen.
Perform damage-control procedure.
Leave abdomen open.
Figure 1 Algorithm outlines the approach to initial operative exposure in abdominal trauma patients.
control can be achieved. Mesenteric bleeding sites are clamped. be examined, and particular care must be taken not to miss an
Solid organs are initially packed as for blunt trauma, then treated injury at the mesenteric border. Careful consideration should also
with directed repair. In either scenario, bleeding that remains be given to the possibility of mesenteric vascular injuries, which
uncontrolled by packing requires immediate attention. may be manifested as mesenteric hematomas.
The enteric viscera are then examined in an orderly fashion. Next, the colon is inspected from the cecum to the rectum. If
The anterior aspect of the stomach is inspected from the esopha- injuries are present or missile tracts are noted in proximity to a
gogastric junction down to the pylorus. If an injury is present or is portion of the ascending or descending colon, the retroperitoneal
strongly suspected on the basis of the mechanism of injury or the portion of the colon is inspected by incising the white line of Toldt
presence of a hematoma or soilage, the posterior aspect of the (the retroperitoneal reflection) so as to allow access to the poste-
stomach is examined by opening the gastrocolic omentum; this rior surface of the colon. Finally, the laparotomy pads around the
measure also permits examination of the anterior surface of the solid organs are removed, one organ at a time, to permit inspec-
body of the pancreas. The exploration then continues distally tion for hemorrhage or injury.
along the course of the GI tract. If duodenal or pancreatic injury Once the peritoneal survey is complete, the retroperitoneum is
is a possibility, the duodenum is mobilized fully by means of a inspected for potential injuries. Retroperitoneal hematomas are
Kocher maneuver.The duodenojejunal junction at the ligament of classified on an anatomic basis: zone 1 is the central area, bound-
Treitz is then inspected, and the small intestine is inspected all the ed laterally by the kidneys and extending from the diaphragmatic
way to the ileocecal valve. Both sides of the small intestine must hiatus to the bifurcation of the vena cava and the aorta; zone 2
comprises the lateral area of the retroperitoneum, from the kidneys the necessary repairs. The repairs themselves are described in
laterally to the paracolic gutters; and zone 3 is the pelvic portion [see greater detail elsewhere [see 7:6 Injuries to the Liver, Biliary Tract,
Figure 2].Whether exploration is warranted for a retroperitoneal Spleen, and Diaphragm; 7:7 Injuries to the Stomach, Small Bowel,
hematoma depends on the mechanism of injury and the location of Colon, and Rectum; 7:8 Injuries to the Pancreas and Duodenum; 7:10
the hematoma [see Priorities in Management, Repair of Retroperi- Injuries to the Great Vessels of the Abdomen; and 7:11 Injuries to the
toneal Injuries, below,and 7:10 Injuries to the GreatVessels of the Abdo- Urogenital Tract].
men]. A careful evaluation is performed to identify possible occult AORTA AND BRANCHES
injuries to organs (e.g., the pancreas, the duodenum, the retroperi-
toneal colon, the kidneys, and vascular structures). Control of the aorta can be gained at several different levels,
The initial exploration concludes with a brief pelvic survey depending on the site of injury. The supraceliac aorta can be
aimed at excluding injuries to the rectum or the distal urogenital exposed by incising the gastrohepatic ligament, retracting the left
hemiliver laterally and cephalad, and retracting the stomach cau-
tract (including the bladder). At the end of the operation, this ini-
dally. The esophagus and periesophageal fat pad are then mobi-
tial inspection should be repeated, following the same sequence, to
lized laterally to permit identification of the abdominal aorta at the
confirm that no injuries have been missed.
diaphragmatic hiatus, at which point the aorta can be encircled,
clamped, or compressed. This exposure allows control of the
Operative Exposure aorta, but it is inadequate in terms of providing vascular access for
definitive repair. Better exposure of the supraceliac aorta and its
To expose the various organs that may be injured in patients branches can be obtained by means of a left medial visceral rota-
who have sustained abdominal trauma, the surgeon must be famil- tion [see Figure 3]. To perform this maneuver, the splenorenal lig-
iar with a number of different techniques. In what follows, we ament is mobilized with a combination of sharp and blunt dissec-
detail the operative exposures that enable the surgeon to perform tion. The left peritoneal reflection is incised from the splenocolic
flexure down the paracolic gutter to the level of the distal sigmoid
colon. The left-side viscera are then gently mobilized to the mid-
line (mostly with blunt dissection) in a plane anterior to Gerota’s
fascia.This technique allows exploration of the entire length of the
abdominal aorta, the origin of the celiac axis, the origin of the
superior mesenteric artery, the left iliac system, and the origin of
the right common iliac artery. In addition, it facilitates control of
1
the left renal vascular pedicle before exploration of a left-side zone
2 retroperitoneal hematoma. Alternatively, a variation on the stan-
dard left medial visceral rotation (the Mattox maneuver6) may be
2 2 employed, in which the left kidney is also included in the organs
that are rotated (the plane being anterior only to the muscles of the
posterior abdominal wall).This variant may afford better access to
the origin of the left renal artery.
If the injury is more distal, the aorta may be approached in a
transperitoneal fashion. The small intestine is retracted to the
right, the transverse colon is retracted cephalad, and the descend-
ing colon is retracted laterally. The peritoneum is then incised
directly over the aorta, and the third and fourth portions of the
duodenum are mobilized cephalad.The proximal limit of this dis-
section extends to the left renal vein, which may be divided if nec-
essary to provide more cephalad access to the aorta. If ligation of
the left renal vein is called for, it should be done at a point where
3
the gonadal vein will be left intact to drain the kidney. A more lim-
ited dissection may suffice to expose the distal infrarenal aorta.
Depending on the injury, distal control may or may not be
required. Control may be achieved at the level of the distal
infrarenal aorta, above the bifurcation.
Once again, if the patient is in extremis, formal dissection may
be curtailed and proximal control achieved either by manually
compressing the aorta against the spine at the level of the esopha-
gogastric junction or by using an aortic occluder [see 7:10 Injuries
to the Great Vessels of the Abdomen].
VENA CAVA AND BRANCHES
Access to the suprahepatic inferior vena cava can be gained only

by either incising the central tendon of the diaphragm or by per-
forming a median sternotomy and opening the pericardium. The
Figure 2 Shown are the anatomic zones of the retroperitoneum: infrahepatic inferior vena cava is exposed by performing a right
zone 1 (central), zone 2 (flank), and zone 3 (pelvic). medial visceral rotation (the Cattell-Braasch maneuver) [see Figure
Figure 3 Left medial visceral rota-

tion is performed to provide expo-
sure of the entire length of the
abdominal aorta, the left renal vas-
culature, the origins of the mesen-
teric arteries, and the common iliac
bifurcation.
4]. The right colon is mobilized by taking down the hepatic flex- step is challenging and may have to be performed partly by palpa-
ure and then incising the right peritoneal reflection along the para- tion, with care taken not to injure the inferior vena cava, the hepat-
colic gutter.The colon is once again reflected medially toward the ic veins, or the phrenic vessels [see 7:6 Injuries to the Liver, Biliary
aorta in a plane anterior to Gerota’s fascia with careful blunt dis- Tract, Spleen, and Diaphragm].
section. If additional exposure is necessary, the inferior margin of
SPLEEN
the peritoneal incision may be extended to the root of the mesen-
tery—and even beyond, if the inferior mesenteric vein is sacrificed. The spleen can be mobilized into the midline by dividing the
This exposure permits visualization of both the aorta below the phrenicosplenic and splenorenal ligaments with a mixture of sharp
origin of the superior mesenteric artery and the vena cava below and blunt dissection. In cases where the spleen has been injured
the third portion of the duodenum. Exposure of the portion of the by blunt trauma, these ligaments often are already disrupted, and
vena cava directly below the liver alone can be achieved by per- this disruption facilitates the dissection. The splenocolic ligament
forming a Kocher manuever [see Figure 5] with medial mobiliza- often contains sizeable blood vessels that must be controlled, and
tion of the duodenum and the head of the pancreas. the gastrosplenic ligament contains the short gastric arteries. Once
the spleen is mobilized into the midline, control of the vascular
LIVER
pedicle can be achieved, the splenic injury can be assessed, and
Mobilization of the liver begins with division of the round liga- splenorraphy or splenectomy can be performed as appropriate [see
ment (ligamentum teres), followed by takedown of the falciform 7:6 Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm and
ligament (to prevent iatrogenic trauma to the liver capsule during 5:25 Splenectomy].
exposure and identification of other intraperitoneal injuries). This
PANCREAS
mobilization may be extended as far cephalad as is necessary.
Further mobilization can be achieved by incising the left triangu- Intraoperative evidence of a central hematoma, peripancreatic
lar ligament, with care taken not to injure the suprahepatic inferi- edema, or bile staining in the retroperitoneum or the lesser sac rais-
or vena cava at the diaphragmatic hiatus during the dissection. es the possibility of pancreatic injury.The contents of the lesser sac
When visualization of the right hemiliver is required, the falciform can be visualized by performing a direct inspection through the
ligament should be incised to its most superior extent, and the gastrohepatic ligament or by dividing the ligament. Alternatively,
right triangular ligament should then be carefully divided. This access can be gained by dividing and ligating two or three gas-
troepiploic arcades of the gastrocolic ligament. If it proves neces- DUODENUM, BILIARY TRACT, AND SMALL INTESTINE
sary to explore the pancreas, the stomach is separated from the Exposure of the posterior surface of the duodenum is
transverse colon by completing the division of the gastrocolic lig- achieved by means of a Kocher maneuver [see Pancreas, above,
ament, and a Kocher maneuver is performed to reflect all portions and Figure 5].This technique is also used when injury to the dis-
of the duodenum medially, along with the head of the pancreas. tal extrahepatic biliary system is suspected. The proximal extra-
The peritoneum lateral to the duodenum is incised, and careful hepatic biliary tree is visualized by using a Kocher maneuver in
blunt dissection is employed to mobilize the duodenal loop from conjunction with local exploration of the porta hepatis. In
the common bile duct superiorly to the superior mesenteric vein patients with injuries to the distal duodenum or the proximal
inferiorly. This mobilization allows inspection of the anterior and jejunum, division of the ligament of Treitz may also be neces-
posterior surfaces of the head of the pancreas, as well as the unci- sary for accurate identification of the site of injury. Because of
nate process. If injury to the body or tail of the pancreas is suspect- the mobility of the small intestine, injuries to this structure gen-
ed, the splenorenal and splenocolic ligaments are incised. At this erally are readily identified and repaired without additional
point, the spleen and then the pancreas can be mobilized medial- mobilization.
ly to a position near the level of the superior mesenteric vessels,
and the anterior and posterior aspects of the body and tail of the COLON AND RECTUM
pancreas can be examined [see 7:8 Injuries to the Pancreas and Evidence of staining, pneumatosis, or hematoma in proximity
Duodenum]. to a portion of the ascending or descending colon, particularly in
the setting of related injuries or missile tracts, should prompt a full
KIDNEYS
evaluation of the colon. Because the colon is a partially retroperi-
Operative exposure of the kidneys starts with either a left or a toneal structure, the retroperitoneal reflection must be incised to
right medial visceral rotation, depending on which kidney is allow inspection of the posterior surface of the colon. Sometimes,
involved. The renal vascular pedicle should be controlled before rectal injuries are not accessible via an intraperitoneal approach; in
any hematoma in Gerota’s fascia is opened [see 7:11 Injuries to the this situation, consideration should be given to a diverting colosto-
Urogenital Tract]. Repair of the kidney may be facilitated by mobi- my and presacral drainage [see 7:7 Injuries to the Stomach, Small
lizing the organ out of Gerota’s fascia and retracting it medially. Bowel, Colon, and Rectum].7,8
Figure 4 Right medial visceral rotation is

performed to provide exposure of the infe-
rior vena cava, the infrarenal abdominal
aorta and iliac vessels, and the right reno-
vascular pedicle.
Hepatoduodenal
Ligament Common Duct
Node
Pancreas
Superior
Mesenteric
Renal Artery
Veins
Duodenum
Inferior
Vena Cava
Figure 5 The Kocher maneuver reflects

the duodenum and the pancreatic head
Gonadal Aorta from the retroperitoneum, allowing
Vessels access to the infrahepatic inferior vena
cava as well as to the distal common bile
duct, the duodenum, and the pancreatic
head.
Priorities in Management be placed. Injuries to the proximal abdominal aorta often necessi-
tate that the vessel be controlled in the chest to permit repair.
CONTROL OF HEMORRHAGE In patients who have sustained parenchymal injuries to solid
In the event that the patient remains hemodynamically unstable viscera, control of the vascular inflow is crucial as both a diagnos-
because of persistent uncontrolled hemorrhage, the primary focus tic and a therapeutic maneuver. Gaining control of the splenic
of the initial exploration is control of bleeding. As noted (see hilum effectively arrests further splenic hemorrhage. Similarly, use
above), the approach to hemorrhage control differs depending on of the Pringle maneuver [see 7:6 Injuries to the Liver, Biliary Tract,
whether the patient sustained blunt trauma or penetrating trauma. Spleen, and Diaphragm] to control the vessels in the porta hepatis
In cases of blunt trauma with bleeding from a solid organ, the first (the hepatic artery and the portal vein) helps determine the source
thing that should be done is to attempt repeat packing of the spe- of perihepatic hemorrhage. This maneuver is initially performed
cific bleeding site with a sufficient number of laparotomy pads. by digitally compressing the portal structures; if digital compres-
This is an important skill to master and can be effective as a tem- sion causes the hemorrhage to diminish, the surgeon’s hand is
porizing measure until either more definitive vascular control can replaced with an atraumatic vascular clamp or a Rumel tourni-
be achieved or coagulopathy can be corrected. In cases of pene- quet. Although the Pringle maneuver can be maintained for at
trating trauma, bleeding is more effectively managed by means of least 30 to 45 minutes without causing permanent liver damage,
either vascular control just proximal and distal to the site of injury the clamp or tourniquet should be removed as soon as is feasible.
or direct control at the bleeding site. In the vast majority of cases of liver trauma—aside from those
When significant hemorrhage is anticipated, control of the involving an injury to the retrohepatic vena cava—the use of the
injured vessel should be obtained by the operative techniques dis- Pringle maneuver, combined with perihepatic packing, should
cussed previously [see Operative Exposure, above]. Given the pos- arrest hemorrhage.
sibility of exsanguinating hemorrhage, the surgeon must be pre- In patients who have sustained injuries to the retrohepatic vena
pared to gain proximal aortic control at the diaphragmatic hiatus cava, it may be necessary to gain vascular control by performing
or even within the chest via a left lateral thoracotomy. For immedi- hepatic exclusion before definitive repair can be attempted [see 7:6
ate control, the aorta can be manually compressed at the hiatus; a Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm]. Hepatic
padded Richardson retractor, an aortic compressor, or an assis- exclusion may be achieved by means of either atriocaval shunting
tant’s hand can then take over this function to allow the surgeon to (which is rarely if ever used9,10) or occlusion of the inferior vena
continue the exploration. If a need for prolonged proximal aortic cava both above and below the liver.The latter may lead to signif-
control is anticipated, an atraumatic aortic vascular clamp should icant hemodynamic instability, particularly in volume-depleted
REPAIR OF DAMAGED OR DEVITALIZED BOWEL

patients; however, it may reasonably be considered in patients
whose volume status is adequate. Complete hepatic exclusion Once vascular injuries have been addressed, the next priority is
involves both (1) atriocaval shunting or clamping of both the infra- to repair any enteric injuries [see 7:7 Injuries to the Stomach, Small
hepatic and the suprahepatic inferior vena cava and (2) control of Bowel,Colon,and Rectum]. Because the stomach is a large and well-
hepatic arterial and portal venous inflow.11 In general, injuries to vascularized organ, gastric injuries are usually amenable to prima-
the retrohepatic vena cava are best dealt with by means of dam- ry repair. Injuries to the small intestine that involve less than 50%
age-control procedures. of bowel circumference after debridement of devitalized edges can
Hepatic parenchymal hemorrhage can be challenging, and any be repaired with either a single-layer or a two-layer closure; single-
of a number of techniques may be used to control it, depending layer closure, being less likely to compromise the lumen of the
on the location, type, and degree of bleeding. These techniques bowel, is generally preferred. In cases involving multiple enterot-
range from simple electrocauterization and parenchymal suturing omies in close proximity or a large area of devitalized tissue, a seg-
to argon beam cauterization, direct vessel ligation, hepatotomy, mental enterectomy with primary anastomosis is preferable. The
and even resection [see 7:6 Injuries to the Liver, Biliary Tract, Spleen, anastomosis may be either hand-sewn or stapled; the latter tends
and Diaphragm].12,13 In difficult cases, it may be advisable to per- to be more expeditious but less cost-effective.
form an abbreviated laparotomy, pack the liver extensively, and Solitary injuries to the colon that do not necessitate resection
transport the patient to the angiography suite, where selective after debridement and are not associated with multiple transfu-
embolization can be performed; the patient can then be transport- sions or significant gross contamination are managed by means of
ed to the ICU, undergo warming, and have any coagulopathy cor- primary closure. Large or multiple injuries to the right colon are
rected before returning to the OR to have the packs removed. best managed with a right hemicolectomy followed by an imme-
Mesenteric bleeding can usually be controlled with manual com- diate ileocolic anastomosis. Similar injuries to the left colon are
pression of the vessel followed by suture ligation. Retroperitoneal generally treated with resection and proximal diversion.The distal
hematomas are often harbingers of vascular injury, and proximal limb may be exteriorized as a mucous fistula, or, if inadequate
and distal vascular control should be obtained before exploration bowel length renders diversion impossible, a Hartmann procedure
is initiated [see 7:10 Injuries to the GreatVessels of the Abdomen].Typi- may be performed. 14-16
cally, bleeding from injured hollow viscera is minor and can be
REPAIR OF RETROPERITONEAL INJURIES
controlled by repairing the injury; on occasion, however, tempo-
rary hemostatic suturing or stapling may be required. Once all injuries within the peritoneal cavity have been
addressed, the next priority is to inspect the retroperitoneum once
CONTROL OF CONTAMINATION
more, paying particular attention to the possibility of hematoma
Once hemorrhage has been controlled, the next priority is to expansion. The decision whether to explore a retroperitoneal
control contamination. All gross spillage should be removed hematoma is based on the mechanism of injury and on the zone
from the abdomen with suction and laparotomy pads, and fur- in which the injury is located. All zone 1 hematomas should be
ther contamination should be prevented by temporarily closing explored regardless of the injury mechanism: they signal possible
small enterotomies with Babcock clamps (or, alternatively, with aortic, vena caval, duodenal, or pancreatic injury. Zone 2 and 3
a continuous suture or skin staples). When multiple enteroto- hematomas should be explored in cases of penetrating trauma but
mies are present, suture closure is preferred (to ensure that mul- not, as a rule, in cases of blunt trauma (with the exception of
tiple clamps are not present in the operative field). If the injuries expanding zone 2 hematomas).
are in close proximity, the preferred method of controlling Before a retroperitoneal hematoma is opened, proximal vascu-
intestinal spillage is to apply atraumatic bowel clamps at both the lar control should be obtained so that hemorrhage will be mini-
proximal and the distal end of the injury site. Alternatively, if the mized once the effect of the tamponade has been lost. Injuries to
injured segment will have to be resected, rapid control of further retroperitoneal organs (e.g., the kidneys, the pancreas, and the
spillage can be obtained by firing a GI stapler at each end of the adrenal glands) are treated by means of debridement or resection,
injured segment. with drainage as indicated. Vascular injuries are repaired as dis-
cussed previously [see Repair of Vascular Injuries, above, and 7:10
REPAIR OF VASCULAR INJURIES
Injuries to the Great Vessels of the Abdomen].
Once intestinal contamination has been dealt with, the next pri-
ority is definitive vascular repair [see 7:10 Injuries to the Great Vessels
of the Abdomen]. If proximal and distal control of the injured ves- Closure
sel has not already been obtained, it is obtained at this point. The
GENERAL TECHNIQUE
extent of the vascular injury is determined, dead or devitalized tis-
sue is carefully debrided, and vessel continuity is reestablished if Once the abdominal exploration has been completed, the
possible. If the injury is not amenable to primary repair and the abdomen is copiously irrigated with an isotonic crystalloid solu-
vessel cannot be ligated, autogenous tissue should be obtained tion. The closure method employed is typically determined on the
(usually from the proximal greater saphenous vein) and used for basis of five main considerations: (1) the degree of blood loss, (2)
either patch angioplasty or interposition grafting. If no suitable the volume of resuscitation fluid received, (3) the degree of conta-
autogenous venous tissue is available, synthetic material may be mination, (4) the patient’s perceived nutritional status, and (5) the
considered as an alternative vascular conduit. For aortic or iliac patient’s hemodynamic stability. In cases that necessitate an abbre-
arterial injuries, primary ligation with subsequent extra-anatomic viated or damage-control procedure, the speed with which the clo-
bypass is an acceptable alternative. In cases in which an abbreviat- sure can be performed may be the most important factor. Provided
ed laparotomy is necessary, vascular shunting may serve as a sub- that the risk of subsequent abdominal compartment syndrome
stitute for definitive repair until hypothermia, coagulopathy, and (ACS) is considered to be low, every effort should be made to close
acidosis are corrected. the fascia. Fascial closure is usually accomplished with a continu-
a b
Capstan Up
Capstan Down
2 cm
Fat
Muscle
Omentum
Peritoneum
Figure 6 Retention sutures may be used to bolster fascial closure in wounds at high risk for break-
down. (a) Sutures are placed in the subfascial plane. (b) The defect is approximated, and the sutures
are tied over skin bridges.
ous absorbable or nonabsorbable monofilament suture, though it abbreviated or damage-control procedure is indicated. It may be
may also be accomplished with interrupted sutures.The rate of fas- necessary to perform a rapid abdominal closure—with the provi-
cial dehiscence is essentially the same for the two techniques; how- so that further exploration, as well as definitive repair of injuries
ever, the extent of dehiscence is more limited when closure is done that have been temporarily controlled, will be required. The deci-
with interrupted sutures.17,18 With either technique, it is important sion to perform a damage-control procedure should be made at an
not to place excessive tension on the fascial tissues. early stage, before the so-called lethal triad (hypothermia, acidosis
In cases where there is a specific reason to be concerned about and coagulopathy) has had time to develop. Damage control has
possible dehiscence (e.g., in patients who are malnourished or undoubtedly led to improved survival for trauma patients, but it
obese or are receiving steroid therapy), large monofilament sutures has also led to an increase in the number of patients whose
may be placed at intervals within the standard closure to serve as abdomens are left open.19
retention sutures. They may be tied over bolsters created from a
red rubber catheter or over plastic skin bridges [see Figure 6]. If TEMPORARY ABDOMINAL CLOSURE
rapid closure is required, the abdomen may be closed with four or When a damage-control procedure is required, it is often most
five retention sutures of this type that are placed through the expedient to perform a rapid temporary abdominal closure, then
abdominal wall and just above the peritoneum. These sutures to transport the patient to the intensive care unit. This measure
must be checked daily and should be loosened if there is evidence may also be necessary in patients whose abdomens cannot be
that they are cutting through the abdominal skin as a consequence closed because of intestinal and organ edema caused by intraop-
of edema creating increased tension on the wound.
erative fluid resuscitation.The simplest form of temporary abdom-
SKIN CLOSURE inal closure is the use of towel clips to close only the skin [see Figure
7], in conjunction with the application of a bioocclusive dressing
If the patient has minor injuries without evidence of enteric con-
to control fluid loss and contamination. This closure, however,
tamination, the skin may be closed primarily. Stapled closure is
leaves the patient still at risk for subsequent ACS.
most expeditious, but suture closure is also acceptable. A degree of
clinical judgment is required in assessing a wound’s suitability for The first temporary abdominal dressing described was the so-
closure. If the skin is closed primarily, it should be inspected daily, called Bogotá bag—that is, an empty intravenous fluid bag that
and the wound should be opened without delay if there is concern was cut in half and sewn to the wound edges. This dressing can
about subsequent infection. Alternatively, primary delayed closure still be used in circumstances where no other equipment is avail-
may be performed by leaving the wound open, packed with moist able.The so-called vacuum pack technique involves the placement
gauze. If the wound shows no evidence of infection when examined of a sterile plastic drape over the bowel contents and under the fas-
after 3 to 5 days, it may be closed with Steri-Strips or with inter- cia, followed by insertion of two or more suction drains, over
rupted sutures that are placed (without being tied) during the orig- which sterile towels or open laparotomy pads may be placed. To
inal operation. If intraperitoneal contamination has occurred, minimize heat loss and insensible fluid loss, an adherent bioocclu-
either primary delayed closure should be performed or the wound sive dressing is placed over the entire dressing and the abdominal
should be packed and left to heal by secondary intention. wall, with the drains attached to suction. Several commercial
devices are now available that can be used to facilitate temporary
ABBREVIATED OR DAMAGE-CONTROL LAPAROTOMY closure of the open abdomen; these include the VAC Abdominal
If a patient remains unstable after surgical bleeding and contam- Dressing System (Kinetic Concepts Inc., San Antonio,Texas) and
ination have been controlled or is cold and coagulopathic, an the Wittmann Patch (Star Surgical, Burlington,Wisconsin).20,21
MANAGEMENT OF THE OPEN ABDOMEN

Patient has open abdomen after operative
Once the patient’s physiologic status has stabilized, he or she exploration for abdominal injury
should be returned to the OR for reexploration and definitive repair
of any remaining injuries [see Figure 8], preferably within 48 hours Place temporary abdominal dressing at
initial operation.
after the first operation. At this juncture, the abdomen should be
Return to OR in 24–48 hr, depending on
assessed for the feasibility of closure. In some patients, the fascial patient’s condition.
edges cannot be approximated, because of edema; in others, reap-
proximation may cause a significant rise in intra-abdominal pres-
sure, as evidenced by a rise in pulmonary inspiratory pressures.These
patients are at risk for ACS, and their abdomens should be left open.
At this point, if temporary abdominal coverage continues to be Abdomen can Abdomen cannot be closed
be closed
required, a temporary abdominal dressing should be placed that
Wash out abdomen.
attempts to prevent fascial retraction and the associated increased
Place fascial retention device, use
risk of nonclosure of the abdomen. Options include dynamic vacuum-assisted closure, or repeat
retention sutures, the Suture Tension Adjustment Reel (STAR) original dressing.
(WoundTEK, Inc., Newport, Rhode Island), the Wittmann Patch, Return to OR every 24–48 hr; wash
nonabsorbable mesh, fascial zippers, and the VAC Abdominal out abdomen and reevaluate for
Dressing System.20-25 Once the dressing is placed, it should be feasibility of closure.
Abdomen can Abdomen cannot be closed

be closed
Attempt partial fascial closure.
Return to OR every 24–48 hr; wash
out abdomen. (Alternatively, this may
be done at the bedside in the ICU if
Perform definitive necessary.)
abdominal closure. If abdomen cannot be closed by
10–14 days after operation, consider
alternative closure methods.
Figure 8 Algorithm outlines the approach to the open abdomen

in a patient with abdominal injuries.
examined every 24 to 48 hours, depending on the degree of cont-

amination; this is often best done in the OR, but it may also be
done in the ICU if the patient remains unstable. At every subse-
quent procedure, the fascia should be assessed for the possibility
of closure. Partial closure of the incision (i.e., closure of the cepha-
lad and caudad portions) should be considered, even if full closure
cannot be accomplished. In approximately 50% of patients, clo-
sure of the fascia is not possible; however, there is some evidence
to suggest that this figure may be lowered by employing some of
the devices now commercially available.20,26,27
ABDOMINAL COMPARTMENT SYNDROME
Patients who undergo fascial closure are at risk for ACS as a

consequence of ongoing resuscitation efforts and associated bowel
and organ edema. ACS is defined as intra-abdominal hypertension
greater than 25 mm Hg in conjunction with dysfunction of one or
more organ systems (e.g., pulmonary, renal, or cardiac). 28,29 Intra-
abdominal pressure is determined indirectly by measuring bladder
pressure. Bladder pressure can be measured by using an arterial
transducer at the level of the symphysis pubis that is connected to
the urinary catheter after 30 to 50 ml of sterile water has been
introduced. Alternatively, an idea of the intra-abdominal pressure
can be gained by raising the Foley tubing above the bed after instil-
lation of the water, then measuring the column.30 A rising trend in
pressure can be as significant as a single elevated measurement.
Figure 7 Shown is a “quick out” closure with surgical Patients who have undergone a long operation, have been the
towel clips. object of vigorous resuscitation efforts, or who have sustained mul-
a b
Split-Thickness
Skin Graft
Mesh
Mesh
Granulation
Tissue Omentum
Relaxing
Incision
Tissue Bridge
Figure 9 Mesh may be used for temporary or permanent abdominal closure in patients at risk for
increased abdominal pressure. (a) Mesh is sutured into the fascial plane, then covered with a split-
thickness skin graft. (b) The abdominal defect is closed with mesh.
tiple injuries should be monitored closely for the development of Abdominal fascial defects may also be closed with sheets of
ACS. If the diagnostic criteria for ACS are met, prompt abdomi- nonincorporable synthetic material (e.g., Gore-Tex; W. L. Gore
nal decompression is indicated. On occasion, this measure may and Associates, Inc., Newark, Delaware). The advantages of these
have to be carried out at the bedside in the ICU. nonabsorbable materials are that they do not react with tissue and
Occasionally, ACS develops in patients who have a temporary that they are associated with a low incidence of complications
abdominal dressing in place (so-called tertiary ACS). Accordingly, (e.g., fistula formation). The disadvantages are that they are
it is mandatory to continue to monitor intra-abdominal pressure expensive and that they must ultimately be removed unless the
in these patients.29 skin can be closed over them to prevent contamination.
Another option for achieving primary closure of the abdomen is
CLOSURE OF THE OPEN ABDOMEN
component separation of the rectus sheath. The external oblique
It is important to close the abdomen as early as possible: an aponeurosis is incised and mobilized, along with the rectus sheath,
open abdomen carries an increased risk of desiccation of the to bring the fascia to the midline. Defects as wide as 14 to 20 cm can
intestines and subsequent fistula formation. In certain patients, be bridged in this fashion, but recurrent hernia rates remain high.31
however, despite aggressive efforts to close the fascia, it proves Several biosynthetic materials are now available to be used for
impossible to accomplish primary closure, even after many days bridging abdominal fascial defects. One such material is Surgisis
and repeated procedures.There are several techniques that may be (Cook Biotech Inc., West Lafayette, Indiana), a porcine submuco-
employed to obtain final closure in this situation. sal matrix that can provide scaffolding for the ingrowth of fibrous
The simplest method is to allow granulation tissue to form over tissue while supporting abdominal contents and permitting skin
the omentum and the exposed intestines and later, when there is closure.32 Another is AlloDerm (LifeCell Corp., Branchburg, New
a good clean granulation bed with no evidence of infection, to place Jersey), a denatured human cadaveric product that can be used in
a split-thickness skin graft. Alternatively, a piece of absorbable a similar fashion to replace denuded fascia or to bridge the fascial
mesh may be placed; this helps facilitate dressing changes, pro- gap in cases where primary closure cannot be accomplished.33,34 At
vides a modicum of protection to the intestines, and serves to con- present, long-term follow-up data are lacking for both products,
trol evisceration [see Figure 9]. A skin graft can then be placed in and their use is further limited by their very high cost.
the same fashion, once a granulation bed has developed. Morbidity is very high in these patients; subsequent complica-
Another option is to employ relaxing incisions, either to allow a tions range from prolonged ventilator dependence to enteric fistu-
skin-only closure or to allow the skin to be closed over absorbable las to massive ventral hernias.35,36 Major ventral hernias represent
mesh. Open skin wounds should be left open to heal by secondary a significant technical challenge and should not be repaired until
intention. Unfortunately, the use of relaxing incisions will not pre- the patient’s recovery from injury is complete and his or her nutri-
vent the formation of large ventral hernias, which will have to be tional and general status has returned to normal.This may take as
repaired at a later date. long as 12 months from the time of the initial trauma.
References
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hepatic injury: a paradigm shift from operative to management of colonic trauma. Injury 36:1011, nal trauma. J Trauma 57:1082, 2004
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Trauma 45:841, 1998
19. Nicholas JM, Rix EP, Easley KA, et al: Changing of intra-abdominal pressure using a transurethral
5. Jurkovich GJ, Moore EE, Medina G: Autotrans- patterns in the management of penetrating bladder catheter: clinical validation of the tech-
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148:782, 1984 more they stay the same. J Trauma 55:1095, 2003 31. de Vries Reilingh TS, van Goor H, Rosman C, et
6. Mattox KL, McCollum WB, Beall AC, et al: 20. Suliburk JW, Ware DN, Balogh Z, et al: Vacuum- al: “Components separation technique” for the
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suprarenal aorta. J Trauma 15: 808, 1975 Surg 196:32, 2003
sure of open abdomens after severe trauma. J
7. Weinberg JA, Fabian TC, Magnotti LJ, et al: Trauma 55:1155, 2003 32. Pu LL; Plastic Surgery Educational Foundation
Penetrating rectal trauma: management by DATA Committee: Small intestinal submucosa
21. Cipolla J, Stawicki SP, Hoff WS, et al: A proposed
anatomic distinction improves outcome. J Trauma (Surgisis) as a bioactive prosthetic material for
algorithm for managing the open abdomen. Am
60:508, 2006 repair of abdominal wall fascial defect. Plast
Surg 71:202, 2005
8. Gonzalez RP, Falimirski ME, Holevar MR: The Reconstr Surg 115:2127, 2005
22. Koniaris LG, Hendrickson RJ, Drugas G, et al:
role of presacral drainage in the management of 33. Scott BG,Welsh FJ, Pham HQ, et al: Early aggres-
Dynamic retention: a technique for closure of the
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Recommended Reading
Blaisdell FW, Trunkey DD: Abdominal Trauma. Mattox KL: Complications of Trauma. Churchill Living- and Practice, 2nd ed. Williams & Wilkins, Baltimore,
Thieme Medical Publishers, New York, 1993 stone, New York, 1994 1996
Donovan AJ: Trauma Surgery. Mosby–Year Book Co, Mattox KL, Feliciano DV, Moore EE: Trauma, 4th ed.
St Louis, 1994 Appleton & Lange, Stamford, Connecticut, 1998
Greenfield LJ: Complications in Surgery and Trauma. Maull KI, Rodriguez A, Wiles CE: Complications in
Acknowledgments
JB Lippincott Co, Grand Rapids, Michigan, 1990 Trauma and Critical Care. WB Saunders Co, Figures 2 and 5 Susan Brust, C.M.I.
Hirshberg A, Mattox KL:Top Knife:The Art and Craft Philadelphia, 1996
Figures 3 and 4 Carol Donner.
of Trauma Surgery. tfm publishing Ltd, Harley, Thal ER, Weigelt JA, Carrico CJ: Operative Trauma Figures 6, 7, and 9 Tom Moore. Adapted from
Shropshire, United Kingdom, 2005 Management: An Atlas, 2nd ed. McGraw-Hill, New Operative Trauma Management: An Atlas, by C. J.
Ivatury RR, Cayten CG: The Textbook of Penetrating York, 2002 Carrico, E. R. Thal, and J. A. Weigelt. Appleton &
Trauma. Williams & Wilkins, Baltimore, 1996 Wilson RF, Walt AJ: Management of Trauma: Pitfalls Lange, Stamford, Connecticut, 1998.
7 TRAUMA AND THERMAL INJURY 10 Injuries to the Great Vessels of the Abdomen — 1
10 INJURIES TO THE GREAT VESSELS

OF THE ABDOMEN
David V. Feliciano, M.D., F.A.C.S.
In patients who have injuries to the great vessels of the abdomen, the three zones of the retroperitoneum or in the portal-retrohe-
the findings on physical examination generally depend on whether a patic area of the right upper quadrant [see 7:9 Operative Exposure
contained hematoma or active hemorrhage is present.1 In the case of Abdominal Injuries and Closure of the Abdomen]. The magnitude
of contained hematomas around the vascular injury in the retro- of injury is usually described according to the Abdominal
peritoneum, the base of the mesentery, or the hepatoduodenal liga- Vascular Organ Injury Scale, devised in 1992 by the American
ment, the patient often has only modest hypotension in transit or on Association for the Surgery of Trauma [see Table 1].6
arrival at the emergency center; the hypotension can be temporarily
reversed by the infusion of fluids and may not recur until the
hematoma is opened at the time of laparotomy.This is usually the Injuries in Zone 1
situation when an abdominal venous injury is present. In the case of
SUPRAMESOCOLIC
active intraperitoneal hemorrhage, the patient typically has signifi-
cant hypotension and may have a distended abdomen on arrival. It is helpful to divide midline retroperitoneal hematomas into
Another physical finding that is occasionally noted in association those that are supramesocolic and those that are inframesocolic.1
with an injury to the common or external iliac artery is intermittent Hematoma or hemorrhage in the midline supramesocolic area of
or complete loss of a pulse in the ipsilateral femoral artery; this find- zone 1 is cause to suspect the presence of an injury to the suprarenal
ing in a patient with a transpelvic gunshot wound is pathognomon- aorta, the celiac axis, the proximal superior mesenteric artery, or
ic of an injury to the iliac artery. the proximal renal artery.
Injuries to the great vessels of the abdomen are caused by pene- When a hematoma is present in the midline supramesocolic
trating wounds in 90% to 95% of cases; accordingly, they are often area, one usually has time to perform left medial visceral rotation
accompanied by injuries to multiple intra-abdominal organs, in- [see Figure 3 and 7:9 Operative Exposure of Abdominal Injuries and
cluding those in the gastrointestinal tract.2-5 The general principles Closure of the Abdomen].7,8 The advantage of this technique is that
governing the sequencing of repairs of injuries to the great vessels it allows visualization of the entire abdominal aorta, from the aor-
and the GI tract are outlined elsewhere [see 7:9 Operative Exposure of tic hiatus of the diaphragm to the common iliac arteries [see
Abdominal Injuries and Closure of the Abdomen]. Figure 4]. Obvious disadvantages include the 4 to 5 minutes
A hematoma [see Figures 1 and 2] or hemorrhage associated required to complete the maneuver when the surgeon is inexpe-
with an injury to a great vessel of the abdomen occurs in one of rienced; the risk of damage to the spleen, the left kidney, or the
Patient presents with penetrating injury to the abdomen along with

hypotension or peritonitis; intra-abdominal hematoma is present
Zone 1 Zone 2 Zone 3 Portal area Retrohepatic area
Expose ipsilateral Expose bifurcation Perform Pringle Do not open

renal vessels at of infrarenal aorta maneuver for hematoma unless
Supramesocolic Inframesocolic base of transverse and junction of proximal control. it is ruptured, pulsatile,
mesocolon. inferior vena cava Apply distal or rapidly expanding.
Perform left medial Obtain exposure at Obtain proximal with iliac veins. vascular clamp or
visceral rotation. base of transverse control of renal Obtain proximal forceps, if possible.
Divide left crus of mesocolon. vessels. control of common Dissect common
aortic hiatus. Obtain proximal iliac vessels and bile duct away from
control of infrarenal distal control of common hepatic
Obtain proximal control external iliac vessels.
of distal descending abdominal aorta. artery and portal vein.
thoracic aorta or
diaphragmatic aorta.
Open hematoma.
Figure 1 Algorithm illustrates management of intra-abdominal hematoma found at operation after

penetrating trauma.
Patient presents with blunt injury to the abdomen along with hypotension
or peritonitis; intra-abdominal hematoma is present
Zone 1 Zone 2 Zone 3 Portal area Retrohepatic area
Do not open hematoma Do not open Proceed as for Proceed as for

if kidney appears normal hematoma unless it is penetrating injury penetrating injury
Supramesocolic Inframesocolic on preoperative CT or ruptured, pulsatile, or [see Figure 1]. [see Figure 1].
arteriography. rapidly expanding or
Proceed as for Proceed as for If kidney does not appear unless ipsilateral iliac
penetrating injury penetrating injury normal, still do not open pulse is absent.
[see Figure 1]. [see Figure 1]. hematoma unless it is
ruptured, pulsatile, or
rapidly expanding.
Figure 2 Algorithm illustrates management of intra-abdominal hematoma found at operation

after blunt trauma.
posterior left renal artery as the maneuver is performed; and the to the structure as well as the distortion resulting from rotation.
anatomic distortion that results when the left kidney and the left Because of the density of the celiac ganglia and nerve plexus and
renal artery are rotated anteriorly. When the hematoma is near the lymphatic vessels surrounding the upper abdominal aorta,
the aortic hiatus of the diaphragm, it may be advisable to leave this portion of the aorta is difficult to visualize even when left
the left kidney in its fossa, thereby eliminating potential damage medial visceral rotation has been performed. It is frequently help-
Table 1—AAST Abdominal Vascular Organ Injury Scale

Grade Characteristics of Injury OIS Grade ICD-9 AIS-90
Unnamed superior mesenteric artery or superior mesenteric vein branches I 902.20/902.39 NS

Unnamed inferior mesenteric artery or inferior mesenteric vein branches I 902.27/902.32 NS
Phrenic artery or vein I 902.89 NS
I Lumbar artery or vein I 902.89 NS
Gonadal artery or vein I 902.89 NS
Ovarian artery or vein I 902.81/902.82 NS
Other unnamed small arterial or venous structures requiring ligation I 902.90 NS
Right, left, or common hepatic artery II 902.22 3

Splenic artery or vein II 902.23/902.34 3
Right or left gastric arteries II 902.21 3
II Gastroduodenal artery II 902.24 3
Inferior mesenteric artery, trunk, or inferior mesenteric vein, trunk II 902.27/902.32 3
Primary named branches of mesenteric artery (e.g., ileocolic artery) or mesenteric vein II 902.26/902.31 3
Other named abdominal vessels requiring ligation or repair II 902.89 3
Superior mesenteric vein, trunk III 902.31 3

Renal artery or vein III 902.41/902.42 3
III* Iliac artery or vein III 902.53/902.54 3
Hypogastric artery or vein III 902.51/902.52 3
Vena cava, infrarenal III 902.10 3
Superior mesenteric artery, trunk IV 902.25 3

†
Celiac axis, proper IV 902.24 3
IV*
Vena cava, suprarenal and infrahepatic IV 902.10 3
Aorta, infrarenal IV 902.00 4
Portal vein V 902.33 3

Extraparenchymal hepatic vein V 902.11 3 (hepatic vein)
V† 5 (liver + veins)
Vena cava, retrohepatic or suprahepatic V 902.19 5
Aorta, suprarenal and subdiaphragmatic V 902.00 4
Note: This classification is applicable to extraparenchymal vascular injuries. If the vessel injury is within 2 cm of the parenchyma of a specific organ, one should refer to the injury
scale for that organ.
*Increase grade by I if there are multiple injuries involving > 50% of vessel circumference.
†
Reduce grade by I if laceration is < 25% of vessel circumference.
AAST—American Association for the Surgery of Trauma—AIS—Abbreviated Injury Scale—ICD—International Classification of Diseases
Figure 3 Left medial visceral rotation is performed by means of

sharp and blunt dissection with elevation of the left colon, the left
kidney, the spleen, the tail of the pancreas, and the gastric fundus.
ful to transect the left crus of the aortic hiatus in the diaphragm
at the 2 o’clock position to allow exposure of the distal descend-
ing thoracic aorta above the hiatus.Visualization of this portion of
the vessel is much easier to achieve than visualization of the
diaphragmatic or visceral abdominal aorta below, and an aortic
cross-clamp can be applied much more quickly at this level.
Active hemorrhage from the midline supramesocolic area is con-
trolled temporarily by packing with laparotomy pads or using an
aortic compression device [see Figure 5].9,10 A definitive approach is
to divide the lesser omentum manually, retract the stomach and
Figure 5 An aortic compression device is used to control hem-
esophagus to the left, and manually dissect in the area just below the orrhage from the visceral portion of the abdominal aorta.
aortic hiatus of the diaphragm to obtain rapid exposure of the
supraceliac abdominal aorta.11 An aortic cross-clamp can then be
applied. Distal control of the upper abdominal aorta is difficult to
obtain because of the presence of the anteriorly located celiac axis otherwise healthy, ligation and division of the celiac axis allow easier
and superior mesenteric artery. In young trauma patients who are application of the distal aortic clamp and better exposure of the
supraceliac area for subsequent vascular repair.12
Small penetrating wounds to the supraceliac abdominal aorta
are repaired with a continuous 3-0 or 4-0 polypropylene suture.
If two small perforations are adjacent to each other, they can be
connected and the defect closed in a transverse fashion. If closure
of a perforation would result in significant narrowing of the aorta
or if a portion of the aortic wall is missing, patch aortoplasty with
polytetrafluoroethylene (PTFE) is indicated. On rare occasions,
in patients with extensive injuries to the diaphragmatic or supra-
celiac aorta, resection of the area of injury and insertion of a vas-
cular conduit are indicated. Even though many of these patients
have associated gastric, enteric, or colonic injuries, the most ap-
propriate prosthesis with such a life-threatening injury is a 12 mm
or 14 mm Dacron or PTFE graft [see Figure 6].13 Provided that
vigorous intraoperative irrigation is performed after repair of GI
tract perforations, that proper graft coverage is ensured, and that
perioperative antibiotics are appropriately employed, it is extraor-
dinarily rare for a prosthesis inserted in the healthy aorta of a
young trauma patient to become infected.
The aortic prosthesis is sewn in place with a continuous 3-0 or
4-0 polypropylene suture. Both ends of the aorta are flushed
Figure 4 Shown is an autopsy view of the supraceliac aorta and before the distal anastomosis is completed, and the distal aortic
the celiac axis, the proximal superior mesenteric artery, and the cross-clamp is removed before the final knot is tied to eliminate
medially rotated left renal artery after removal of lymphatic and air from the system. The proximal aortic cross-clamp is removed
nerve tissue. very slowly as the anesthesiologist rapidly infuses fluids and intra-
Another option is to perform left medial visceral rotation (see

above) and apply a clamp directly to the origin of the superior
mesenteric artery. Injuries to the superior mesenteric artery in this
area or just beyond the base of the mesocolon are often associated
with injuries to the pancreas.The potential for a postoperative leak
from the injured pancreas near the arterial repair has led numerous
authors to suggest that any extensive injury to the artery at this loca-
tion should be ligated [see Figure 7].
Because of the intense vasoconstriction of the distal superior
mesenteric artery in patients who have sustained exsanguinating
hemorrhage from more proximal injuries treated with ligation,
the collateral flow from the foregut and hindgut is often inade-
quate to maintain the viability of the organs in the distal midgut,
especially the cecum and the ascending colon. Therefore, it is
safest to place a saphenous vein or PTFE graft on the distal
infrarenal aorta, away from the pancreatic injury and any other
upper abdominal injuries.15 Such a graft can be tailored to reach
the side or the anterior aspect of the superior mesenteric artery,
Figure 6 A 22-year-old man with a gunshot wound to the right or it can be attached to the transected distal superior mesenteric
upper quadrant had injuries to the prepyloric area of the stom- artery in an end-to-end fashion without significant tension [see
ach and to the supraceliac abdominal aorta. The aortic injury was Figure 8]. Soft tissue must be approximated over the aortic suture
managed by means of segmental resection and replacement with
line of the graft to prevent the development of an aortoenteric fis-
a 16 mm polytetrafluoroethylene (PTFE) graft. The patient went
home 46 days after injury.
tula in the postoperative period.
In patients with severe shock from exsanguination caused by a
complex injury to the superior mesenteric artery, damage-control
venous bicarbonate to reverse so-called washout acidosis from the laparotomy is indicated [see Damage-Control Laparotomy, below]:
previously ischemic lower extremities. The retroperitoneum is the injured area should be resected and a temporary intraluminal
then irrigated with an antibiotic solution and closed over the graft Argyle, Javid, or Pruitt-Inahara shunt inserted to maintain flow to
in a watertight fashion with an absorbable suture. the midgut during resuscitation in the surgical intensive care unit.16
Cross-clamping of the diaphragmatic or supraceliac abdominal
aorta in a patient with hemorrhagic shock results in severe
ischemia of the legs. Restoration of flow through the repaired
abdominal aorta may then cause a reperfusion injury in addition
to the ischemic edema that develops in the muscle compartments
below the knee. In a patient who is hemodynamically stable after
repair of the suprarenal abdominal aorta and other injuries, mea-
surement of compartmental pressures below the knees should be
performed before the patient is moved from the operating room.
Pressures in the range of 30 to 35 mm Hg are likely to rise in the
intensive care unit; accordingly, at many centers, bilateral below-
the-knee two-incision four-compartment fasciotomies would be
performed in this situation.
The survival rate in patients with injuries to the suprarenal
abdominal aorta had been 30% to 35% but was lower than 10%
in one 2001 review.4,13
Injuries to branches of the celiac axis are often difficult to re-
pair because of the amount of dissection required to remove the
dense neural and lymphatic tissue in this area. Because most pa-
tients have excellent collateral flow in the upper abdomen, major
injuries to either the left gastric or the proximal splenic artery
generally should be ligated. Because the common hepatic artery
may have a larger diameter than either of these two arteries, an
injury to this vessel can occasionally be repaired by means of lat-
eral arteriorrhaphy, an end-to-end anastomosis, or the insertion
of a saphenous vein graft. One should not worry about ligating
the common hepatic artery proximal to the origin of the gastro-
duodenal artery: there is extensive collateral flow to the liver
from the midgut.When the entire celiac axis is injured, it is best Figure 7 An 18-year-old man experienced a gunshot wound to
to ligate all three vessels and forgo any attempt at repair. the head of the pancreas and the proximal superior mesenteric
Injuries to the superior mesenteric artery are managed according artery. A Whipple procedure was performed, and a 6 mm PTFE
to the anatomic level of the perforation or thrombosis.14 On rare oc- graft was placed in the artery. The artery-graft suture line
casions, in patients with injuries beneath the neck of the pancreas, dehisced secondary to a pancreatic leak on day 30 after injury,
one may have to transect the pancreas to obtain proximal control. and the patient died on day 42.
a b
Figure 8 (a) When complex grafting procedures to the superior mesenteric artery are necessary,
it may be dangerous to place the proximal suture line near an associated pancreatic injury. (b)
The proximal suture line should be on the lower aorta, away from the upper abdominal injuries,
and should be covered with retroperitoneal tissue.
When ligation is indicated for more distal injuries to the superior There is excellent evidence that young trauma patients tolerate
mesenteric artery, segments of the ileum or even the right colon ligation of the superior mesenteric vein well when vigorous postop-
may have to be resected because of ischemia. erative fluid resuscitation is performed to reverse the peripheral hy-
The survival rate in patients with penetrating injuries to the povolemia that results from splanchnic hypervolemia.18,19 Typically,
superior mesenteric artery is approximately 50% to 55% overall ligation is followed almost immediately by swelling of the midgut
[see Table 2] but only 20% to 25% when any form of repair more and discoloration suggestive of impending ischemia. In such cases,
complex than lateral arteriorrhaphy is necessary.1-4,15,17 temporary coverage of the midgut with a silo, followed by early re-
An injury to the proximal renal artery may also be present operation, may be necessary to reassure the operating surgeon that
under a supramesocolic hematoma or bleeding area.When active the ischemia has not become permanent.
hemorrhage is present, control of the supraceliac abdominal aorta The survival rate in patients with injuries to the superior
in or just below the aortic hiatus must be obtained. When only a mesenteric vein ranges from 36% to 71%, depending on whether
hematoma or a known thrombosis of the proximal renal artery is other vascular injuries are present [see Table 3].1-4,18
present, proximal vascular control can be obtained by elevating
INFRAMESOCOLIC
the transverse mesocolon and dissecting the vessel from the later-
al aspect of the abdominal aorta. Options for repair of either the The lower area of the midline retroperitoneum in zone 1 is
proximal or the distal renal artery are described elsewhere [see known as the midline inframesocolic area. Injuries to either the
Injuries in Zone 2, below]. infrarenal abdominal aorta or the inferior vena cava occur in this
The superior mesenteric vein is the other great vessel of the area.
abdomen that may be injured in the supramesocolic or retrome- An injury to the inframesocolic abdominal aorta that is under
socolic area of the midline retroperitoneum. Because of the over- a hematoma is controlled by performing the same maneuvers
lying pancreas, the proximity of the uncinate process, and the used to gain proximal control of an infrarenal abdominal aortic
close association of this vessel with the superior mesenteric artery, aneurysm. The infrarenal abdominal aorta is exposed by pulling
repair of the superior mesenteric vein is quite difficult. As with the transverse mesocolon up toward the patient’s head, eviscerat-
injuries to the superior mesenteric artery (see above), one may ing the small bowel to the right side of the abdomen, and open-
have to transect the neck of the pancreas between noncrushing ing the midline retroperitoneum until the left renal vein is ex-
vascular or intestinal clamps to gain access to a perforation of the posed. A proximal aortic cross-clamp is then placed immediately
superior mesenteric vein. An injury to this vein below the inferi- inferior to this vessel [see Figure 9].When the entire inframesoco-
or border of the pancreas can be managed by compressing it lic area is distorted by the presence of a large pulsatile hematoma,
manually between one’s fingers as an assistant places a continu- the inexperienced trauma surgeon should remember that the hole
ous 5-0 polypropylene suture to complete the repair.When a pen- in the infrarenal abdominal aorta is under the highest point of the
etrating injury to the vein has a posterior component, one must hematoma (the so-called Mt. Everest phenomenon). When there
ligate multiple collateral vessels entering the vein in this area to is active hemorrhage from this area, rapid proximal control is
achieve proper visualization. obtained in the same fashion or, if necessary because of the need
Table 2—Survival after Injuries to Arteries in the Abdomen
Asensio et al2 (2000)

Injured Artery Davis et al3 (2001)* Tyburski et al4 (2001)
Isolated Injury With Other Arterial Injury
Abdominal aorta as a whole 21.7% (10/46) 17.6% (3/17) 39.1% (25/64) 21.1% (15/71)
Pararenal to diaphragm — — — 8.3% (3/36)
Infrarenal — — — 34.2% (12/35)
Superior mesenteric artery 52.4% (11/21) 28.6% (2/7) 53.3% (8/15) 48.8% (20/41)
Renal artery 62.5% (5/8) 33.3% (2/6) 56.2% (9/16) 73.7% (14/19)
Iliac artery
Common — — 55.5% (5/9) 44.7% (17/38)
External — — 65.2% (30/46) 62.5% (20/32)
*Excludes patients who exsanguinated before repair or ligation.
to apply compression, by dividing the lesser omentum and apply- Injury to the inferior vena cava below the liver should be sus-
ing the cross-clamp just below the aortic hiatus of the diaphragm. pected when the aorta is found to be intact underneath an
Distal control of the infrarenal abdominal aorta is obtained by inframesocolic hematoma, when such a hematoma appears to be
dividing the midline retroperitoneum down to the aortic bifurca- more extensive on the right side of the abdomen than on the left,
tion, taking care to avoid the origin of the inferior mesenteric or when there is active hemorrhage coming through the base of
artery on the left side. the mesentery of the ascending colon or the hepatic flexure. It is
Injuries to the infrarenal aorta are repaired by means of lateral certainly possible to visualize the inferior vena cava through the
aortorrhaphy, patch aortoplasty, an end-to-end anastomosis, or midline retroperitoneal exposure just described (see above); how-
insertion of a Dacron or PTFE graft. Much as with injuries to the ever, most surgeons are more comfortable with visualizing the
suprarenal abdominal aorta in young trauma patients, it is rarely vessel by mobilizing the right half of the colon and the C loop of
possible to place a tube graft larger than 12 or 14 mm. Because the duodenum.1 With this right medial visceral rotation maneu-
the retroperitoneal tissue is often thin at this location in young ver, the right kidney is left in situ unless there is an associated
patients, an important adjunctive measure after the aortic repair injury to the posterior aspect of the right renal vein, to the
is to mobilize the gastrocolic omentum, flip it into the lesser sac suprarenal vena cava, or to the right kidney itself. Right medial
superiorly, and then bring it down over the infrarenal aortic graft visceral rotation, in conjunction with the Kocher maneuver, per-
through a hole in the left transverse mesocolon. An alternative is mits visualization of the entire vena caval system from the con-
to mobilize the gastrocolic omentum away from the right side of fluence of the iliac veins to the suprarenal vena cava below the
the colon and then swing the mobilized tissue into the left lateral liver [see 7:9 Operative Exposure of Abdominal Injuries and Closure
gutter just below the ligament of Treitz to cover the graft. With of the Abdomen]. Local exposure of the iliac vein–vena cava junc-
either technique, it is mandatory to suture the viable omental tion in the lower abdomen and of the renal vein–vena cava junc-
pedicle superior to the aortic suture line to prevent a postopera- tion in the upper abdomen is appropriate before completion of
tive aortoduodenal fistula.20,21 right medial visceral rotation. This measure allows rapid applica-
The survival rate in patients with injuries to the infrarenal tion of proximal and distal vascular clamps on the inferior vena
abdominal aorta had been approximately 45% but was 34% in a cava in the event that exsanguinating hemorrhage results when
2001 review [see Table 2].1-4 the caval injury is exposed.
Table 3—Survival after Injuries to Veins in the Abdomen
Asensio et al2 (2000)

Injured Vein Davis et al3 (2001)* Tyburski et al4 (2001)
Isolated Injury With Other Venous Injury
Inferior vena cava as a whole 29.3% (12/41)† 22.2% (8/36)† 56% (47/84) 43% (61/142)
Pararenal to diaphragm — — — 40.3% (31/77)
Infrarenal — — — 46.2% (30/65)
Superior mesenteric vein 47.4% (9/19) 35.7% (5/14) 71.4% (15/21) 56.3% (18/32)
Renal vein — 44.1% (15/34) 70% (21/30) 68.8% (22/32)
Iliac vein (all) 62.2% (23/37) 33.3% (5/15) — —

Common — — 81% (17/21) 49% (24/49)
External — — 74.5% (41/55) 66.7% (16/24)
*Excludes patients who exsanguinated before repair or ligation.
†Excludes retrohepatic vena cava.
well as control of both renal veins with Silastic loops to facilitate

the direct application of angled vascular clamps. As noted, medi-
al mobilization of the right kidney may permit the application of
a partial occlusion clamp across the inferior vena cava at its junc-
tion with the right renal vein as an alternative approach to an
injury in this area. Another useful technique for controlling hem-
orrhage from the inferior vena cava at any location is to insert a
5 ml or 30 ml Foley balloon catheter into the caval laceration and
then inflate it in the lumen.24, 25 Once the bleeding is controlled,
vascular clamps are positioned around the perforation, and the
balloon catheter is removed before repair of the vessel.
Anterior perforations of the inferior vena cava are managed by
means of transverse repair with a continuous 4-0 or 5-0 poly-
propylene suture. Much has been written about visualizing pos-
terior perforations by extending anterior perforations, but in my
experience, opportunities to apply this approach have been rare.
It is often easier to roll the vena cava to one side to complete a
continuous suture repair of a posterior perforation. When both
anterior and posterior perforations have been repaired, there is
usually a significant degree of narrowing of the inferior vena cava,
which may lead to slow postoperative occlusion. If the patient’s
condition is unstable and a coagulopathy has developed, no fur-
ther attempt should be made to revise the repair. If the patient is
stable, there may be some justification for applying a large PTFE
patch to prevent this postoperative occlusion [see Figure 10].
Ligation of the infrarenal inferior vena cava is appropriate for
Figure 9 Shown is a gunshot wound to the infrarenal abdominal young patients who are exsanguinating and in whom a complex
aorta viewed through standard inframesocolic exposure. Patient’s repair of the vessel would be necessary. After the damage-control
head is at the bottom of the photograph.
abdominal procedure has been completed and a silo has been
used to cover the midgut, it is, once again, worthwhile to measure
For proper exposure of a hole in a large vein such as the inferior the compartmental pressures below the knees before the patient
vena cava, the loose retroperitoneal fatty tissue must be dissected is moved from the OR. Below-the-knee two-incision four-com-
away from the wall of the vessel. Active hemorrhage coming from partment fasciotomies are performed when pressures exceed 30
the anterior surface of the inferior vena cava is best controlled by to 35 mm Hg. Three-compartment fasciotomies in the thighs
applying a Satinsky vascular clamp. If it is difficult to apply this have proved necessary in some surviving patients after caval liga-
clamp, one should try grasping the area of the perforation with a
pair of vascular forceps or several Judd-Allis clamps; this step may
facilitate safe application of the Satinsky clamp.22 When the perfora-
tion in the inferior vena cava is more lateral or posterior, it is often
helpful to compress the vessel proximally and distally around the
perforation, using gauze sponges placed in straight sponge sticks.
On occasion, an extensive injury to the inferior vena cava can be
controlled only by completely occluding the entire inferior vena
cava with large DeBakey aortic cross-clamps.This maneuver inter-
rupts much of the venous return to the right side of the heart and is
poorly tolerated by hypotensive patients unless the infrarenal ab-
dominal aorta is cross-clamped simultaneously.
There are two anatomic areas in which vascular control of an
injury to the inferior vena cava below the liver is difficult to
obtain: (1) the confluence of the common iliac veins and (2) the
junction of the renal veins with the inferior vena cava. One inter-
esting approach to an injury to the inferior vena cava at the con-
fluence of the iliac veins is temporary division of the overlying
right common iliac artery, coupled with mobilization of the aor-
tic bifurcation to the patient’s left.23 This approach yields a better
view of the common iliac veins and the proximal inferior vena
cava and makes repair considerably easier than it would be if the
aortic bifurcation were left in place. Once the vein is repaired, the
right common iliac artery is reconstituted via an end-to-end
anastomosis. The usual approach to injuries to the inferior vena
cava at its junction with the renal veins involves clamp or sponge- Figure 10 Shown is PTFE patch repair of an injury to the
stick compression of the infrarenal and suprarenal vena cava, as infrarenal inferior vena cava.
one may control the ipsilateral renal artery with a Silastic loop in the
midline of the retroperitoneum at the base of the mesocolon [see
Figure 12].30,31 Control of the left renal vein can be obtained at the
same location; however, control of the proximal right renal vein re-
quires mobilization of the C loop of the duodenum and dissection
of the vena cava at its junction with this vessel.
If there is active hemorrhage from the kidney through Gerota’s
fascia or from the retroperitoneum overlying the renal vessels, no
central renal vascular control is necessary. In such a situation, the
retroperitoneum lateral to the injured kidney should be opened,
and the kidney should be manually elevated directly into the
abdominal incision. A large vascular clamp should then be
applied directly to the hilar vessels of the elevated kidney to con-
trol any further bleeding until a decision is reached on repair ver-
sus nephrectomy.
Occasionally, a small perforation of the renal artery can be
Figure 11 A right perirenal hematoma was not opened at opera- repaired by lateral arteriorrhaphy or resection with an end-to-end
tion, because preoperative abdominal CT documented a reason- anastomosis.32 Interposition grafting and replacement of the
ably intact kidney. renal artery with either the hepatic artery (on the right) or the
splenic artery (on the left) have been used on rare occasions, but
such approaches ordinarily are not indicated unless the injured
tion. Patients who have undergone ligation of the infrarenal infe- kidney is the only one the patient has. In patients who have sus-
rior vena cava require vigorous resuscitation with crystalloid solu- tained multiple intra-abdominal injuries from penetrating
tions in the postoperative period; in addition, both lower extrem- wounds or have undergone a long period of ischemia while other
ities should be wrapped with elastic compression wraps and ele- injuries were being repaired, nephrectomy is the appropriate
vated for 5 to 7 days after operation. Patients who have some choice for a major renovascular injury, provided that intraopera-
residual edema during the later stages of hospitalization despite tive palpation has confirmed the presence of a normal contralat-
the elastic compression wraps should be fitted with full-length eral kidney.
custom-made support hose. Ligation of the suprarenal inferior The role of renal revascularization in patients who have intimal
vena cava is occasionally necessary when the patient has an exten- tears in the renal arteries as a result of deceleration-type trauma
sive injury at this location and appears to be in an irreversible remains controversial. If a circumferential intimal tear is noted on
shock state during operation.26 If the patient’s condition improves preoperative arteriography but flow to the kidney is preserved, the
during a brief period of resuscitation in the SICU, reoperation decision whether to repair the artery depends on whether laparot-
and reconstruction with an externally supported PTFE graft are omy is necessary for other injuries and whether the opportunity
usually necessary to prevent renal failure. for anticoagulation is available. If there are no other significant
The survival rate in patients with injuries to the inferior vena injuries and flow to the kidney is preserved despite the presence
cava depends on the location of the injury; in the past, it ranged of an intimal tear, anticoagulation and a repeat isotope renogram
from 60% for the suprarenal vena cava to 78% for the infrarenal within the first several days may be justified. An alternative
vena cava but decreased to approximately 33% to 56% if injuries approach involves insertion of an endovascular stent in the renal
to the retrohepatic vena cava were included. Current studies indi-
cate survival rates of 22% to 56% for inferior vena cava injuries
taken as a whole.1-3,26-28 A 2001 review reported survival rates of
46.1% for the infrarenal inferior vena cava and 40.3% for more
superior injuries.4
Injuries in Zone 2
Hematoma or hemorrhage in zone 2 is cause to suspect the pres-
ence of injury to the renal artery, the renal vein, or the kidney.
In patients who have sustained blunt abdominal trauma but in
whom preoperative intravenous pyelography, renal arteriography,
or abdominal CT confirms that a reasonably intact kidney is pres-
ent, there is no justification for opening a perirenal hematoma if
one is found at a subsequent operation [see Figure 11].29
In highly selected stable patients with penetrating wounds to the
flank, there are some data to justify performing preoperative CT.
On occasion, documentation of an isolated minor renal injury in the
absence of peritoneal findings on physical examination makes it
possible to manage such patients nonoperatively.29 In all other pa-
tients with penetrating wounds, when a perirenal hematoma is
found during initial exploration, the hematoma should be unroofed
and the wound tract explored. If the hematoma is not rapidly ex- Figure 12 Midline looping of respective renal vessels is per-
panding and there is no active hemorrhage from the perirenal area, formed before entry into any perirenal hematoma.
nique of repair. If ligation of the right renal vein is necessary to con-

trol hemorrhage, nephrectomy should be performed, either at initial
laparotomy or at reoperation after a damage-control laparotomy;
the medial left renal vein may be ligated as long as the left adrenal
and gonadal veins are intact. It should be noted, however, that in
some series, more postoperative renal complications were noted
when this maneuver was used on the left side.35
The survival rate in patients with isolated injuries to the renal
veins is approximately 70% [see Table 3].1,3,4
Injuries in Zone 3
Hematoma or hemorrhage in either lateral pelvic area is sug-
gestive of injury to the iliac artery or the iliac vein. When lateral
pelvic hematoma or hemorrhage is noted after penetrating trau-
ma, compression with a laparotomy pad or the fingers should be
Figure 13 A 24-year-old man experienced a gunshot wound to maintained as proximal and distal vascular control is obtained.
the left external iliac artery and vein. The arterial injury was The proximal common iliac arteries are exposed by eviscerating
repaired with segmental resection and insertion of an 8 mm the small bowel to the right and dividing the midline retroperi-
PTFE graft; the venous injury was repaired with segmental resec- toneum over the aortic bifurcation. In young trauma patients, the
tion and an end-to-end anastomosis. common iliac artery usually is not adherent to the common iliac
vein, and Silastic loops can be passed rapidly around these ves-
artery, followed by a period of anticoagulation.33 If occlusion of sels to provide proximal vascular control. Distal vascular control
the proximal renal artery from blunt deceleration-type trauma is is most easily obtained where the external iliac artery and vein
documented, the critical factor for renal salvage is the time from come out of the pelvis proximal to the inguinal ligament. Even
occlusion to revascularization. Renal artery occlusion from decel- with proximal and distal control of the common or the external
eration-type trauma that is detected within 6 hours of injury may iliac artery and vein, there is often continued back-bleeding from
be treated with immediate operation, resection of the area of inti- the internal iliac artery. Such bleeding is controlled by elevating
mal damage, and an end-to-end anastomosis performed by an the Silastic loops on the proximal and distal iliac artery and then
experienced vascular trauma team. Given proper exposure and either clamping or looping the internal iliac artery, which is the
medial mobilization of the kidney, this operation is not technical- only major branch vessel that descends into the pelvis.
ly difficult in a young trauma patient whose renal artery is other- For transpelvic bilateral iliac vascular injuries resulting from a
wise normal. In a 1998 review, fewer than 20% of kidneys revas- penetrating wound, a technique of total pelvic vascular isolation
cularized in this manner regained any significant degree of func- has been described. Proximally, the abdominal aorta and the
tion.34 Hypertension develops in 40% to 45% of patients who inferior vena cava are cross-clamped just above their bifurcations,
undergo observation only after thrombosis is detected. and distally, both the external iliac artery and the external iliac
The survival rate in patients with isolated injuries to the renal vein are cross-clamped, with one clamp on each side of the distal
arteries ranges from 56% to 74% [see Table 2].1,3,4 pelvis. Back-bleeding from the internal iliac vessels is minimal
Many patients with penetrating wounds to the renal veins are with this approach.
quite stable as a result of the retroperitoneal tamponade described Ligation of either the common or the external iliac artery in a hy-
earlier (see above). Once vascular control is obtained with the direct potensive trauma patient leads to a 40% to 50% amputation rate in
application of clamps, lateral venorrhaphy is the preferred tech- the postoperative period; consequently, injuries to these vessels
should be repaired if at all possible. The standard options for re-
pair—lateral arteriorrhaphy, completion of a partial transection
with an end-to-end anastomosis, and resection of the injured area
with insertion of a conduit—are feasible in most situations [see Fig-
ure 13].36 On rare occasions, it may be preferable either to mobilize
the ipsilateral internal iliac artery to serve as a replacement for the
external iliac artery or to transpose one iliac artery to the side of the
contralateral iliac artery.37 When a patient is in severe shock from
exsanguination caused by a complex injury to the common or the
external iliac artery, damage control laparotomy [see Damage Con-
trol Laparotomy, below] is indicated.38 The injured area should be
resected and a temporary intraluminal Argyle, Javid, or Pruitt-Ina-
hara shunt inserted to maintain flow to the ipsilateral lower extrem-
ity during resuscitation in the SICU.1
One unique problem associated with repair of the common or the
external iliac artery is the choice of technique when significant en-
Figure 14 Failure to properly dissect out the structures in the teric or fecal contamination is present in the pelvis. In such cases,
porta hepatis after a penetrating wound led to the creation of an there is a substantial risk of postoperative pelvic cellulitis, a pelvic ab-
iatrogenic hepatic artery–portal vein fistula, which was corrected scess, or both, which may lead to blowout of any type of repair.
after the arrival of the attending surgeon. When extensive contamination is present, it is appropriate to divide
the common or external iliac artery above the level of injury, close If hemorrhage is occurring, compression of the bleeding vessels
the injury with a double row of continuous 4-0 or 5-0 polypropylene with the fingers should suffice until the vascular clamp is in place.
sutures, and bury the stump underneath uninjured retroperitoneum. Once proximal and distal vascular control is obtained, the three
If a stable patient has obvious ischemia of the ipsilateral lower ex- structures in the hepatoduodenal ligament must be dissected out
tremity at the completion of this proximal ligation, one may perform very carefully because of the danger of blindly placing sutures in
an extra-anatomic femorofemoral crossover bypass with an 8 mm proximity to the common bile duct [see Figure 14].
externally supported PTFE graft to restore arterial flow to the ex- Injuries to the hepatic artery in this location are occasionally
tremity.1 If the patient is unstable, one should take several minutes to amenable to lateral repair, though ligation without reconstruction
perform an ipsilateral four-compartment below-knee fasciotomy; is ordinarily well tolerated because of the extensive collateral arte-
this step will counteract the ischemic edema that inevitably leads to a rial flow to the liver.44-47 If an associated hepatic injury calls for
compartment syndrome and compromises the early survival of the extensive suturing or debridement, ligation of the common
leg. After adequate resuscitation in the SICU, the patient should be hepatic artery or artery to the injured lobe will certainly lead to
returned to the OR for the femorofemoral graft within 4 to 6 hours. increased postoperative necrosis of the hepatic repair. Moreover,
Injuries to the internal iliac arteries are usually ligated even if ligation of the common hepatic artery, the right or left hepatic
they occur bilaterally, because young trauma patients typically artery supplying the injured lobe, and the portal vein branch to
have extensive collateral flow through the pelvis. that lobe will lead to necrosis of the lobe and will necessitate
The survival rate in patients with isolated injuries to the exter- hepatectomy. Finally, ligation of the right hepatic artery to con-
nal iliac artery exceeds 80% when tamponade is present. If the trol hemorrhage should be followed by cholecystectomy.
injury is large and free bleeding has occurred preoperatively, how- Because of the large size of the portal vein and its posterior
ever, the survival rate is only 45%. Current studies report overall position in the hepatoduodenal ligament, injuries to this vessel are
survival rates of approximately 45% to 55% for injuries to the particularly lethal. Once the Pringle maneuver has been per-
common iliac artery and 62% to 65% for injuries to the external formed, mobilization of the common bile duct to the left and of
iliac artery [see Table 2].1,3,4,39 the cystic duct superiorly, coupled with an extensive Kocher
Hemorrhage from injuries to the iliac veins can usually be con- maneuver, allows excellent visualization of any injury to this vein
trolled by means of compression with either sponge sticks or the above the superior border of the pancreas. When the perforation
fingers. As noted, division of the right common iliac artery may extends underneath the neck of the pancreas, it may be necessary
be necessary for proper visualization of an injury to the right com- to have an assistant compress the superior mesenteric vein below
mon iliac vein. Similarly, ligation and division of the internal iliac the pancreas and then to divide the pancreas between noncrush-
artery on the side of the pelvis yield improved exposure of an ing intestinal clamps to obtain exposure of the junction of the
injury to an ipsilateral internal iliac vein.40 superior mesenteric vein and the splenic vein.
Injuries to the common or the external iliac vein are best treat- The preferred technique for repairing an injury to the portal vein
ed by means of lateral venorrhaphy with continuous 4-0 or 5-0 is lateral venorrhaphy with continuous 4-0 or 5-0 polypropylene
polypropylene sutures. Significant narrowing often results, and a sutures.48,49 Complex repairs that have been successful on rare occa-
number of reports have demonstrated occlusion on postoperative sions include end-to-end anastomosis, interposition grafting with
venography. For patients with narrowing or occlusion, as well as externally supported PTFE, transposition of the splenic vein, and a
for those in whom ligation was necessary to control exsanguinat- venovenous shunt from the superior mesenteric vein to the distal
ing hemorrhage, the use of elastic compression wraps and eleva- portal vein or the inferior vena cava. Such vigorous attempts at
tion for the first 5 to 7 days after operation is mandatory.41 restoration of blood flow are not justified in patients who are in
In some centers, once the patient’s perioperative coagulopathy severe hypovolemic shock, for whom ligation of the portal vein is
has resolved, anticoagulation with a low-molecular-weight hep- more appropriate. In addition, if a portosystemic shunt is performed
arin is initiated to prevent progression or migration of a venous in such a patient, hepatic encephalopathy will result because
thrombus. The patient is then discharged on a regimen of oral hepatofugal flow will be present in the rerouted or bypassed portal
warfarin sodium, and serial measurement of the international vein. As with ligation of the superior mesenteric vein, it is necessary
normalized ratio (INR) is continued for 3 months. to infuse tremendous amounts of crystalloids to reverse the transient
The survival rate in patients with injuries to the iliac veins peripheral hypovolemia that occurs secondary to the splanchnic
ranges from 33% to 81%, depending on whether associated vas- hypervolemia resulting from ligation of the portal vein.18,19,49
cular injuries are present [see Table 3].1-4,38,42 Since the early 1980s, the survival rate in patients with injuries
to the portal vein has been approximately 50%.1,3,48,49
Injuries in the Porta Hepatis or Retrohepatic Area RETROHEPATIC AREA
Retrohepatic hematoma or hemorrhage is cause to suspect the

PORTA HEPATIS
presence of injury to the retrohepatic vena cava, a hepatic vein, or
Hematoma or hemorrhage in the area of the portal triad in the a right renal blood vessel. In addition, hemorrhage in this area
right upper quadrant is cause to suspect the presence of injury to may signal injury to the overlying liver [see 7:6 Injuries to the Liver,
the portal vein or the hepatic artery or of vascular injury com- Biliary Tract, Spleen, and Diaphragm].
bined with an injury to the common bile duct. If there is a hematoma that is not expanding or ruptured and
If a hematoma is present, the proximal hepatoduodenal liga- clearly has no association with the right perirenal area, a tampon-
ment should be occluded with a vascular clamp (the Pringle aded injury to the retrohepatic vena cava or a hepatic vein is pres-
maneuver [see 7:6 Injuries to the Liver, Biliary Tract, Spleen, and ent. Perihepatic packing around the right lobe of the liver for 24
Diaphragm]) before the hematoma is entered.43 If the hematoma to 48 hours has been shown to prevent further expansion and
is centrally located in the porta, one may also be able to apply an should be considered.
angled vascular clamp to the distal end of the portal structures at If hemorrhage is occurring that does not appear to be coming
their entrance into the liver. from the overlying liver, the right lobe of the liver should be com-
pressed posteriorly to tamponade the caval perforation. The The patient is then rapidly moved to the SICU for further
Pringle maneuver is then applied, and the surgical and nursing resuscitation. Priorities in the SICU include rapid restoration of
team, the anesthesiologist, and the blood blank are notified. Once normal body temperature, reversal of shock, infusion of intra-
the proper instruments and banked blood are in the OR, the venous bicarbonate to correct a persistent pH lower than 7.2, and
overlying injured hepatic lobe or the lobe closest to the presumed administration of fresh frozen plasma, platelets, and cryoprecipi-
site of injury is mobilized by dividing the triangular and coronary tate when indicated. It is usually possible to return the patient to
ligaments and then lifted out of the subdiaphragmatic area.50 On the OR for removal of clot and packs, reconstruction of the GI
occasion, an obvious perforation of the retrohepatic or suprahe- tract, irrigation, and reapplication of silo coverage or application
patic vena cava or an obvious area where a hepatic vein was avulsed of a vacuum-assisted closure device within 48 to 72 hours.55,56
from the vena cava may be grasped with a forceps or a series of When massive distention of the midgut persists after 7 days
Judd-Allis clamps; a Satinsky clamp may then be applied.4 Be- of intensive care and use of the vacuum-assisted closure device
cause of the copious bleeding that occurs as the liver is lifted and (15% to 25% of patients), the safest approach is to convert the
the hole in the vena cava sought, the anesthesiologist should start patient to an open abdomen (i.e., without closure of the midline
blood transfusions as the lobe is being mobilized. incision) and cover the midgut with a double-thickness layer of
If the retrohepatic hemorrhage is not controlled after one or absorbable mesh.With proper nutritional support and occasion-
two direct attempts, another technique must be tried. The most al use of Dakin solution to minimize bacterial contamination
common choice is the insertion of a 36 French chest tube or a 9 of the absorbable mesh, most patients are ready for the applica-
mm endotracheal tube as an atriocaval shunt [see 7:9 Operative tion of a split-thickness skin graft to the eviscerated midgut
Exposure of Abdominal Injuries and Closure of the Abdomen and 7:6 within 3 to 4 weeks of the original operation for an injury to a
Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm].51 The great vessel.
shunt can reduce bleeding by 40% to 60%, but vigorous hemor-
rhage persists until full control of the perforation is obtained with
clamps or sutures. An alternative approach is to isolate the liver Complications
and the vena cava by cross-clamping the supraceliac aorta, the Besides those already mentioned, major complications associ-
porta hepatis, the suprarenal inferior vena cava, and the intraperi- ated with repair of injuries to the great vessels in the abdomen
cardial inferior vena cava.52 Because profoundly hypovolemic include thrombosis, dehiscence of the suture line, and infection.
patients usually cannot tolerate cross-clamping of the inferior vena Because of the risk of occlusion of repairs in small vasoconstrict-
cava, this approach is rarely employed. Some experienced hepatic ed vessels (e.g., the superior mesenteric artery), it may be worth-
surgeons have successfully used extensive hepatotomy to expose while to perform a second-look operation within 12 to 24 hours
and repair the retrohepatic vena cava.53 if the patient’s metabolic state suggests that ischemia of the
The retrohepatic vena cava is repaired with continuous 4-0 or midgut is present. Early correction of an arterial thrombosis in
5-0 polypropylene sutures.When the atriocaval shunt is removed the superior mesenteric artery may permit salvage of the midgut.
from the heart after the vessel has been repaired, the right atrial As noted [see Injuries in Zone 1, above], dehiscence of an end-
appendage is ligated with a 2-0 silk tie. to-end anastomosis or a vascular conduit inserted in the proximal
The survival rate in patients not in cardiac arrest who under- superior mesenteric artery when there is an injury to the adjacent
go atriocaval shunting and repair of the retrohepatic vena cava pancreas may be prevented or the incidence lowered by inserting
has ranged from 33% to 50%.51,52 a distal aorta–superior mesenteric artery bypass graft.To prevent
adjacent loops of small bowel from adhering to the vascular
suture lines, both lines should be covered with soft tissue
Damage-Control Laparotomy (retroperitoneal tissue for the aortic suture line and mesenteric
Patients with injuries to the great vessels of the abdomen are tissue for the superior mesenteric arterial suture line). Also as
ideal candidates for damage-control laparotomy54: they are uni- noted [see Injuries in Zone 3, above], when an extensive injury to
formly hypothermic, acidotic, and coagulopathic on completion either the common or the external iliac artery occurs in the pres-
of the vascular repair, and a prolonged operation would lead to ence of significant enteric or fecal contamination in the pelvis, li-
their demise. In such patients, packing of minor or moderate gation and extra-anatomic bypass may be necessary.
injuries to solid organs, packing of the retroperitoneum, stapling On occasion, vascular-enteric fistulas occur after repair of the
and rapid resection of multiple injuries to the GI tract, and con- anterior aorta or the insertion of grafts in either the abdominal
sideration of diffuse intra-abdominal packing are all appropriate, aorta or the superior mesenteric artery.6 In my experience, such
as is silo coverage of the open abdomen, in which a temporary fistulas all occur at suture lines; hence, once again, proper cover-
silo made from a urologic irrigation bag is sewn to the skin edges age of suture lines with soft tissue should eliminate or lower the
with a continuous 2-0 polypropylene or nylon suture. incidence of this complication.20,57
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1990 Traumatic injuries of the portal vein. The role of
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Figures 3, 5, 8, 10, 12, and 14 Tom Moore.
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Moore, D. V. Feliciano, and K. L. Mattox, McGraw-Hill,
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Balloon catheter tamponade in cardiovascular eral arterial flow after interruption of hepatic L. Mattox, Appleton & Lange, Stamford, Connecticut,
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7 TRAUMA AND THERMAL INJURY 11 Injuries to the Urogenital Tract — 1
11 INJURIES TO THE UROGENITAL

TRACT
Hunter Wessells, M.D., F.A.C.S.
The World Health Organization (WHO) predicts a dramatic cases of suspected renal trauma in hemodynamically normal and
worldwide rise in the burden of disease caused by road traffic stable patients. A standard examination includes helical (spiral)
accidents and war.1 This rise will directly influence the incidence CT with a portal venous phase (from the diaphragm to the ischial
of urogenital trauma, in that motor vehicle crashes (MVCs) and tuberosities) to visualize active arterial bleeding [see Figure 2a],
firearm injuries are responsible for the overwhelming majority of followed after 10 minutes by delayed images (from the kidneys to
major renal and pelvic injuries.2 In one population-based study, the ischial tuberosities) to identify urinary contrast extravasation
the percentage of trauma patients in the United States who had [see Figure 2b]. CT should not be used as the primary evaluation
renal injuries was 1.2% (incidence, 4.9 per 100,000 population).3 method in hemodynamically unstable patients: other diagnostic
Thus, in 1 year, some 14,000 patients with renal injuries are hos- tests, such as diagnostic peritoneal lavage (DPL) or ultrasonogra-
pitalized nationwide. Approximately 45,000 pelvic fractures occur phy, should be performed before renal imaging with CT.
each year in the United States, 15% to 25% of which are associ- The American Association for the Surgery of Trauma (AAST)
ated with urologic injury. Urogenital injuries, though rarely fatal, Organ Injury Scale is used to classify blunt and penetrating renal
can cause profound long-term morbidity and permanently impair injuries and corresponds closely to the appearance of the kidney
quality of life. on CT [see Figure 3 and Table 2].7
Blood in the urine is the hallmark of injury to the urogenital
MANAGEMENT
system; however, as an isolated indicator, it is not specific for
injury location or severity. In penetrating abdominal trauma, Differences in the management of blunt and penetrating renal
hematuria is a signal that the kidneys, the ureters, and the bladder trauma are a result of the greater instability of the patient after
must be evaluated. Urethral and genital injuries are suspected penetrating trauma and the higher likelihood of severe renal
only in the setting of wounds to the pelvis, the perineum, or the injuries after firearm and stab wounds.
buttocks. When hematuria occurs in association with blunt trau-
ma, the entire urogenital system must be evaluated: the forces Nonoperative
associated with high-speed MVCs and falls can cause injuries to Increasing numbers of renal injuries are being been managed
both the upper and the lower regions of the urogenital tract. nonoperatively.The accuracy and rapidity of helical CT, combined
In what follows, each of the major urogenital organs is treated with the improvements achieved in resuscitation methods, have
separately. New imaging modalities and a growing emphasis on reduced the number of renal explorations performed.8 Currently,
nonoperative management of upper and lower urinary tract one half of all penetrating renal injuries and fewer than 5% of blunt
injuries have dramatically changed the field of urologic trauma. injuries necessitate operative management.3 All grade I and II renal
Concomitant injury to both the upper and the lower urinary tract injuries, regardless of the mechanism of injury, can be managed
is rare, but extra vigilance must be maintained to detect such with observation alone because the risk of delayed bleeding is
injury when it does occur. Evaluation and management of trauma extremely low. Most grade III and IV injuries, including those with
to the female reproductive organs requires special expertise, par- devitalized parenchymal fragments and urinary extravasation, can
ticularly when the patient is the victim of a sexual assault. be managed nonoperatively with close monitoring, serial hemat-
ocrit measurement, and repeat imaging in selected cases. Active
arterial bleeding, in the absence of other associated injuries, can be
Injuries to the Kidneys treated with emergency arteriography and angioembolization.
Thrombosis of the renal artery or its branches is treated expec-
INITIAL EVALUATION
tantly unless the contralateral kidney is absent or injured, in which
The most reliable sign of injury to the kidney is hematuria [see case emergency revascularization is indicated. Treatment with
Figure 1], except in patients with renal artery thrombosis or pedi- modalities such as endoluminal stenting and thrombolytic thera-
cle avulsion, who may have no blood in their urine. However, the py is a promising but still experimental approach.9-11
degree of hematuria correlates poorly with the severity of renal
injury,4 and as a result, criteria for imaging in these patients must Operative
take into account both the mechanism of injury and the proba- The only absolute indications for renal exploration are pedicle
bility of severe kidney injury.5 Accordingly, a Consensus State- avulsion, pulsatile or expanding hematoma, and hemodynamic
ment from a Renal Trauma Subcommittee convened by the WHO instability resulting from renal injury.6 Shattered kidneys (grade V)
proposed guidelines for imaging renal injuries [see Table 1].6 As and renal vascular injuries (grades IV and V) call for immediate
with all guidelines, exceptions exist. A high degree of suspicion for renal exploration and, usually, nephrectomy [see Figure 4].12,13 In
renal trauma is required for patients who do not meet the hema- patients who require laparotomy for associated injuries, renal
turia criteria for imaging but who have experienced a fall from a exploration and reconstruction of grade III and IV injuries may
height, have sustained a direct blow to the flank, or have other reduce the likelihood of delayed complications. Thus, exploration
indicators (e.g., persistent flank pain or severe associated injuries). of suspected kidney injuries (as determined by previous imaging or
Computed tomography is the first-line imaging modality for all on-table evaluation) in patients undergoing laparotomy for major
Patient presents with signs, symptoms, or

mechanism of injury suggestive of renal injury
Perform urinalysis.
Assess hemodynamic stability.
Patient is stable Patient is unstable or has expanding or

pulsatile hematomas
Perform on-table I.V. pyelography (IVP).

Blunt trauma
Penetrating trauma
Perform CT with delayed cuts.

Adult patient has Patient has gross hematuria
microscopic hematuria or systolic BP < 90 mm Hg, Grade injury.
and systolic BP 90 or patient is not an adult
mm Hg
Perform CT with delayed cuts.
Discharge from ED. Grade injury.
Repeat urinalysis in 3 wk.
Grade I or II Grade III or nonvascular grade IV Vascular grade IV or grade V
Determine whether there are other intraperitoneal injuries

that necessitate laparotomy.
Laparotomy is unnecessary Laparotomy is necessary
Explore kidney.
Attempt reconstruction of all renal units. If kidney is unreconstructable
or there is a major renal injury in a patient exsanguinating from other
injuries, perform nephrectomy.
Keep patient on bed rest until urine is grossly clear.

Remove Foley catheter when patient is ambulatory.
Watch for delayed bleeding. If this occurs, consider renal
angiography and selective embolization.
Treat persistent urinary extravasation with internalized Figure 1 Algorithm outlines management
ureteral stent. of renal injuries.
splenic or bowel injury should be attempted by surgeons experi- Intraoperative IVP (so-called one-shot IVP) is indicated when
enced in repairing an injured kidney. In reality, the success of non- exploration of a kidney is planned and no preoperative imaging is
operative management for most grade III and IV injuries means available. The main purpose of a one-shot IVP in this setting is to
that operative intervention in cases of blunt trauma is typically lim- confirm the presence of a contralateral functioning kidney; a
ited to patients with the most severe renal injuries, in whom con- potential benefit is the ability to rule out major injury. The plain
servative management fails either because of bleeding or because abdominal film is obtained 10 minutes after injection of a 150 ml
of ongoing urinary extravasation despite ureteral stenting.14 bolus of iodinated contrast material. If the injured kidney is ade-
A significant number of patients with a penetrating injury and quately imaged and found to be normal, exploration may be omit-
a minority of those with blunt trauma require immediate laparot- ted16; otherwise, the kidney should be explored. In critically ill pa-
omy before radiographic evaluation.15 Hematuria should alert the tients with multiple associated injuries, renal exploration is indicat-
surgeon to the possibility of renal injury, and the presence of a ed only if a pulsatile or expanding hematoma is present, in which
perinephric hematoma visible through the mesocolon should case expeditious nephrectomy is necessary. If exploration is not
prompt further evaluation. If a major renal injury is suspected on done, staging with CT should be completed once the patient is sta-
the basis of the size of the hematoma or an abnormal intraopera- ble; angioembolization and percutaneous drainage can be used to
tive intravenous pyelogram (IVP), exploration is indicated. manage bleeding and urinary extravasation, respectively.17-19
Table 1 Criteria for Imaging of Renal Injuries Renal reconstruction includes sharp debridement of all devital-
ized tissue, achievement of hemostasis, closure of the collecting
Type of Trauma Criteria for Imaging system, coverage of the defect, and drainage [see Figure 5]. Renal
salvage should be possible in nearly 90% of grade III and IV
Gross hematuria (visibly blood-tinged urine) injuries. Nephrectomy is reserved for destroyed kidneys that can-
Adult with microhematuria (defined as ≥ 1 +
Blunt RBC on dipstick or > 3 RBC/hpf) with a period
not be reconstructed or for cases of serious renal injury associat-
of hypotension (systolic BP < 90 mm Hg) ed with other life-threatening injuries (e.g., vascular or hepatic
Child (< 15 yr) with > 50 RBC/hpf trauma) in which taking the time required for attempted renal
repair would jeopardize the life of the patient.3,23
Penetrating Stable patient with any degree of hematuria and
injury near urinary tract A number of sophisticated products are available for enhancing
surgical hemostasis and reducing the need for tedious ligation of
individual small arterioles on the parenchymal surface. Such
The priorities of operative management for grade III, IV, and V products include a hemostatic bandage applied directly to the cut
injuries are hemorrhage control and definitive repair of the col- surface of the kidney,24 polyethylene glycol–based hydrogels, fi-
lecting system. A midline transabdominal incision permits explo- brin glue, and a gelatin matrix–thrombin tissue sealant (FloSeal;
ration of the kidneys and provides optimal access to the renal Baxter International, Inc., Deerfield, Illinois).25-28 To date, none of
hilum. After intraperitoneal sources of bleeding have been con- these products have been evaluated in the setting of blunt renal
trolled, preliminary isolation of the renal artery and vein should injuries, but results in elective partial nephrectomy models are
be achieved before Gerota’s fascia is opened. There is some con- encouraging.
troversy regarding the value of early vascular control, with one Once hemostasis is satisfactory, the collecting system is scruti-
randomized controlled trial showing no benefit from early isola- nized for evidence of injury. If the extent of the injury is unclear,
tion of the vessels in cases of renal gunshot wounds20; however, the 2 to 3 ml of methylene blue is directly injected into the renal
weight of the remaining evidence suggests that this technique is pelvis while the ureter is occluded with a vessel loop to identify
still valuable if renal reconstruction is the goal of exploration.6,21,22 any openings in the collecting system. Open calyces or
Isolation of the renal vessels is accomplished by opening the pos- infundibula are closed with 4-0 absorbable sutures. Often, the
terior peritoneum medial to the inferior mesenteric vein or by renal capsule can be used to cover exposed renal parenchyma
reflecting the ipsilateral colon (provided that the perineph- and provide additional hemostasis.The defect in the parenchyma
ric hematoma is left undisturbed). can be filled with folded absorbable gelatin sponges as the cap-
Once vessel loops have been placed around the renal artery and sule is closed over the bolsters. If the capsule has been destroyed,
vein, Gerota’s fascia is opened. If massive bleeding occurs when coverage may be obtained with an omental or perinephric fat flap
the hematoma is entered, Rumel tourniquets or vascular clamps tacked down over the defect, a patch constructed from polygly-
are applied to occlude the renal artery. If this maneuver does not colic acid or peritoneum, or an entire sac of polyglycolic acid
stop the bleeding, one should suspect a venous injury and occlude wrapped around the kidney, with the parenchymal edges kept
the renal vein as well. Surface cooling of the kidney is not advo- well apposed.29
cated, because of time constraints and concerns about possibly At the end of the procedure, the kidney is returned to its loca-
exacerbating hypothermia.Total exposure of the kidney by means tion within Gerota’s fascia, which is not reapproximated. Closed-
of sharp and blunt dissection facilitates identification of injury to suction drainage of the renal fossa is recommended only after
the parenchyma, the renal pedicle, or the collecting system. The repair of the collecting system; internalized stents are reserved for
renal capsule should not be pulled off the parenchyma: doing so complex injuries (e.g., large lacerations of the renal pelvis or the
would complicate subsequent repair. ureteropelvic junction [UPJ]).
a b
Figure 2 Shown are (a) a deep laceration with vascular contrast extravasation (arrow) and (b) a deep laceration with
urinary contrast extravasation (arrow).
Grade I Grade II Grade III
Grade IV Grade V
Figure 3 Illustrated is the AAST classification of renal injuries into grades I through V.
Postintervention Care resolution of extravasation can take weeks to months.

Management of patients after operative or nonoperative inter- Ultrasonography is useful for following such collections and for
vention for renal trauma depends to a large extent on the presence reducing the patient’s radiation exposure. For small uninfected
and severity of associated injuries. The most significant urologic collections adjacent to the kidney, no intervention is needed. If a
complications are urinary leakage, urinoma formation, and delayed perinephric fluid collection is large enough to compress the ureter
bleeding. or becomes infected, additional percutaneous drainage is indicat-
ed [see Figure 6].The drain fluid is tested for creatinine, and if the
After nonoperative management Bed rest is prescribed findings are consistent with a urine leak, the drain is left in place
until the urine becomes grossly clear. Drainage of the bladder with until the collection resolves and leakage can no longer be demon-
a Foley catheter is necessary only until other injuries are stable and strated on contrast imaging.
the patient can void spontaneously. For grade IV injuries with large Delayed bleeding is a rare but serious complication of nonop-
amounts of urinary extravasation, follow-up imaging 48 to 72 erative management of major lacerations.32 Pseudoaneurysm for-
hours after the initial scan is recommended to evaluate the degree mation is the most common cause of delayed bleeding [see Figure
of ongoing extravasation. CT is recommended, though in children, 7].33 Gross hematuria usually, but not invariably, accompanies the
protocols that reduce the radiation exposure should be used. If at bleeding. If it is seen in conjunction with hypotension or a
72 hours the amount of extravasation has not decreased from that decreasing hematocrit, urgent angiography is the best initial
seen on the initial scan, stenting is indicated. Cystoscopy and inter- approach; selective embolization is an effective treatment that ren-
nal double J stenting allow successful treatment of the small per- ders exploration unnecessary in most instances.
centage of cases in which the injury does not close spontaneously.30
When a double J stent is used to manage persistent extravasation, After operative management Retroperitoneal drains are
the urinary bladder should be decompressed with a Foley catheter. removed within 48 hours after renal exploration unless the creati-
Parenchymal fragmentation and arterial thrombosis cause nine concentration in the drained fluid is higher than that in the
ischemia and often delay resolution of urinary leakage.31 serum. Persistent urinary leakage is best evaluated by means of
Nevertheless, internal stenting almost invariably suffices, though repeat CT with delayed cuts. As with nonoperative management,
Table 2 AAST Organ Injury Scales for Urinary Tract

I Contusion with microscopic or gross hematuria, urologic studies normal;

2; 2
nonexpanding subcapsular hematoma without parenchymal laceration
Nonexpanding perirenal hematoma confined to renal retroperitoneum;

II laceration < 1.0 cm parenchymal depth of renal cortex without urinary 2; 2
extravasation
Laceration > 1.0 cm parenchymal depth of renal cortex without collect-

Kidney* III 3
ing system rupture or urinary extravasation
Parenchymal laceration extending through renal cortex, medulla, and

IV collecting system; injury to main renal artery or vein with contained 4; 4
hemorrhage
V Completely shattered kidney; avulsion of renal hilum that devascularizes 5; 5

kidney
I Contusion or hematoma without devascularization 2
II < 50% transection 2
Ureter* III ≥ 50% transection 3
IV Complete transection with < 2 cm devascularization 3
V Avulsion with > 2 cm devascularization 3
I Contusion, intramural hematoma; partial-thickness laceration 2; 3
II Extraperitoneal bladder wall laceration < 2 cm 4
Bladder† III Extraperitoneal bladder wall laceration > 2 cm or intraperitoneal bladder 4

wall laceration < 2 cm
IV Intraperitoneal bladder wall laceration > 2 cm 4
V Intraperitoneal or extraperitoneal bladder wall laceration extending into 4

bladder neck or ureteral orifice (trigone)
I Contusion with blood at urethral meatus and normal urethrography 2
II Stretch injury with elongation of urethra but without extravasation of 2

urethrography contrast material
Urethra* III Partial disruption with extravasation of urethrography contrast material at 2

injury site with visualization in the bladder
Complete disruption with < 2 cm urethral separation and extravasation

IV of urethrography contrast material at injury site without visualization in 3
the bladder
V Complete transection with ≥ 2 cm urethral separation or extension into 4

the prostate or vagina
*Advance one grade for bilateral injuries, up to grade III.
†Advance one grade for multiple injuries, up to grade III.
AAST—American Association for the Surgery of Trauma AIS-90—Abbreviated Injury Score, 1990 version
internal stenting and percutaneous drainage are the mainstays of operative nuclear imaging has not been determined, but by 3
treatment for leaks and urinomas, respectively. Postoperative months, the hematoma and inflammation related to the injury
hemorrhage is rare if the injured parenchyma has been adequate- usually have resolved.
ly debrided and repaired. Angiographic evaluation with emboliza- Hypertension is a rare late complication of renal reconstruc-
tion is the best approach for postoperative renal bleeding. tion, usually renin-mediated and deriving from an ischemic seg-
ment of renal parenchyma. Occasionally, angiography delineates
Functional imaging Postoperative nuclear imaging is rec- the ischemic segment of the kidney, and excision of the nonper-
ommended in patients with grade IV and V injuries involving sig- fused segment or complete nephrectomy may be required.
nificant parenchymal loss or vascular injury.34 The goal is to iden-
tify patients with significant loss of functioning renal tissue who
are at potential risk for chronic renal insufficiency. Patients whose Injuries to the Ureters
level of residual function in the injured kidney, as determined by
INITIAL EVALUATION
radionuclide scintigraphy, is less than 25% should be considered
as having a solitary kidney. This information is useful in counsel- Ureteral trauma [see Table 2] is rare, accounting for fewer than
ing patients who participate in high-risk sports activities (e.g., sky- 1% of genitourinary injuries. Furthermore, the absence of physi-
diving, motocross, and hang gliding).The optimal timing of post- cal signs of injury makes diagnosis difficult, and a delayed presen-
hematoma is found near the kidney or ureter. Direct inspection of

the entire trajectory of the offending agent requires particular vig-
ilance for direct injury to or contusions of the ureter. Injection of
indigo carmine into the collecting system identifies extravasation.
Direct injection saves time and ensures that injuries are not
missed as a result of low urine output from shock or renal injury.
One study found that all penetrating ureteral injuries were detect-
ed at laparotomy without previous imaging.36
Reconstruction and Repair
Ureteral injuries should undergo surgical reconstruction as
soon as they are recognized unless associated injuries prevent such
a strategy. For example, gunshot injuries to the iliac vessels or the
ureters may necessitate heroic vascular reconstruction. Ligation of
the ureter with subsequent nephrostomy tube drainage or exteri-
orization of a ureteral stent allows elective reconstruction months
later. Percutaneous and endoscopic approaches can also be used
to establish urinary drainage if ureteral exploration is not feasible.
Reconstructive steps in ureter repair include debridement of
devitalized tissue, creation of a spatulated tension-free anastomo-
sis, watertight mucosal approximation, stenting, coverage of the
repair with vascularized tissue when feasible, and appropriate
drainage.41 Stab wounds generally cause less tissue damage than
gunshot wounds and are more easily repaired; partial transections
may be closed primarily.
Figure 4 Shown is the intraoperative appearance
of a shattered, ischemic, nonviable kidney that was
removed (grade V injury).
Upper ureter Disruption or transection of the upper ureter
or the UPJ is repaired by means of debridement and primary
anastomosis of the renal pelvis and the ureter. Mobilization of the
tation is not uncommon. Gross or microscopic hematuria may be ureter is limited to ensure that the blood supply is not compro-
absent in 25% to 70% of patients with ureteral injuries, and as mised. Interrupted 5-0 or 6-0 absorbable sutures are preferred,
many as one half of all ureteral injuries resulting from blunt trau- and a double J ureteral stent or a nephrostomy tube is inserted
ma are not recognized immediately. A high index of suspicion and before completion of the anastomosis.
a high degree of vigilance are necessary if the diagnosis is to be
made early enough to prevent late consequences such as urinoma, Medial ureter Injuries to the abdominal ureter between the
sepsis, and nephrectomy.35-37 UPJ and the pelvic brim are repaired by means of uretero-
The mechanism of injury has a particular bearing on the diag- ureterostomy [see Figure 10]. After debridement, the ends are
nosis and management of ureteral injury. Overall, penetrating spatulated on opposite sides, and an interrupted approximation is
wounds are the predominant cause of these injuries. CT with completed over a double J stent. In cases of overlying colonic,
delayed cuts should be performed when ureteral injury is sus- duodenal, or pancreatic injury, the anastomosis should be covered
pected and the patient is stable. Imaging is of variable usefulness with omentum or retroperitoneal fat. Large defects in the abdom-
in the detection of ureteral injuries, but extravasation of the con- inal ureter may necessitate transureteroureterostomy, in which the
trast agent is diagnostic.38 Only 10% to 20% of ureteral injuries injured ureter is passed behind the mesocolon to the contralater-
are caused by blunt trauma, and within this category, MVCs pre- al side. Anastomosis of the injured ureter to a 1 to 2 cm opening
dominate.35 In children, ureteral injury at the UPJ often occurs in the medial side of the normal ureter can be achieved without
after severe deceleration.39 Children’s ureters are particularly tension. With transureteroureterostomy, a stent (usually a 5
prone to injury at this location because the hyperextensibility of French pediatric feeding tube) should cross the anastomosis and
their spines can result in ureteral avulsion at the UPJ.37,38,40 be brought out through the normal lower ureter or bladder.
MANAGEMENT
Distal ureter Ureteral injuries in the pelvis should be man-
All injuries to the ureter should be repaired surgically [see Figure aged with reimplantation into the bladder. The distal stump is li-
8] unless a delay in diagnosis has resulted in an abscess or a uri- gated, and after the anterior bladder wall is opened, the proximal
noma [see Figure 9]. If an abscess or a urinoma is present, drainage end of the ureter is brought through a new hiatus on the back wall
by means of percutaneous nephrostomy, coupled with ureteral of the bladder. The ureter is then spatulated and approximated to
stenting, allows infection and inflammation to resolve before the bladder mucosa with interrupted chromic sutures. One 3-0
definitive management; in this setting, an operative approach is anchoring stitch brings the distal apex of the ureter to the muscle
likely to result in nephrectomy. and mucosa; the rest of the sutures approximate the mucosa. A
refluxing reimplantation is acceptable in adults. Larger defects can
Ureteral Exploration be bridged by performing a vesicopsoas hitch, in which the bladder
In stable patients, blunt ureteral injuries are typically identified is sewn to the central tendon of the psoas muscle. The dome is
by preoperative radiographic studies, which allow directed explo- mobilized by dividing the obliterated umbilical arteries bilaterally
ration and repair (see below). With penetrating trauma, ureteral and, if necessary, the contralateral superior vesical artery. Three
injury may not be suspected until the time of laparotomy, when a interrupted nonabsorbable sutures that enter the detrusor muscle
a b c
d e
Figure 5 Depicted are the steps in renal reconstruction. (a)

The patient has suffered a deep midrenal laceration into the
renal pelvis. If the renal capsule is present at the wound margins,
it should be peeled back and preserved for subsequent closure.
The devitalized renal parenchyma is removed with a scalpel until
bleeding occurs at the margin. Polar injuries can be debrided by
guillotine amputation of the parenchyma. (b) The collecting sys-
tem having been closed, vessels are ligated. Manual compression
usually controls bleeding during ligation. Ligation of individual
vessels with absorbable monofilament suture material achieves
hemostasis. Temporary release of renal artery occlusion for the
assessment of hemostasis is not recommended. Ligation of
venous bleeding points generally controls adjacent arterial
sources. (c) Sutures are placed to close the defect. (d) An absorb-
able gelatin sponge is placed. (e) Alternatively, the defect may be
closed with an omental pedicle flap.
(but not the bladder lumen) anchor the dome above the iliac ves- Injuries to the Bladder
sels. Complex bladder or vascular injuries in the pelvis make trans-
INITIAL EVALUATION
ureteroureterostomy a more attractive option for avoiding further
dissection in the injured area. A ureteral stent should be used in all Bladder injury [see Table 2] is most often caused by blunt
ureteral reimplantations.The bladder is closed in two layers with a injuries, with penetrating trauma accounting for 14% to 33% of
continuous 2-0 absorbable suture. Closed-suction retroperitoneal civilian cases. About 9% of patients with a pelvic fracture have an
drainage and Foley catheter decompression of the bladder are
essential.
Postintervention Care
Postoperative care of ureteral trauma relates mainly to the
manipulation of drains and the management of complications.
Retroperitoneal drains may have significant output for several days
but are removed after 2 to 3 days unless output is consistent with
a urine leak as determined by creatinine measurement (see above).
Bladder catheterization is necessary for 7 days after ureteral reim-
plantation. In combined bladder and ureteral reconstructions, con-
trast cystography is indicated before catheter removal. Cystoscopic
removal of the double J stent is usually performed with local anes-
thesia 4 to 6 weeks after operation. CT, IVP, or renal scintigraphy
3 months after removal of the stent rules out the possibility of
asymptomatic obstruction.
Fistula formation, usually the result of distal obstruction or
necrosis of the ureter, should be managed by means of antegrade
or retrograde drainage of the collecting system with percutaneous
or endoscopic techniques. Drainage of periureteral fluid collec- Figure 6 CT scan shows an infected urinoma in a patient with
tions may also be necessary. If recognition of an injury or a com- left grade IV injury who presented 7 days after injury with fever
plication is delayed, reconstruction should be deferred for at least and sepsis and subsequently underwent ureteral stenting. The
3 to 6 months until all inflammation has subsided. urinoma was drained percutaneously.
MANAGEMENT
Nonoperative
Extraperitoneal bladder injuries caused by blunt trauma are gen-
erally managed nonoperatively with 10 days of catheter drainage.47
Contraindications to nonoperative management include urinary
infection; pelvic fractures requiring internal fixation; the presence
of bony fragments in the bladder; bladder neck injury, which may
compromise continence; rectal injury; and female genital lacera-
tions associated with pelvic fracture. After 10 days, plain-film or
CT cystography is performed to document healing. Once the
extravasation has resolved, catheter removal can be based on the
patient’s overall status and mobility. If extravasation persists, cys-
tography is repeated at appropriate intervals until healing occurs.
Operative
All penetrating injuries and all intraperitoneal ruptures of the
bladder are managed by means of bladder exploration and repair.
Figure 7 Shown is a pseudoaneurysm of the left kidney after
blunt injury.
Patient presents with mechanism of injury
associated injury to the bladder, though there is only a weak asso- suggestive of ureteral injury
ciation between the type of fracture sustained and the likelihood Maintain high index of suspicion: physical signs
of bladder injury.42 Because the fracture type has poor predictive are rare, and presentation may be delayed.
value for the type of associated genitourinary trauma, all patients Perform urinalysis.
with pelvic fractures and any degree of hematuria should be sus- Assess hemodynamic stability.
pected of having a bladder injury. Approximately two thirds of
bladder injuries are extraperitoneal and one third intraperitoneal,
a distinction that has important management ramifications.
The signs and symptoms of bladder injury are generally non- Patient is stable Patient is unstable
specific [see Figure 11], though 95% of patients with bladder rup-
ture present with gross hematuria. Patients may complain of Perform IVP or CT. Perform laparotomy.
suprapubic pain, dysuria, or an inability to void. Physical exami- Perform on-table I.V. pyelography (IVP) with
nation may reveal tenderness in the suprapubic region, ileus, or an one film at 10 min.
acute abdomen. The percentage of patients without any hema- Look for periureteral hematoma.
turia ranges from 0% to 3%.43,44 Laboratory studies are usually
inconclusive unless significant reabsorption of urine causes ele-
vated serum creatinine levels, hyperkalemia, or hyponatremia.45
Bladder rupture can be accurately diagnosed with either retro- Findings are normal Findings are abnormal
grade CT cystography or plain-film retrograde cystography. The Observe patient. Perform laparotomy.
indications for cystography include blunt trauma with gross
hematuria in the presence of free abdominal fluid on CT; blunt
trauma with a pelvic fracture and any degree of hematuria (> 3
red blood cells [RBCs] per high-power field [hpf]); stable pene- Explore ureter, exposing entire ureter and renal
trating trauma with any degree of hematuria; and an injury to the pelvis.
pelvis.The appearance of intraperitoneal and extraperitoneal rup- Determine location and type of injury.
ture with each modality is characteristic [see Figure 12]. Repair injuries surgically over indwelling stent.
Insufficient instillation of the contrast agent can yield false nega-
tive results. At one large center, the sensitivity and specificity of
CT cystography for bladder rupture caused by blunt trauma were Remove retroperitoneal drains when output is low.
95% and 100%, respectively.44 With current patterns of CT usage Remove Foley and suprapubic catheters after
7–10 days.
for trauma evaluation, including imaging of pelvic bony fractures,
CT cystography appears to be more efficient than plain-film stud- Remove double J stent after 4–6 wk.
ies. Furthermore, CT cystography clearly identifies the location of Perform follow-up IVP after 8 wk.
many bladder injuries and may be able to identify bladder neck
injuries [see Figure 12a].With penetrating trauma, there must be a
If recognition of injury is delayed or if abscess or
higher level of suspicion for bladder injury because the sensitivity
urinoma occurs postoperatively, consider
and specificity of cystography (CT or conventional) in this setting percutaneous nephrostomy and abscess drainage.
has not been determined. If bladder injury is associated with a Stent ureter if possible.
pelvic fracture in a male patient, the possibility of a urethral injury
is 10% to 29% and must be excluded.46 A successfully placed
Foley catheter rules out a complete urethral disruption. Figure 8 Algorithm outlines management of ureteral injuries.
The perivesical drain can be removed after 48 hours unless the

creatinine level in the drained fluid indicates ongoing urinary
leakage. In the majority of patients with a bladder repair, 7 days
of catheter drainage is sufficient to allow healing. Because blad-
der repair is reliable, any complications of bladder injury are usu-
ally related to a delay in diagnosis rather than to postoperative
morbidity. Azotemia, ascites, and sepsis can result from an un-
recognized intraperitoneal injury. Bladder neck injury, if over-
looked, leads to scarring and incompetence of the proximal
sphincter mechanism, with resultant incontinence, especially in
females.
Injuries to the Urethra
INITIAL EVALUATION
Almost all injuries to the male urethra [see Table 2] are caused
by blunt trauma. Prostatomembranous urethral distraction
Figure 9 CT scan shows extravasation and urinoma caused by
unrecognized right upper ureteral injury.
If the patient requires laparotomy for associated injuries and can a b

tolerate the extra operating time, repair of extraperitoneal bladder
injuries is also recommended. Conversely, in severely unstable
patients, catheter drainage can be used as a temporizing measure
until the patient is able to undergo exploration.
Bladder exploration can be performed via an intraperitoneal
approach or by entering the extraperitoneal space of Retzius in
the anterior pelvis. Intraperitoneal injuries present as a stellate
rupture of the dome of the bladder. By enlarging this opening,
one can inspect the interior of the bladder to exclude concomitant
extraperitoneal injuries, which occur in 8% of cases.48 In cases
involving orthopedic reconstruction of the pelvis, the bladder may
be approached extraperitoneally through the incision used to
expose the pubic symphysis. Although extensive hemorrhage has
been described in this scenario, it is a rare occurrence. Most
extraperitoneal bladder injuries associated with pelvic fractures
are anteriorly located, small in size, and easily closed without a
more extensive bladder exploration.
Penetrating injuries and unrecognized blunt injuries discovered
at laparotomy without previous CT cystography call for system-
atic evaluation. By opening the bladder vertically at the dome or
along the anterior surface, one can identify sites of injury intra- c d
vesically and inspect the ureteral orifices and the bladder neck.
Lacerations are closed with 3-0 absorbable sutures, which
approximate detrusor muscle and mucosa in one layer and pro-
vide hemostasis. In patients with penetrating injuries, entrance
and exit sites must be identified. The cystotomy is then closed
with two layers of continuous 2-0 slowly absorbable sutures.
Postintervention Care
Adequate urinary drainage is essential to successful healing of
the repaired bladder. There is no evidence that suprapubic
catheters are superior to urethral catheters in this context.49,50
However, the catheters placed during trauma resuscitation are not
of sufficient caliber to allow easy bladder decompression; there-
fore, a 20 French urethral catheter should be substituted at the
end of the operation. A closed-suction drain near the bladder clo-
sure (but not overlying the suture line) is recommended. Cases of
severe hematuria resulting from extensive injuries or coagulopa- Figure 10 Depicted are the steps in a ureteroureterostomy. (a)
thy warrant additional drainage with a suprapubic cystostomy The injured ureter is dissected free. (b) The ends are debrided
tube to allow irrigation of clots and proper decompression of the and spatulated. (c) A stent is placed, and the anastomosis is
bladder. begun. (d) The anastomosis is completed.
MANAGEMENT
Patient presents with trauma suggestive of bladder injury
Traumatic urethral injuries have traditionally been managed by
Perform retrograde plain-film cystography or CT cystography means of suprapubic cystostomy, with reconstruction delayed for
with adequate bladder filling. 3 to 6 months; however, most urethral trauma patients can under-
Perform retrograde urethrography if there are signs go immediate realignment, with or without sutured repair. The
of urethral injury.
exception is the patient with a straddle-type crush injury to the
bulbar urethra, which should always be treated with urinary diver-
sion and delayed repair.The recommended treatment is based on
the location and mechanism of injury [see Figure 14 and Table 3].
Patient has Patient has extraperitoneal rupture
intraperitoneal rupture from blunt trauma Posterior Urethra
or penetrating injury
Assess for contraindications to Posterior urethral (prostatic and membranous urethral) injuries
conservative management: urinary can be managed with suprapubic cystostomy or early primary ure-
tract infection, bony fragments in the thral realignment. Realignment without sutured repair renders
bladder, bladder neck injury, female
genital lacerations from pelvic fracture,
definitive reconstruction unnecessary in a significant percentage of
and requirement for laparotomy for patients.52 Bladder neck injury and wide separation of the bladder
associated injuries. from the urethra warrant immediate surgical intervention.53
Simultaneous rectal injury often occurs in this setting and neces-
sitates evacuation of the pelvic hematoma, irrigation, placement of
drains, and primary realignment of the urethra. Primary realign-
Conservative management No contraindications
to conservative ment is also preferred in cases of open reduction and internal fix-
is contraindicated
management are present ation of pelvic fractures because the risk of hardware contamina-
tion is considered to be lower with a urethral catheter than with
Manage with large-bore suprapubic cystostomy.54
Explore bladder via intraperitoneal catheter drainage for
or extraperitoneal approach. 10 days. Primary realignment is usually performed through a lower mid-
Repair injuries from inside bladder. line abdominal incision, which allows antegrade passage of instru-
Close bladder in two layers. ments through the bladder at the same time as retrograde passage
Provide adequate urinary drainage. of instruments from the urethral meatus. Flexible cystoscopes or
magnetic-tipped catheters advanced under fluoroscopic guidance
are used to place a wire into the bladder beyond the injury, and a
Remove perivesical drain when output is low. Council-tip Foley catheter is then advanced over the wire. Neither
Obtain follow-up cystogram at 7–10 days.
mucosal approximation nor direct anastomosis is the goal. Supra-
pubic catheter drainage is not required, but a perivesical drain
Remove catheters when there is no extravasation.
should be left in place for 48 hours.
Figure 11 Algorithm outlines the management of bladder injury. Anterior Urethra

Immediate surgical reconstruction is preferred for penetrating
injuries of the bulbar and penile urethra and for urethral injuries
injuries in males occur in 5% of pelvic fractures, which are the associated with penile fracture. For these grade III and IV injuries,
most common cause of posterior urethral injury. Anterior urethral primary repair is associated with a lower stricture rate than simple
(penile and bulbar urethral) injuries are commonly caused by realignment.55,56 Wounds accompanied by major tissue loss and
straddle injury but may be the result of penile fracture or pene- defects larger than 2 cm (e.g., grade V injuries) or major associated
trating injuries to the genitalia. The female urethra is rarely
injuries are best treated with suprapubic tube urinary diversion (see
injured, but when such injury occurs, it is usually associated with
below) and subsequent reconstruction at a tertiary referral center.
bladder injury and pelvic fracture.51
Blood at the urethral meatus—the classic sign of injury to the Suprapubic Cystostomy
male urethra—is an indication for immediate urethrography.
Many centers continue to use suprapubic cystostomy as the pri-
Attempts at catheter placement risk converting an incomplete
injury to a complete disruption and are to be discouraged if ure- mary management of prostatomembranous urethral disruption
thral injury is suspected. and straddle injuries to the bulbar urethra. Suprapubic cystosto-
Because signs of urethral injury are variable, retrograde ure- my, with the tube percutaneously placed under fluoroscopic guid-
thrography is the essential diagnostic test used for documenting ance, allows temporary urinary diversion for initial stabilization
the location, nature, and extent of injury. Extravasation of the con- and evaluation of the patient. Cystography can then be performed
trast agent is evidence of urethral injury [see Figure 13]. In the via the suprapubic tube to rule out associated bladder injury.
absence of extravasation, a Foley catheter should be passed. If a Straddle injuries must be treated with suprapubic diversion unless
catheter has been placed but its position is unclear, contrast injec- the urethral disruption is only partial and allows passage of a guide
tion will confirm its placement in the bladder. In such cases, the wire or catheter under fluoroscopic guidance. Finally, suprapubic
catheter should be left in place until a pericatheter contrast study cystostomy is also recommended for penetrating injuries to the
can fully evaluate the urethra. In cases of pelvic fracture and com- anterior urethra if the injuries were caused by high-velocity
plete posterior urethral injury, bladder injury must be excluded by weapons and are characterized by extensive tissue loss; if serious
open bladder exploration or via cystography through a percuta- associated injuries are present; or if bony fractures prevent proper
neously placed suprapubic tube. placement of the patient in the lithotomy position.
a b
Figure 12 (a) CT cystogram shows extraperitoneal bladder rupture. A definitive discontinuity in

the bladder wall is visible (arrow). (b) CT cystogram shows intraperitoneal bladder rupture.
Postintervention Care reconstruction can be performed. Stricture formation or complete

Catheter care is of great importance after urethral reconstruc- obliteration of the urethra may be the final result of this nonoper-
tion or suprapubic cystostomy. Urethral catheters should be ative approach. Subsequent radiographic studies will indicate
whether secondary endoscopic or open procedures are needed.
secured to the abdominal wall in the early postoperative period.
After immediate reconstruction of the anterior urethra, the Foley
catheter should remain in place for 3 weeks, at which time a con- Injuries to the Vagina, Uterus, and Ovaries
trast voiding cystourethrogram should be obtained. If extravasa- Injuries to the female genitalia [see Table 4 and Figure 15] must
tion is present, the catheter should be replaced for 1 week and the be regarded as especially morbid because of their association with
study repeated. After primary realignment of urethral injuries, the sexual assault and interpersonal violence, as well as because of the
urethral catheter is left in place for 6 weeks, at which time a peri- potential medical complications (infection and bleeding). Genital
catheter retrograde urethrogram is obtained, with the expectation trauma is reported in 20% to 53% of sexual assault victims.57,58
that any extravasation will have resolved. Blunt unintentional trauma, including pelvic fracture and straddle
If the patients initially underwent diversion with a suprapubic injuries, often results in perineal and vaginal injuries and, less
tube alone, the tube should be changed after a tract has formed commonly, cervical and uterine trauma.59-61 Enlargement of a
(usually about 4 weeks after the procedure) and then monthly until reproductive organ predisposes that organ to injury.62 Penetrating
a b
Figure 13 (a) Retrograde urethrogram of a posterior urethral injury after pelvic fracture shows extravasation
at the level of the urogenital diaphragm. (b) Retrograde urethrogram of an anterior urethral injury caused by a
gunshot wound shows extravasation at the level of the bulbar urethra.
Only large hematomas must be incised and drained, with ligation

of vessels. Lacerations of the vulva may be closed primarily after
irrigation and debridement. Interrupted absorbable sutures allow
any accumulated fluid to drain and eliminate the need for suture
removal. Drains are used if there is a large cavity; if hemostasis is
suboptimal, the wound may be packed.61
Vaginal and cervical lacerations from either blunt or penetrat-
ing injury will bleed extensively if the pudendal vessels are
injured.61 If bleeding is not severe, examination and repair with
Posterior local anesthesia is possible in the ED. If large lacerations are asso-
ciated with bleeding and hematoma, speculum examination under
anesthesia permits more complete assessment and repair of
injuries. Vaginal lacerations should be closed with continuous or
interrupted absorbable sutures that include mucosal and muscu-
lar layers. Antibiotic-soaked vaginal packing should be left in place
Anterior for 24 hours. Perioperative administration of broad-spectrum
antibiotics is sufficient, unless injuries are more complex.
Complex vaginal and perineal lacerations associated with pelvic
fracture must be managed much more aggressively to prevent the
morbidity and mortality characteristic of open fractures.67
Figure 14 Shown are the posterior and anterior portions of the Evaluation of vaginal injuries with the patient under anesthesia,
urethra. The posterior portion comprises the prostatic urethra and cystography, and rigid proctoscopy are mandatory.The vaginal lac-
the membranous urethra; the anterior portion comprises the bul- eration should be closed with absorbable sutures. Even in the
bar urethra and the penile urethra. Treatment of urethral injury absence of injury to the bladder or the rectum, diversion of the uri-
depends on the location and mechanism of injury. nary and fecal streams should be considered to facilitate care of the
perineal wound67; however, I rarely divert the fecal stream unless
injuries account for almost all injuries to the fallopian tubes, the the perineal injury extensively involves the rectum or the sphinc-
ovaries, and the nongravid uterus.63 ter.68 Extraperitoneal bladder rupture associated with vaginal lac-
erations must be repaired operatively to prevent infection of a
INITIAL EVALUATION pelvic hematoma or formation of a vesicovaginal fistula. Urologic,
A history of sexual trauma must be sought; if such a history is gynecologic, and orthopedic consultations are necessary for care of
elicited, appropriate police and support services must be noti- associated injuries.
fied.64 In addition, if sexual assault has occurred, informed con- Injury to the pelvic genital organs is rare in a nongravid patient.
sent for the rest of the patient assessment must be obtained. This Penetrating trauma is the most common cause, and the majority of
assessment includes a history, physical examination, collection of patients have associated injuries necessitating laparotomy.62 Blunt
evidence and laboratory specimens, and treatment, as outlined by injury of the nongravid uterus and the pelvic organs occurs in the
the American College of Obstetricians and Gynecologists.65 The face of preexisting abnormalities; DPL demonstrates hemoperi-
percentage of assault victims with identifiable spermatozoa in the toneum in these instances.63 The uterus, the organ most commonly
vaginal specimens is lower than 50%.66 injured, is repaired with figure-eight sutures or a two-layer closure
All female patients with evidence of lower urinary tract and using slowly absorbable sutures.62 Avulsion of the uterine artery or
urethral injury should undergo examination of the external geni- extensive blast destruction of the uterus may necessitate hysterecto-
talia, as well as speculum examination of internal organs.The find- my.61 When hysterectomy is necessary for trauma, the vaginal cuff
ing of blood implies vaginal laceration. In the presence of pelvic should be left open to allow drainage of the operative bed.69 Lacera-
fracture or impalement injury, vaginal laceration warrants com- tions to the ovary or the fallopian tube are managed by primary clo-
plete evaluation (with cystourethrography, proctoscopy, and sure or salpingo-oophorectomy if contralateral structures are normal.
laparotomy, as indicated) to rule out associated urinary tract and After hysterectomy or repair of vaginal lacerations, a vaginal pack
GI tract injuries. Failure to identify vaginal injury associated with should remain in place for 24 hours. Hemorrhage caused by uter-
pelvic fracture may lead to abscess formation, sepsis, and death. ine injury has been treated with oxytocin, which increases uterine
tone and controls bleeding. Fertility after injury to the female repro-
MANAGEMENT
ductive organs is not well documented, but patients must be coun-
Perineal lacerations in the absence of associated urinary tract seled about the possible adverse consequences of uterine and
and rectal injury can be managed in the emergency department. adnexal trauma.
Table 3 Management of Urethral Trauma
Mechanism of Injury
Location of Injury
Blunt Penetrating Penile Fracture
Posterior (prostatic and membranous urethra) Realignment or suprapubic cystostomy Realignment NA
Anterior (bulbar and penile urethra) Suprapubic cystostomy Surgical repair Surgical repair
Table 4 AAST Organ Injury Scales for Female Reproductive Tract
I Contusion or hematoma 1
II Superficial laceration (mucosa only) 1
Vagina* III Deep laceration (into fat or muscle) 2
IV Complex laceration (into cervix or peritoneum) 3
V Injury to adjacent organs (anus, rectum, urethra, bladder) 3
II Superficial laceration (skin only) 1
Vulva* III Deep laceration (into fat or muscle) 2
IV Avulsion (skin, fat, or muscle) 3
V Injury to adjacent organs (anus, rectum, urethra, bladder) 3
II Superficial laceration (< 1 cm) 2
Nongravid uterus* III Deep laceration (≥ 1 cm) 3
IV Laceration involving uterine artery 3
V Avulsion or devascularization 3
I Hematoma or contusion 2
II Laceration < 50% of circumference 2
Fallopian tube† III Laceration ≥ 50% of circumference 2
IV Transection 2
V Vascular injury or devascularized segment 2
II Superficial laceration (depth < 0.5 cm) 2
Ovary† III Deep laceration (depth ≥ 0.5 cm) 3
IV Partial disruption of blood supply 3
V Avulsion or complete parenchymal destruction 3
I Contusion or hematoma (without placental abruption) 2
II Superficial laceration (< 1 cm) or partial placental abruption (< 25%) 3
III Deep laceration (≥ 1 cm) in second trimester or placental abruption

3; 4
Gravid uterus* > 25% but < 50%; deep laceration in third trimester
IV Laceration involving uterine artery; deep laceration (≥ 1 cm) with 4; 4

> 50% placental abruption
V Uterine rupture in second trimester; uterine rupture in third trimester; 4; 5; 4–5

complete placental abruption

†Advance one grade for bilateral injuries, up to grade III.
Injuries to the Penis

penile replantation successfully restores erectile capability.
Injury to the flaccid penis is rare, occurring mainly as a result
of penetrating trauma and machinery accidents.56,70,71 The INITIAL EVALUATION
increased use of protective armor on the torso has caused a shift Missed intromission, acute bending of the penis, and a snapping
in battlefield urologic injuries from renal structures to pelvic and or popping sound followed by acute pain and immediate detumes-
genital organs.72 Penile fracture is an uncommon injury of the cence are characteristic of penile fracture. Delayed presentation,
tunica albuginea that occurs only with full penile rigidity.73-75 attributable to embarrassment, is common. Penetrating injuries to
Prompt operative treatment allows recovery of erectile function the penis may result from deliberate attempts at mutilation, as well
after most penile injuries [see Table 5]. Remarkably, in many cases, as from accidental firearm injury (typically occurring when a
amputated organ is critical for successful restoration of function.

Patient presents with evidence of gynecologic injury or
sexual assault The amputated part should be placed on saline-soaked gauze
inside a clean bag, which should then be sealed and placed inside
Examine external genitalia and, by speculum, internal organs. a second bag containing ice slush.77 Cold ischemia times longer
Notify support services if there is evidence of sexual trauma. than 24 hours are acceptable and allow transport of the patient to
tertiary centers, where replantation can be performed. Even at
normal temperatures, replantation 16 hours after injury has been
successful.78 Microsurgical repair techniques have certain advan-
Patient has Patient has Patient has pelvic tages, including better preservation of the penile shaft skin and
perineal injury cervical or genital organ injury the possibility of a sensate glans and normal orgasmic func-
vaginal
Look for associated injury (Such injury is usually tion. However, astonishing results have also been reported with
rectal and urinary found at laparotomy the conventional technique of corporal reattachment with-
tract injuries. Differentiate rather than on out microvascular reanastomosis of the dorsal neurovascular
Small hematomas: between examination, and there structures.
treat conservatively. simple is a high incidence of
and complex associated injuries.) MANAGEMENT
Large hematomas: injuries.
treat with incision, Close ovarian
lacerations primarily; if A circumferential subcoronal incision provides exposure after
drainage, and
injury is severe, consider penile fracture and most penetrating injuries of the shaft and per-
ligation of vessels.
salpingo-oophorectomy. mits corporal and urethral repair. The superficial layers and skin
Lacerations: treat
with irrigation, Repair uterus in two are bluntly degloved back to the base of the penis. For deeper
debridement, and layers. injuries, proximal to the suspensory ligament or in the crura, a
primary closure. If bleeding is penoscrotal or perineal incision is required to provide access to
uncontrolled or uterine the corpus cavernosum. Rupture of the corpus cavernosum as a
artery is avulsed,
result of a fracture, a stab wound, or a bullet wound is signaled by
consider hysterectomy.
the presence of active bleeding and a defect in the fibrous tunica
albuginea. Careful exploration and inspection of the corpus spon-
giosum are mandatory, even if urethrography shows no extravasa-
Patient has simple vaginal or Patient has complex vaginal tion.Tunical ruptures caused by fracture are transversely oriented
cervical lacerations or perineal lacerations [see Figure 16] and sometimes extend behind the spongiosum; this
structure may have to be mobilized and retracted for adequate
Place antibiotic-soaked vaginal Evaluate vaginal injuries with visualization of the injury.
pack and leave for 24 hr. patient under anesthesia.
The tunica albuginea is closed with interrupted 3-0 slowly
Give perioperative broad- Perform contrast cystography absorbable sutures. Debridement and curettage have occasionally
spectrum antibiotics. and rigid proctoscopy.
been used in this setting but generally are reserved for late pre-
Minor lacerations: close Close vaginal injuries primarily.
primarily.
sentations. Skin closure is possible with most penetrating injuries
Give I.V. antibiotics. to the penis. The extensive vascular supply to the skin is rarely
Major lacerations: examine via Consider urinary and fecal
speculum with patient under compromised. Interrupted chromic sutures provide a cosmetic
diversion.
anesthesia, and repair injury. closure and allow drainage of residual blood between the sutures.
Large hematomas: evacuate A lightly compressive dressing is sufficient; tight wraps are to be
and drain. avoided because they may lead to necrosis of swollen shaft skin.
Catheter drainage is mandatory if urethral injury is present.
Figure 15 Algorithm outlines management of injuries to the Sexual intercourse is contraindicated for 1 month after penile
female genitalia. injury.
handgun goes off while in a man’s pants pocket). Because of the Penile Amputation
pliability of the flaccid penis, entry and exit wounds may be com- Microsurgical replantation differs from simple corporal reat-
plex. Penile swelling is usually limited to the shaft of the penis by tachment in that the neurovascular structures are reanastomosed
Buck’s fascia; scrotal and perineal ecchymosis develop if the deep in addition to the urethra and the tunica albuginea.With corporal
investing fascia of the penis is disrupted. Imaging of the corpora reattachment, a spatulated end-to-end urethral anastomosis is
cavernosa with contrast cavernosography has limited sensitivity performed with interrupted absorbable sutures over a urethral
and specificity and thus is not recommended.76 Associated ure- catheter. The adventitia of the corpus spongiosum is reapproxi-
thral, scrotal, bladder, and rectal injuries must be excluded. mated in a second layer, and the tunica albuginea and its septum
Inability to void, gross hematuria, and blood at the meatus all are then connected.The restored cavernosal blood flow preserves
imply urethral injury and warrant further investigation. A uniform the distal corpora, the glans, and the urethra. Ischemic skin loss is
policy of exploration for all penile fractures and penetrating injuries expected without reanastomosis of the dorsal artery and vein.
will ensure that urethral injuries are identified. Passage of a When microsurgical techniques are available, the dorsal nerves,
catheter in the operative field with inspection of the involved ure- the dorsal arteries, and the deep dorsal vein are each reanasto-
thra allows identification and primary repair of a lacerated or tran- mosed with fine nonabsorbable sutures. Meticulous closure of the
sected urethra. superficial tunica dartos and the skin completes the repair.
Temporary ectopic replantation of the penis has been described
Penile Amputation in cases where the perineum is heavily contaminated or too exten-
Whether caused by a jealous lover or by self-mutilation, penile sively damaged for immediate replantation.79 Postoperative care
amputation is a catastrophic event.77 Proper preservation of the includes urinary diversion, bed rest, anticoagulation (in selected
Table 5 AAST Organ Injury Scales for Male Genitalia
I Contusion 1
II Laceration < 25% of scrotal diameter 1
Scrotum III Laceration ≥ 25% of scrotal diameter 2
IV Avulsion < 50% 2
V Avulsion ≥ 50% 2
II Subclinical laceration of tunica albuginea 1
Testis* III Laceration of tunica albuginea with < 50% parenchymal loss 2
IV Major laceration of tunica albuginea with ≥ 50% parenchymal loss 2
V Total testicular destruction or avulsion 2
I Cutaneous laceration or contusion 1
II Laceration of Buck’s fascia (cavernosum) without tissue loss 1
Penis† III Cutaneous avulsion, laceration through glans or meatus, or caver- 3

nosal or urethral defect < 2 cm
IV Partial penectomy or cavernosal or urethral defect ≥ 2 cm 3
V Total penectomy 3
*Advance one grade for bilateral injuries, up to grade III.

†Advance one grade for multiple injuries, up to grade III.
cases), hydration, and monitoring of arterial flow in the distal Injuries to the Scrotum and Testes
penis.
INITIAL EVALUATION
Scrotal trauma may result in testicular injury or genital skin

loss [see Table 5]. Because blunt injuries to the testicle are difficult
to recognize, high-resolution ultrasonography has become a key
element in the evaluation of scrotal trauma [see Figure 17]. When
a straddle injury or penetrating mechanism suggests the possibil-
ity of urethral injury, retrograde urethrography is indicated.
Penetrating scrotal injuries commonly involve not only the testis
but also the corpora cavernosa, the urethra, and the spermatic
cord. Ultrasonography is useful to ascertain the integrity of the
arterial inflow to the testis.80 The excellent blood supply of the scro-
tal skin allows most penetrating injuries to be debrided and closed.
Even simple bite injuries can be irrigated and closed with appro-
priate antibiotic coverage. Exceptions to this general rule include
complex contaminated human and animal bites, which are left
open and are treated with intravenous antibiotics and local wound
care (or debridement in cases of severe soft tissue infection).81
Rupture of the testicle is often immediately painful, with rapid
onset of swelling. Falls, straddle injuries, and direct blows are
common mechanisms of injury.82 However, seemingly minor
degrees of trauma may be associated with delayed onset of pain;
in this scenario, testicular torsion must be included in the differ-
ential diagnosis. Physical signs of rupture include scrotal swelling,
tenderness, and ecchymosis. Injury to the scrotal wall or the tuni-
ca vaginalis may cause significant swelling without rupture of the
tunica albuginea of the testis; pelvic hematoma caused by fracture
can result in massive scrotal swelling. For these reasons, blunt
injury to the scrotum should be evaluated by ultrasonography
unless the findings from the physical examination are normal.
Figure 16 Shown is a case of penile fracture. A lin- The ultrasonographic characteristics of testicular rupture [see
ear tear in the tunica albuginea can be seen (arrow). Figure 18] include loss of normal homogeneity of the testicular
parenchyma, loss of continuity of the tunica albuginea, and intra-

Patient presents with injury to scrotum parenchymal hematoma.83 A discrete break in the tunica is rela-
tively rare. In cases of pelvic fracture with massive scrotal edema,
Obtain retrograde urethrogram to rule out urethral ultrasonography can document the integrity of the testis and allow
injury if indicated.
conservative management of the swelling. If rupture is not docu-
mented, treatment with ice packs, analgesics, and elevation allows
resolution of swelling.
Injury is penetrating Injury is blunt MANAGEMENT
Perform scrotal ultrasonography. Exploration of the scrotum through a vertical incision allows
inspection of the scrotal contents; when spermatic cord injury is
discovered, the incision can be extended cephalad to the groin.
The goal is preservation of testicular parenchyma for endocrine
Evidence of rupture is seen No evidence of rupture and cosmetic purposes; normal sperm production and transport
is seen are not expected after repair of rupture. Clots and extruded sem-
Manage conservatively
iniferous tubules are debrided with scissors to allow closure of the
Explore scrotum through vertical tunica albuginea over the edematous parenchyma. A continuous
with ice, analgesia, and
incision.
elevation. 3-0 slowly absorbable suture is sufficient.
Extend any penetrating lacerations. When spermatic cord injury is detected, the first priority is
Debride devitalized scrotal skin. determination of the viability of the testis. A small incision into the
tunica albuginea should cause some bleeding; if the testis is cyan-
otic and does not bleed when cut, orchiectomy should be per-
formed. If only the vas deferens or spermatic vessels are injured,
Patient has testicular injury Patient has spermatic cord injury the testis will remain viable. Ligation of the spermatic vessels is
performed in the standard fashion; if vasal ligation is necessary,
use of nonabsorbable suture with long tails enables later identifi-
cation for reconstruction if infertility ensues.
Testis is viable Testis is Testis is viable
Scrotal skin lacerations can be closed primarily in most
not viable
Debride extruded If vas is injured, instances. Exceptions arise if there is a prolonged delay between
seminiferous tubules Perform debride both ends injury and definitive care or if grossly contaminated wounds are
sharply. orchiectomy. and ligate with associated with rectal injuries. Hemostasis should be meticulous.
Preserve all viable Ligate vas nonabsorbable suture. Interrupted suture closure of the tunica dartos and skin in sepa-
tissue. and vessels Ligate bleeding vessels. rate layers, with a Penrose drain brought out through a separate
Close tunica separately. Extend incision dependent stab wound, limits postoperative hematoma forma-
albuginea. cephalad as needed. tion. Fluffed gauze should be used for dressing, and a scrotal sup-
Close skin primarily, porter should be used to keep the scrotum elevated. The Penrose
leaving Penrose
drain is removed on postoperative day 1. There are no major
drain in scrotum.
restrictions to activity after scrotal surgery, and patients can be
Consider contralateral
exploration. discharged once they have recovered from associated injuries.
Scrotal avulsion can be devastating and must be differentiated
from complex lacerations. Skin avulsed by shear forces in MVCs
Figure 17 Algorithm outlines management of injury to the scro- may be suitable for cleansing and preparation for full- or split-
tum or testes. thickness grafts; however, when high-speed rotating machinery is
a b
Figure 18 (a) Ultrasonogram of ruptured testes shows intraparenchymal hematoma and het-
erogeneous echotexture. (b) Ultrasonogram of ruptured testes shows indistinct testicular con-
tour and abnormal echotexture.
the mechanism, as when clothing and skin are caught in a power the demarcation between viable and nonviable tissue should be
takeoff, this approach is not recommended. The intrinsic identified before extensive debridement.84 Management de-
microvasculature of the skin is probably damaged. Scrotal skin pends on the amount of skin remaining. Options include prima-
loss caused by burns or electrical or mechanical injury usual- ry closure, immediate coverage with meshed split-thickness skin
ly spares the testis, which has a separate blood supply. grafts, and placement of the testes in subcutaneous pouches in
Conservative debridement is possible if there is no infection, but the thigh.
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ment of trauma to the male external genitalia: ogists ACOG: Sexual assault. ACOG Educ Bull tation injuries of the male genitalia. Urol Clin
the usefulness of American Association for the (242):1, 1997 North Am 16:359, 1989
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170:2311, 2003 et al: Analysis of 418 cases of sexual assault. gical replantation of a completely amputated penis.
57. Sugar NF, Fine DN, Eckert LO: Physical injury Forensic Sci Int 131:125, 2003 Ann Plast Surg 10:317, 1983
after sexual assault: findings of a large case 67. Niemi TA, Norton LW: Vaginal injuries in 79. Matloub HS, Yousif NJ, Sanger JR: Temporary
series. Am J Obstet Gynecol 190:71, 2004 patients with pelvic fracture. J Trauma 25:547, ectopic implantation of an amputated penis.
58. Riggs N, Houry D, Long G, et al: Analysis of 1985 Plast Reconstr Surg 93:408, 1994
1,076 cases of sexual assault. Ann Emerg Med 68. Woods RK, O’Keefe G, Rhee P, et al: Open 80. Tsai HN, Wu WJ, Huang SP, et al: Bilateral trau-
35:358, 2000 pelvic fracture and fecal diversion. Arch Surg matic testicular dislocation—a case report.
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Sports Med 1:483, 1982 Schwartz SI, Shires GT, Spencer FC, et al, Eds. to the penis. J Urol 147:1265, 1992
60. Haefner HK, Andersen HF, Johnson MP: Vaginal McGraw-Hill, New York, 1984, p 199 82. Gomez R: Genital injuries. Probl Urol 8:279,
laceration following a jet-ski accident. Obstet 70. Monga M, Moreno T, Hellstrom WJG: A strate- 1994
Gynecol 78:986, 1991 gy for success: managing gunshot wounds to the 83. Wessells H, McAninch JW: Testicular trauma.
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61. Knudson MM, Crombleholme WR: Female gen-
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Trauma. Blaidsell FW, Trunkey DD, Eds. trauma to the male external genitalia. J Trauma tive approach to a heterogeneous entity. World J
Thieme Medical Publishers, New York, 1993, p 44:492, 1998 Urol 17:107, 1999
311 72. Thompson I, Flaherty SF, Morey AF: Battlefield
62. Quast DC, Jordan GL: Traumatic wounds of the injuries. J Am Coll Surg 187:139, 1998
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Acknowledgments
63. Maull KI, Rozycki GS, Pedigo RE: Injury to the 74. Uygur MC, Gulerkaya B, Altug U, et al: 13 The author expresses his thanks to Jack W. McAninch,
female reproductive system. Trauma. Mattox years’ experience of penile fracture. Scand J Urol M.D., F.A.C.S., for guidance and help in preparing
KL, Moore EE, Feliciano DV, Eds. Appleton- Nephrol 31:265, 1997 earlier versions of this chapter.
Lange, San Mateo, California, 1988 75. Karadeniz T, Topsakal M, Ariman A, et al: Penile Figures 3, 5, and 10 Susan Brust, C.M.I. Adapted
64. Bottomley CP, Sadler T,Welch J: Integrated clin- fracture: differential diagnosis, management and from originals by P. Stempen.
ical service for sexual assault victims in a geni- outcome. Br J Urol 77:279, 1996 Figures 1, 8, 11, 15, and 17 Marcia Kammerer.
7 TRAUMA AND THERMAL INJURY 12 INJURIES TO THE PELVIS AND EXTREMITIES — 1
12 INJURIES TO THE PELVIS AND

EXTREMITIES
J. C. Goslings, M.D., Ph.D., K. J. Ponsen, M.D., and O. M. van Delden, M.D., Ph.D.
Injuries to the pelvis and extremities are common, occurring in are always done in two planes (anteroposterior [AP] and lateral).
approximately 85% of patients who sustain blunt trauma. Long bones should be visualized over their entire length, including
Improper management can have devastating consequences. Major the adjacent joints. After reduction of fractures and dislocations, x-
long bone fractures are a sign that substantial force has been rays should be repeated, unless no time is available (e.g., because
applied to the body, and they are frequently associated with torso of the presence of limb-threatening vascular injury).
injuries. Trauma to the pelvis or the extremities can result in Computed tomographic scanning is frequently used as an
injuries that are potentially life-threatening (e.g., pelvic disruption adjunct to conventional x-rays, especially in patients with periar-
with hemorrhage, major arterial bleeding, and crush syndrome) or ticular fractures and dislocations or pelvic fractures. Axial, sagittal,
limb-threatening (e.g., open fractures and joint injuries, vascular coronal, and three-dimensional reconstructions allow exact deter-
injuries and traumatic amputation, compartment syndrome, and mination of the extent of the fracture and the position of fracture
nerve injury secondary to fracture dislocation). In this chapter, we fragments. CT scanning also helps in the process of deciding
outline the basic knowledge the general or trauma surgeon between operative and nonoperative treatment, and it facilitates
requires for initial management of injuries to the pelvis, the preoperative planning when a surgical therapy is adopted. In addi-
extremities, or both. tion, CT scanning may play a role in detecting bleeding sources in
the pelvis, though hemodynamic instability or ongoing blood loss
in the presence of a pelvic fracture usually is best managed with
Evaluation and Assessment immediate angiography rather than CT.
Magnetic resonance imaging can be helpful with complex malu-
INITIAL PRIORITIES
nions, soft tissue injuries, and certain fracture types (e.g., scaphoid
In the surgical management of musculoskeletal injury, the pri- fracture).3 Bone scintigraphy and ultrasonography are less fre-
orities are (1) to save the patient’s life, (2) to save the endangered quently employed in the setting of pelvic and extremity trauma.
limb, (3) to save the affected joints, and (4) to restore function; Triphasic bone scanning is primarily used to detect osteomyelitis,
these priorities are pursued in accordance with advanced trauma avascular necrosis, and malignant lesions, whereas ultrasonogra-
life support (ATLS) guidelines.1 The musculoskeletal injury that it phy is mostly used to assess soft tissue injuries.
is most important to identify during the primary survey is an
CLASSIFICATION OF INJURIES
unstable pelvic injury, which can lead to massive and life-threaten-
ing internal bleeding. If manual compression-distraction of the
iliac crests elicits abnormal movement or pain, a pelvic fracture is Fracture
probably present. In this case, a prefabricated splint or sheet wrap Of the many existing fracture classification systems, the one that
is applied around the pelvis to reduce the intrapelvic volume, and is most frequently used is the system developed by two Swiss orga-
the legs are wrapped together to induce internal rotation of the nizations, the Association for Osteosynthesis (AO) and the Asso-
lower limbs. Grossly deformed extremities are reduced by means ciation for the Study of Internal Fixation (ASIF) [see Figure 1].4
of manual traction to reduce motion and to enhance the tampon- The AO-ASIF fracture classification system serves both as a means
ade effect of the muscles. In the initial phase, control of hemor- of documenting fractures (e.g., for research purposes) and as an
rhage from deep soft tissue lesions and vessel injury is best aid to the surgeon in assessing the severity of the fracture and
achieved with direct compression. determining the appropriate treatment.
During the secondary survey, the rest of the musculoskeletal In the AO-ASIF system, any given extremity fracture can be
system is assessed to identify fractures, dislocations, and soft tissue described in terms of a five-place alphanumeric designation [see
injuries. It is advisable to perform a tertiary survey 24 to 48 hours Figure 1a].The first place represents the bone injured.The second
after admission to detect any missed injuries, especially in multiply represents the segment affected by the injury (proximal, middle or
injured patients whose condition at admission precluded the com- diaphyseal, or distal, with malleolar a fourth category that is some-
pletion of a full secondary survey.2 times employed). The third represents the fracture type (A, B, or
C). In middle-segment long bone fractures, type A refers to simple
IMAGING
fractures with two fragments, type B refers to wedge fractures with
Diagnostic imaging usually begins with conventional x-rays.The contact between the main proximal and distal fragments after
pelvis is imaged during the primary survey, but x-rays of the reduction, and type C refers to complex fractures without contact
extremities typically are obtained only after life-threatening injuries between the main fragments after reduction [see Figure 1b]. In
have been corrected and the patient’s general condition is such that proximal and distal long bone fractures, type A refers to extra-
the surgeon can afford to spend the time necessary to complete articular fractures with the articular surface intact, type B refers to
extremity and spine imaging (which is often as along as several partial articular fractures in which there is some articular involve-
hours). Conventional x-rays of the affected limb are guided by the ment but part of the articular surface remains attached to the dia-
injury mechanism, the history, and the physical examination and physis, and type C refers to complete articular fractures in which
a Bone (1, 2, 3, 4)
1. Humerus
2. Radius, Ulna
3. Femur
4. Tibia, Fibula
Bone Segment (1, 2, 3, 4)

1. Proximal
2. Middle
3. Distal
4. Malleolar
Fracture Type (A, B, C)
Diaphyseal (Middle Segment)

A. Simple
B. Wedge
C. Complex
A B C
Metaphyseal/Epiphyseal
(Proximal or Distal Segment)
A. Extra-articular
B. Partial Articular
C. Complete Articular
A B C
Fracture Group (1, 2, 3)
Fracture Subgroup (.1, .2, .3)
Least Most
Location Morphology Severe Severe
Figure 1 (a) Shown is the AO-ASIF classification system for fractures, as expressed in a five-place alphanumeric
designation. (b) Illustrated are the three types of diaphyseal long bone fractures, along with the three groups into
which each type is divided. (c) Depicted are the three types of metaphyseal or epiphyseal long bone fractures.
the articular surface is disrupted and completely separated from the extent of contamination (if any). With closed injuries, the
the diaphysis [see Figure 1c]. The fracture types are then further intact skin prevents direct assessment of the subcutaneous tissues,
subdivided into three groups (1, 2, or 3), represented by the fourth and as a result, soft tissue injuries are frequently underestimated.
place, and (mainly for scientific purposes) three subgroups (.1, .2, In the emergency department, a single inspection is made, and the
or .3), represented by the fifth place. wound is covered by a sterile dressing; at this point, it may be help-
For the fracture types, groups, and subgroups, increasing letter ful to take pictures with a digital camera. Exact grading of the soft
and number values represent increasing severity, as determined by tissue injury is best done in the operating room by an experienced
the complexity of the fracture, the difficulty of treatment, and the surgeon who can also decide on a treatment plan.
prognosis.Thus, an A1 fracture is the simplest injury with the best The system most commonly used for classification of open frac-
prognosis, and a C3 fracture is the most complex injury with the tures is the one developed by Gustilo and Anderson, which divides
worst prognosis. For practical purposes, the first four places of the these fractures into three types as follows [see Figure 2]4,5:
AO-ASIF alphanumeric designation are usually sufficient for 1. Type I: the wound is smaller than 1 cm and results from an
treatment planning; the fifth (the subgroup) adds little to the inside-out perforation, with little or no contamination; the
process. fracture type is simple (type A or B).
Pelvic ring and acetabular fractures are classified in essentially 2. Type II: the skin laceration is larger than 1 cm but is associat-
the same fashion [see Management of Pelvic and Acetabular ed with little or no contusion of the surrounding tissues; there
Injuries, below]. is no dead musculature, and the fracture type is moderate to
severe (B or C).
Soft Tissue Injury
3. Type III: extensive soft tissue damage has occurred, with or
The type of soft tissue injury present and its extent are deter- without severe contamination, frequently in association with
mined by the type of insult sustained (e.g., blunt, sharp, or crush), compromised vascular status; the fracture is highly unstable
the degree and direction of the force applied, the area affected, and (type C) as a result of comminution or segmental defects.Type
b Diaphyseal Fracture Types
A B C
Diaphyseal Fracture Groups
> 30 o < 30 o
A1 A2 A3 B1 B2 B3 C1 C2 C3
Metaphyseal/Epiphyseal Fracture Types
A B C
III fractures are further divided into the following three sub- of pressure applied by the fragment from the inside; the frac-
categories: ture type is simple or moderate.
a. IIIA: adequate soft tissue coverage of the bone is still possi- 3. Grade II: deep contaminated abrasions and localized skin or
ble. muscle contusion are present as a consequence of direct trau-
b. IIIB: extensive soft tissue loss occurs with periosteal strip- ma, possibly leading to compartment syndrome; the fracture
ping and exposed bone; contamination is usually massive. type is moderate to severe.
c. IIIC: an arterial injury is present that requires repair; any 4. Grade III: extensive skin contusions, destruction of muscula-
open fracture accompanied by such an injury falls into this ture, and subcutaneous tissue avulsion have occurred; the frac-
category, regardless of fracture type. ture is severe and mostly comminuted.
Closed fractures are less frequently classified according to the
type and extent of soft tissue injury, though this does not mean that Timing and Planning of Intervention
such injury is not an important consideration with closed fractures.
In multiply injured patients, the timing of operative treatment of
The classification system most commonly used for closed fractures
injuries to the pelvis and extremities depends both on the condi-
is that of Tscherne, which recognizes the following four grades:
tion of the patient and on the particular combination of skeletal
1. Grade 0: soft tissue injury is absent or minor; the fracture type and soft tissue injuries sustained [see Table 1]. In such cases, the
is simple. threshold for adoption of a damage-control strategy [see Damage-
2. Grade I: superficial abrasion or contusion is present as a result Control Surgery, below] to minimize operating time and tissue
Type I Type II Type III
< 5 cm > 5 cm
Figure 2 Illustrated is the

Gustilo-Anderson classification
system for open fractures.
insult should be low.6,7 The performance of multiple definitive reasonable provisional reduction; however, complete joint disloca-
osteosyntheses is an option only in patients who have been suc- tions are not acceptable. Clinically, sufficient reduction of swelling
cessfully resuscitated (as indicated by stable hemodynamic status has occurred when the skin has regained its creases and is wrinkled
without a need for inotropes; absence of hypoxia, hypercapnia, and over the operative site. Early definitive surgery may also be con-
acidosis; normothermia; normal coagulation parameters; and nor- traindicated when abrasion or degloving injury is present at the
mal diuresis). fracture site on admission.
In other cases, the timing and extent of operative treatment of Swelling is less of a problem with shaft fractures that will be
musculoskeletal injuries may be more complex. Generally, if open treated with intramedullary nailing. If, however, it is not possible to
reduction and internal fixation are indicated, the sooner the oper- perform nailing within 24 to 48 hours after the injury, it is better
ation is performed, the better. With early operation, fracture sur- to postpone the operation for 7 to 10 days; patients operated on
faces are more easily cleaned of blood clots and other material, and between days 3 and 7 are at higher risk for the acute respiratory
reduction is facilitated by the absence of prolonged dislocation and distress syndrome (ARDS).8,9 If the procedure must be delayed for
shortening. After 6 to 8 hours, swelling develops, making both the more than 2 to 3 weeks (e.g., because of sepsis and organ failure),
operation and the subsequent closure more difficult and thereby reconstruction of bones and joints will be substantially more diffi-
increasing the risk of infection and other wound complications. cult. If such delay leads to suboptimal axial alignment and
There are some cases, however, in which it might be preferable to nonanatomic reconstruction of the articular surface, the long-term
postpone a complex articular reconstruction in order to ensure prognosis will be worse.
that the surgical team is optimally prepared. If, for any reason, sig- Thorough preoperative planning is necessary for any operation
nificant swelling precludes a definitive operation, it is usually safer done on the musculoskeletal system. Depending on the procedure
to stabilize the fracture temporarily (e.g., with splinting or external to be performed, logistical considerations may include availability
fixation), then wait 5 to 10 days for the swelling to subside. of the appropriate operating team, availability of the correct oper-
Temporary stabilization usually allows the surgeon to achieve a ating table, availability of the specific instruments needed, avail-
ability of the appropriate implants, and availability of intraoperative Table 2 Goals of and Indications for Damage-
imaging. Technical considerations include the operative approach Control Surgery in Management of Pelvic and
to be followed and the fixation method to be used, which are deter- Extremity Trauma
mined on the basis of an understanding of the extent of the injuries
and a detailed knowledge of the anatomy in the area to be exposed.
Control of hemorrhage
For example, awkward placement of fixator pins could seriously Control of contamination
obstruct soft tissue reconstruction if the pins are in the area that Removal of dead tissue and prevention of ischemia-reper-
Goals
should be used for a soft tissue flap. Before operation, the correct fusion injury
operative site is verified (with the patient awake) and marked with Facilitation of ICU treatment
a permanent marker pen. A drawing of the planned reduction Pain relief
maneuvers and fixation techniques may be helpful for the surgeon Clinical parameters
while also serving as an educational tool for the assisting team Multiple trauma (ISS > 15) and additional chest trauma
members. Correct documentation is important for both medical Pelvic ring injuries with exsanguinating hemorrhage
and legal reasons. Multiple trauma with abdominal or pelvic injuries and
hemorrhagic shock (BP < 90 mm Hg)
DAMAGE-CONTROL SURGERY Radiographic findings indicating (bilateral) lung contusion
Femoral fractures in polytrauma patient
Immediate and complete care of all fractures, dislocations, and Indications
Polytrauma in geriatric patient
soft tissue injuries may seem the ideal treatment strategy for Resuscitation, operation, or both expected to last > 90 min
patients with musculoskeletal injuries. However, this is not always
Physiologic parameters
the case. Major trauma leads to a systemic inflammatory response Severe metabolic acidosis (pH < 7.20)
syndrome (SIRS) characterized by increased capillary leakage, Base deficit (< – 6 mEq/L)
high energy consumption, and a hyperdynamic hemodynamic Hypothermia (T° < 35° C)
state. Especially in the setting of severe single-organ injury or mul- Coagulopathy (PT > 50% of normal)
tiple injuries, the physiologic and immunologic impact of extend- Multiple transfusions
ISS—Injury Severity Score PT—prothrombin time
Table 1 Time Frames for Operative Treatment of

ed surgical procedures on the patient’s general condition can
Pelvic and Extremity Trauma* increase the risk of the multiple organ failure syndrome (MODS),
ARDS, and other complications. Balanced against this risk is the
(Imminent) hemodynamic instability (e.g., pelvic understanding that early fracture fixation in polytrauma patients is
fracture)
Neurovascular injury with compromised vitality
beneficial in terms of mortality and morbidity. Improved under-
Category I: immediate standing of the physiologic response to major trauma over the past
of extremity
(Imminent) compartment syndrome decade has led to the approach known as damage-control surgery
(DCS) or staged surgery, the purpose of which is to keep the
Open fractures (increased risk of infection)
Joint dislocations that cannot be reduced in ED
patient from having to deal with the “second hit” imposed by the
Primary stabilization (e.g., external fixation) in operation right after experiencing the “first hit” imposed by the ini-
multiply injured patients who are hemody- tial trauma.
namically stable Currently, DCS is widely promoted for management of intra-
Category II: urgent Femoral neck fractures in patients < 65 yr (to
(within 6–12 hr) prevent femoral head necrosis)
abdominal, vascular, and musculoskeletal injuries. It can be divid-
Long bone fractures (to prevent complications ed into three main phases: (1) a resuscitative phase, (2) an inten-
and immobilization) sive care phase, and (3) a reconstructive phase.10 The initial focus
Severe soft tissue injury (e.g., degloving is on control of bleeding, contamination, and temporary stabiliza-
caused by rollover accident) tion of fractures; time-consuming reconstructions and osteosyn-
Closed fractures with compromised skin
theses are avoided at this point. At a later stage, when vital func-
Dislocated talar neck fractures
tions have been restored, definitive reconstructions are performed
Femoral neck, intertrochanteric, and sub- during one or more planned reoperations.
trochanteric fractures The decision whether to employ DCS should be made before
Closed reduction of fractures in children
the operation to avoid a scenario in which the patient’s general
Treatment of soft tissue injuries (e.g., to ten-
dons of wrist and hand) condition of the patient deteriorates seriously during a difficult
Category III: semiurgent
(within 12–24 hr) Closed fractures that benefit from early treat- operation (e.g., a complex femoral nailing procedure) [see Table 2].
ment (e.g., to prevent swelling with ankle An experienced and judicious surgeon will make an appropriate
fractures)
decision about DCS more often than not. If, as sometimes hap-
Spine fractures that are unstable or associat-
ed with neurologic deterioration pens despite the surgeon’s best efforts, the patient’s condition does
Wound debridement and irrigation or washout show serious deterioration unexpectedly during operation, the sur-
geon should immediately choose a bailout option, usually involv-
Achilles tendon ruptures
ing external fixation.
Category IV: semielective Stable spine fractures
(within 24–72 hr or Other fractures
As applied to musculoskeletal trauma, DCS begins with
delayed) Revision procedures other than those done debridement of open wounds and irrigation with pulsed lavage
for infection (so-called washout). Amputation of the injured limb or limbs is
considered if it appears potentially lifesaving [see Management of
*These time frames are general guidelines and may be modified in accor-
dance with individual patient parameters (e.g., physiologic condition, soft tis- Life-Threatening or Limb-Threatening Injuries, Mangled
sue injury, and fracture type) and local preferences. Extremity, below]. During the initial debridement, osteochondral
fragments in open joint fractures are retained—provided that they to 48 hours after the initial procedure, when the patient is stable
are not severely contaminated—to allow later reconstruction of and normothermic and has normal or near-normal coagulation
the joint surface. Dislocations and diaphyseal fractures are parameters.10 Subsequent visits to the OR are used to continue
reduced and stabilized with simple external fixator frames (if nec- wound debridement and coverage and to exchange external fixa-
essary, placed so as to span the adjacent joint or joints), and tors for definitive fixation (e.g., with intramedullary nails).12,13
wounds are provisionally closed. Fixator pins are placed through During these operations, multiple teams can work simultaneously
stab incisions in safe zones. Fractures need not be reduced on the repair of abdominal, musculoskeletal, and other injuries.
anatomically under image intensifier control; the only goals at this The period from postinjury day 5 to day 10 is often referred to as
point are to restore length and align long bone fractures and the window of opportunity for reconstruction of intra-articular or
joints, to reduce contamination, and to enable postoperative periarticular fractures and of upper-limb fractures.
wound management in the intensive care unit while definitive
treatment is pending. The more complex the fixator frame, the
more time-consuming its application usually is. Muscle compart- Management of Life-Threatening or Limb-Threatening
ments believed to be at risk for compartment syndrome are wide- Injuries
ly decompressed.
LIFE-THREATENING PELVIC TRAUMA
At all times, the operating surgeon must keep the goals of DCS
clearly in mind. The main aim of this strategy is not necessarily a Pelvic fractures are frequently associated with significant hem-
nice-looking postoperative x-ray showing parallel fixator pins and orrhage, not only because of the fracture itself but also because
a perfectly reduced tibia; rather, it is the survival of the patient in pelvic trauma is often accompanied by serious injuries to other
stable physiologic condition. Depending on the severity of the parts of the body (e.g., the chest or the abdomen). Significant arte-
injuries, the reconstructive procedures likely to be performed, and rial hemorrhage is present in approximately 25% of patients with
the availability of specialists or subspecialists, consultation with a unstable pelvic fractures.4,5,10,14,15 Bleeding from pelvic trauma can
plastic surgeon during the initial operation may be advisable to be quite severe: as much as 4 L of blood may accumulate in the
optimize operative and logistical planning.6,7 retroperitoneal space. Whether hemorrhagic shock is associated
Careful attention must be paid to the logistical aspects of DCS. with certain fracture types remains a matter of debate, but there is
As soon as the decision for DCS is made, OR personnel should be certainly a link between the severity of the pelvic injury and the
notified of the type of procedures to be performed and the incidence of hemorrhagic shock. Hemorrhagic shock in patients
implants required. It may be helpful to have a dedicated DCS with pelvic fracture strongly influences outcome and necessitates
equipment trolley with all the materials and equipment necessary immediate evaluation and treatment.
for the first hour.11 Once the patient and the operating team are in Hemorrhage may originate either from within the fractured
the OR, the injuries sustained, the operative plan, and the injuries pelvic bones themselves or from torn arteries and veins in the
(known or suspected) that need special attention (e.g., a small pelvis, which are in close proximity to the bony structures of the
pneumothorax) are written down or sketched on a whiteboard so pelvis. In particular, the presacral venous plexus and the internal
that all persons present in the OR know what is to be done. iliac arteries and side branches may be lacerated. The most com-
During the operation, the surgeon should stay in close contact monly injured anterior branches of the internal iliac artery are the
with the anesthesiologist regarding the condition of the patient and internal pudendal artery and the obturator artery, whereas the
the procedure currently under way. If operative procedures are most commonly injured posterior branches are the superior gluteal
required in more than one organ system (e.g., laparotomy and artery and the lateral sacral artery.16,17
external fixation of the femora), they should, whenever possible, be Given that bleeding in pelvic fracture patients can occur in other
performed simultaneously by multiple teams working together. body compartments besides the pelvis and can be arterial as well
The end of the procedure should be announced well ahead of time as venous, it is of the utmost importance to identify its source and,
so that the anesthesiologist can take the precautions necessary for ideally, determine its nature as soon as possible. This information
transport of a potentially unstable patient and so that the ICU can is crucial in determining what the next steps in management
be notified of the patient’s arrival. In this way, unnecessary waiting should be [see Figure 3].
times in the OR can be kept to a minimum. The first step after diagnosing a pelvic fracture should be the
The second phase of DCS is restoration of vital functions in the immediate application of some type of external stabilization device
ICU. This phase is crucial for ensuring that the patient is fit to (e.g., a sheet wrap or a device such as the Pelvic Binder [Pelvic
undergo a second procedure.10 Close cooperation between sur- Binder Inc., Dallas, Texas]) [see Figure 4].18 The rationale behind
geon and critical care physician is required to outline an aggressive this step is that approximating the fractured bones and thereby
strategy for ventilation, circulatory support, and reversal of decreasing the volume of the pelvis may reduce blood loss, partic-
hypothermia, coagulopathy, acidosis, and other abnormalities. ularly from the fractured bones and the lacerated venous plexus. In
Administration of large volumes of fluid will be necessary as a con- addition, stabilization may minimize further damage to blood ves-
sequence of massive tissue swelling and bowel edema. Cardiac sels and prevent dislodgment of recent clots. It is doubtful, howev-
monitoring with central venous access should usually be er, whether this procedure actually reduces arterial hemorrhage to
employed. Application of external fixators allows the nursing staff a significant degree.
to place the patient in the position that is most suitable for inten- In hemodynamically unstable patients with clinical signs of a
sive care of head, chest, and abdominal injuries, while still allowing pelvic fracture, the next step (immediately after—or, preferably,
wound inspection and dressing changes as required. During this while—x-rays of the chest, the pelvis, and the cervical spine are
phase, imaging studies may be performed (or, if already per- obtained according to ATLS protocols) should be the FAST
formed, repeated) to allow planning for repeated washouts and (focused assessment for sonographic evaluation of the trauma
definitive reconstructive procedures. patient) to rule out a significant intra-abdominal bleeding source.
The third phase in the DCS sequence is the performance of one If the FAST is negative and no other obvious sources of hemor-
or more planned reoperations. This usually takes place at least 24 rhage (e.g., chest or extremities) are found, the pelvis is the most
Patient has unstable pelvic fracture
Perform noninvasive external stabilization with sheet wrap

or prefabricated device (e.g., Pelvic Binder).
Patient is hemodynamically unstable Patient is hemodynamically stable or has

moderate hemodynamic abnormality
Obtain x-rays of chest, pelvis, and cervical
spine according to ATLS protocols. Obtain x-rays of chest, pelvis, and cervical spine
Immediately afterward (or simultaneously, according to ATLS protocols. Perform contrast-
if possible), perform FAST to rule out enhanced CT scanning to look for bleeding source.
intra-abdominal bleeding source.
Little or no intraperitoneal Large amount of intraperitoneal Pelvic bleeding is identified No bleeding is identified
fluid is present fluid is present
Perform angiography and Place external fixation device.
Perform angiography and Perform laparotomy, and place embolization. Place external fixation (Consider retroperitoneal
embolization. Place external fixation external fixation device. If device. (Consider retroperitoneal packing.)
device. (Consider retroperitoneal hemodynamic instability persists, packing.)
packing as an adjunct.) perform angiography and
embolization.
Intra-abdominal bleeding source is identified
Perform laparotomy, and place external fixation

Figure 3 Algorithm outlines management of unstable fracture in device. If persistent hemodynamic abnormality
patients with varying degrees of hemodynamic stability. is present, perform angiography and embolization.
Or (depending on intraabdominal injury type)
Perform primary angiography and embolization.
Place external fixation device. (Consider
retroperitoneal packing.)
likely source of the bleeding.The question then arises whether the and the performance of embolization strongly influences out-
pelvic hemorrhage is predominantly arterial or venous. An arterial come. Angiographic embolization with gel foam or coils can
bleeding source in the pelvis is found in 73% of hypotensive almost always be performed via the common femoral artery
patients who do not respond to initial fluid resuscitation.19 approach, even with a sheet wrap or an external fixation device in
Contrast-enhanced CT scanning is extremely helpful in deter- place. Success rates exceed 90%, and major complication rates are
mining the presence of arterial hemorrhage in cases of pelvic frac- below 5%.This technique does, however, require a skilled, experi-
ture, but it can be performed only if the patient is stable enough to enced, and permanently available interventional radiology service.
undergo the time-consuming transfer to the imaging suite. If a CT In patients with unstable fractures, venous hemorrhage is treat-
scanner is available in the shock room, it may be possible to extend ed with operative placement of an external fixation device. This
the use of this modality to unstable patients. Extravasation of con- measure requires specific expertise on the part of the trauma sur-
trast medium, a large retroperitoneal hematoma, or abrupt cutoff geon; in experienced hands, it should take no longer than 20 min-
of an artery on CT indicates that angiographic embolization is nec- utes to perform. Patients with more severe pelvic fractures (e.g.,
essary. Contrast extravasation (so-called contrast blush) is a par- AO-Tile type B and C fractures and higher grades of lateral com-
ticularly good predictor of arterial hemorrhage necessitating pression and anteroposterior compression fractures [see
embolization, having a sensitivity and specificity of well over Management of Pelvic and Acetabular Injuries, Pelvic Ring,
80%.20 Thus, CT is an ideal means of identifying patients who below]) probably benefit most from this procedure. Retroperitoneal
should be treated with angiographic embolization and ideally packing may be employed as an adjunct to external fixator place-
should be performed in all pelvic fracture patients who are stable ment.23 It is unlikely that external fixation has a significant impact
enough to undergo this procedure. on arterial hemorrhage; consequently, it is vital to decide whether
Arterial hemorrhage should preferably be treated by angio- angiographic embolization should precede placement of an exter-
graphic embolization, which has shown excellent results in current nal fixation device in the OR.
studies [see Table 3].21,22 Several authors have argued that in unsta- The optimal strategy for controlling bleeding in patients with
ble patients, angiographic embolization should be done immedi- life-threatening pelvic injuries remains subject to debate.24,25 We
ately, before operative placement of an external fixation device, favor a prominent role for CT scanning and angiographic
because the chance of finding an arterial bleeding source is high embolization, whereas others favor more liberal use of surgical
and because the duration of the interval between arrival in the ED retroperitoneal packing of the pelvis.
a b
Figure 4 (a) Shown is initial stabilization of pelvic fracture in a patient with severe head injury, life-threat-
ening unstable pelvic fracture, distal femoral fracture, and proximal tibial fracture. (b) Shown is the same
patient after DCS.
OPEN FRACTURES AND SOFT TISSUE RECONSTRUCTION

are instituted according to local protocols.
Approximately 3% to 5% of all fractures and 10% to 15% of all The goals of treatment are to prevent infection, achieve ade-
long bone fractures are open.The prognosis after an open fracture quate soft tissue coverage, allow bone healing, and promote early
is very different from that after a closed fracture; treatment of open and full functional recovery. The basic principles of management
fractures is much more complex than treatment of simple fractures consist of aggressive debridement, open wound treatment, soft tis-
or traumatic wounds.The existence of an open fracture means that sue and bone stabilization, and systemic administration of antibi-
a great deal of energy has been delivered to the bone to produce otics.4,5 These principles have reduced the formerly high mortality
soft tissue disruption. Accordingly, it can be inferred that there has associated with open fractures to acceptable levels.
been considerable stripping of muscle, periosteum, and ligament High-velocity gunshot wounds and open fractures must be
from the bone, resulting in relative devascularization, and that approached differently from closed fractures because of the force
varying degrees of contusion, crushing, and devascularization of imparted to the soft tissues. Open fractures call for emergency sur-
the associated soft tissues have occurred. All of these events great- gical treatment. Ideally, such treatment should begin within 6
ly influence the rate of healing, the incidence of nonunion, and the hours of injury; the incidence of infection is directly related to in
risk of infection (most commonly by Staphylococcus aureus, the time elapsed before initiation of treatment.Typically, a second-
Enterococcus, or Pseudomonas). As noted [see Evaluation and generation cephalosporin is administered for 48 to 72 hours; pro-
Assessment, Classification of Injuries, Fracture, above], open frac- longed administration is not necessary. For grade III open frac-
tures are typically classified according to the system formulated by tures, gentamicin should be added to cover gram-negative bacte-
Gustilo and Anderson.4,5,26 ria; for farmyard injuries, which are at risk for contamination with
Management of open fractures in the ED starts with a detailed Clostridium, penicillin should be added.27,28
history that includes the patient’s medical condition before the The first stage of operative treatment consists of thorough irri-
injury, the mechanism of injury, and the time elapsed since the gation of the wound with 6 L of normal saline; pulsed or jet lavage
injury. A careful physical examination is then performed, with par-
ticular attention paid to neurovascular status, muscle function, and
the presence or absence of associated injuries. Compartment syn-
drome [see Management of Life-Threatening or Limb-Threaten-
ing Injuries, Mangled Extremity, below, and 7:17 Injuries to the Table 3 Indications for Angiographic
Peripheral Blood Vessels] should be ruled out in patients at risk; as Embolization in Patients with Pelvic Fracture
many as 10% of open tibial fractures are associated with compart-
Hemodynamic instability; FAST negative for intra-abdominal bleeding
ment syndrome as a result of severe soft tissue injury. If the limb is source; inadequate response to fluid resuscitation
malaligned, gentle gross reduction should be performed to relieve Contrast blush on contrast-enhanced pelvic CT scan
any vascular compromise.The wound is then inspected, and a ster- Large retroperitoneal hematoma on CT scan; expanding retroperi-
ile dressing is applied. Once this is done, the dressing should not toneal hematoma on sequential CT scans
be removed until the patient is in the OR and preparation for oper- Persistent hemodynamic instability after operative placement of exter-
nal fixator, laparotomy, or both
ation has begun.The need for repeated inspections by various spe- Hemodynamic stability with prolonged transfusion requirement (> 3
cialists can be eliminated by taking pictures of the fractured limb units of RBCs/24 hr) or other clinical signs of ongoing hemorrhage
with a digital camera. A temporary splint is applied to the limb to
relieve pain and prevent further soft tissue injury. X-rays are FAST—focused assessment for sonographic evaluation of the trauma patient
RBCs—red blood cells
obtained in two planes, with the adjacent joints included.
Antibiotic treatment is started in the ED, and antitetanus measures
can be helpful for this purpose. Cultures are ordered at this time. motion of granulation tissue. Sponges are available in different
To determine the true extent of the soft tissue damage, it is fre- sizes and can be further trimmed to fit the size of the wound, fill-
quently necessary to enlarge the skin wound. Foreign contami- ing all dead space. An airtight seal is created with an adhesive drape
nants, as well as dead bone and other devitalized tissues, predis- covering the wound and the sponge. Dressings are changed every
pose to infection and should therefore be removed. It is good prac- 2 to 4 days until the desired goals are reached. NPWT has proved
tice to perform a routine second-look operation 48 to 72 hours to be a viable adjunct for treatment of various soft tissue injuries,
after the initial debridement; debridement should be repeated until including open tibial fractures and pelvic injuries). It is also a use-
the soft tissues appear healthy and clean. ful means of securing skin grafts and is reported to lead to
Although grade I open fractures may sometimes be treated in improved graft survival. Although NPWT has yielded promising
much the same way as similar closed fractures, grade II and grade results in several case series, it should still be regarded primarily as
III open fractures must be surgically stabilized during the second a method of providing temporary coverage of soft tissue defects,
stage of the initial operation. Restoring of the normal anatomy not as a replacement for surgical debridement. Surgeons using
through reduction and stabilization improves circulation; promotes NPWT should take care not to delay definitive closure, even if
healing of bone and soft tissue; reduces inflammation, bleeding, such closure involves a complex free muscle transfer.
and dead space; and increases revascularization of devitalized tis- Rehabilitation should be started soon after the operation. It is
sue. It also results in earlier mobilization of multiply injured trau- facilitated by following an aggressive treatment algorithm consist-
ma patients and improves their overall status. ing of adequate fracture stabilization and early soft tissue coverage
Internal fixation is preferred for most open fractures, with plates to prevent prolonged immobilization of joints and soft tissues.
and screws mostly used for articular and metaphyseal fractures and Infection is the most common complication after an open fracture
intramedullary nailing for femoral and tibial shaft fractures. It is and can be the result of inadequate surgical technique, incomplete
not always necessary, however, to achieve definitive fixation in the debridement, or delayed soft tissue coverage. Open fractures are
first operation. In the case of complex fractures for which addi- also associated with a higher incidence of delayed union and
tional imaging or a specialized operative team is required, a cor- nonunion, which often necessitate placement of a cancellous bone
rectly placed external fixator is a safe and sensible option. External graft or, in the case of a large defect, a free fibular graft.
fixation as a temporary bridge to definitive fixation is also fre-
MANGLED EXTREMITY
quently used for severely contaminated grade III open fractures.
Surgically created wound extensions may be closed; however, the One of the more difficult decisions for a trauma surgeon is
traumatic wound itself should be left wide open. If the wound is whether to amputate a severely injured or mangled extremity [see
small, a portion of the surgical extension should be left open to 7:17 Injuries to the Peripheral Blood Vessels].The Mangled Extremity
allow adequate drainage and to prevent the traumatic wound from Severity Score (MESS) is frequently used as an aid in making this
sealing off prematurely. Every attempt should be made to cover decision,4,5 with a score of 7 or higher generally considered an indi-
bone, joint surfaces, implants, and sensitive structures (e.g., ten- cation for amputation. The final decision whether to amputate or
dons, nerves, and blood vessels) with available local soft tissue, but to attempt salvage, however, is based on the individual patient’s
such coverage must be achieved without tension. As an alternative overall condition, level of neurovascular function, and expected
to soft tissue coverage, a temporary method of wound coverage functional result.34,35
may be chosen (e.g., traditional wet dressings, synthetic mem- The decision between amputation and salvage does not neces-
branes, allografts, or other skin substitutes).4,5,29,30 sarily have to be made immediately; often, it can wait until the
Because leaving a wound open for prolonged periods increases involved specialists have discussed the matter in the hours or days
the risk of infection, skin coverage and soft tissue reconstruction following the initial operation. If a mangled extremity does not
should ideally be achieved within 1 week after the injury. In the pose an acute threat to the patient during the initial resuscitation,
case of a grade I or II open fracture for which the initial culture is it may be best treated with irrigation and debridement (as with
negative, the wound may be allowed to close by granulation and open fractures), some form of external stabilization, and temporary
secondary intention, or the patient may be returned to the OR in soft tissue coverage. Amputation in the acute phase should be per-
5 to 7 days for delayed primary closure. For larger wounds, split- formed at a safe level by means of a guillotine technique, combined
thickness skin grafts are often required. For grade III open frac- with open wound management.
tures, some type of flap is often required for soft tissue coverage [see The functional prognosis after limb salvage is based on the pres-
3:3 Surface Reconstruction Procedures]. Local fasciocutaneous flaps ence or absence of nerve injury and the surgeons’ judgment of
are suitable for smaller defects with intact surrounding skin. whether adequate vascularization, soft tissue coverage and long-
Muscle flaps have the advantage of adding vitality to exposed bone term bony stabilization are likely to be achievable. Often, multiple
and can cover substantial defects; they are frequently covered with operations must be performed over several months, and even then,
a split skin graft. Large wounds and those for which a local flap is the outcome may be uncertain. In patients with limbs at high risk
not suitable require a free flap that is anastomosed to the local ves- for amputation, the 2-year outcomes after reconstruction typically
sels. The flap procedure should preferably be done early, 5 to 10 are about the same as those after amputation.36 Accordingly, some
days after the injury; some authors have even reported good results patients may be better served by early amputation as definitive
with definitive soft tissue reconstruction completed during the ini- treatment.
tial operation (so-called fix and flap).4,5,31
COMPARTMENT SYNDROME
A comparatively new method of wound coverage is negative-
pressure wound therapy (NPWT) with a vacuum-assisted closure Compartment syndrome is defined as high-pressure swelling
device (VAC Abdominal Dressing System; Kinetic Concepts, Inc., within a fascial compartment [see 7:17 Injuries to the Peripheral
San Antonio, Texas).32,33 The perceived advantages of this Blood Vessels]. Many physicians still believe, incorrectly, that com-
approach include provision of a moist wound healing environ- partment syndrome cannot develop in conjunction with an open
ment, reduction of the wound volume, minimization of bacterial fracture, because the break in the skin provides decompression.
colonization, removal of excess fluid, and (most important) pro- This is a dangerous assumption: compartment syndrome occurs in
increases the pain. Paresthesia occurs early and should be actively

Compartment syndrome is suspected
watched for; paralysis develops when ischemia has caused perma-
nent damage. Pulselessness occurs late and is a relatively rare sign;
it has been shown that irreversible damage can occur in a patient
who still has palpable pulses.4,5,10,37
Clinical findings Clinical findings are inconclusive, Measurement of compartment pressures is also employed in the
unequivocally indicate or patient is not alert or reliable diagnosis of compartment syndrome. Monitoring can be particu-
compartment syndrome
larly helpful in patients who are not alert or are difficult to exam-
Measure compartment pressures. In
particular, determine difference between ine.38 There is no agreement on what constitutes the critical pres-
Perform fasciotomy.
diastolic arterial pressure and sure threshold for a definitive diagnosis. An absolute value of 30 to
pressure in involved compartment ( p). 35 mm Hg has frequently been adopted as a diagnostic indicator;
however, the evidence suggests that the difference between the dia-
stolic arterial pressure and the pressure in the involved compart-
ment (delta pressure, or Δp) is more important than any particular
absolute value. Currently, a diagnosis of compartment syndrome is
p < 30 mm Hg p ≥ 30 mm Hg usually made if Δp is less than 30 mm Hg, depending on the clin-
Compartment syndrome is ical signs and the level of suspicion.
considered to be present. If compartment syndrome is suspected, the first step is to
Perform fasciotomy. Perform continuous remove all circumferential bandages to relieve any pressure. If a
compartment pressure plaster cast is present, it should be split, spread, or removed; if nec-
monitoring and serial essary, maintenance of reduction should be sacrificed. If the clini-
clinical evaluations. cal picture does not improve after these measures are taken, then a
decompressive fasciotomy is indicated. Fasciotomy is described in
greater detail elsewhere [see 7:17 Injuries to the Peripheral Blood
Vessels].
Diagnosis of compartment p ≥ 30 mm Hg PERIPHERAL VASCULAR INJURY
syndrome is made on
clinical grounds Vascular injuries can result from either blunt or penetrating
trauma to the extremities, though the vascular injuries seen in
Perform fasciotomy. urban trauma centers tend to be caused more often by penetrat-
ing trauma. Early diagnosis and prompt multidisciplinary treat-
ment are crucial for successful management. The severity of the
p < 30 mm Hg
vascular injury and the length of the interval between injury and
restoration of perfusion are the major determinants of out-
Compartment syndrome is come.37,39-42 Diagnosis and management of such injuries are out-
considered to be present. lined in greater detail elsewhere [see 7:17 Injuries to the Peripheral
Perform fasciotomy. Blood Vessels].
There has been considerable discussion regarding the optimal
Figure 5 Algorithm outlines diagnosis of suspected compart- order of repair in cases of combined musculoskeletal and vascular
ment syndrome. trauma—that is, whether fracture stabilization should precede vas-
cular repair or follow it.43 Fracture stabilization facilitates the expo-
sure needed for vascular repair and reduces the risk of subsequent
disruption of a fresh arterial repair, but it inevitably takes time to
a significant number of patients with open fractures—for example, perform. Rapid application of an external fixator is a good alterna-
as many as 10% of patients with open tibial fractures. The most tive for extensive fracture repairs. Insertion of a temporary intralu-
common cause of compartment syndrome is hemorrhage and minal shunt can be valuable and limb-saving when DCS is per-
edema in the damaged soft tissues seen with fractures. Other caus- formed in a patient with severe vascular extremity injury or when
es include a too-tight dressing or cast, disruption of the limb’s a patient has a grossly unstable fracture that must be stabilized
venous drainage, advanced ischemia, and eschar from a circumfer- before arterial repair is possible.44 Endovascular repair plays a lim-
ential burn. Multiply injured patients with hypovolemia and ited, albeit growing, role in the treatment of arterial injuries asso-
hypoxia are predisposed to compartment syndrome.4,5,10 ciated with extremity trauma.45
The key to diagnosis of compartment syndrome [see Figure 5] is
PERIPHERAL NERVE INJURY
to maintain a high level of suspicion in any situation involving an
extremity injury where there is a significant chance that this syn- Injury to a peripheral nerve can result in loss of motor func-
drome might develop (e.g., tibial fractures, forearm fractures, and tion, sensory function, or both; it is the principal factor account-
all comminuted fractures associated with severe soft tissue injury). ing for limb loss and permanent disability. Because the upper
The diagnosis is primarily a clinical one, with the five Ps—pain, extremities have less muscle and bone mass and more neurolog-
pallor, paresthesia, paralysis, and pulselessness—constituting the ic structures than the lower extremities do, upper-extremity
classic signs. The surgeon should not wait until all these signs are injuries are twice as likely to result in nerve damage as lower-
present; the prognosis is much better if they are not. Severe extremity injuries are. Penetrating injuries from cuts or stab
ischemic muscle pain occurs that is unrelieved by the expected wounds that result in a clean laceration of a nerve are amenable
amounts of analgesia. On palpation, the compartment is tense and to early intervention and repair; penetrating injuries from gun-
swollen, and passive stretching of the digits of the extremity shot wounds are more difficult to assess and manage. Blunt
injuries result primarily from compression or stretching.4,5,46-48 ume and urine flow, may prevent renal failure. Forced diuresis can
Nerve injuries are generally categorized according to the be achieved by giving mannitol or other diuretics. Alkalization of
Seddon classification system, which divides them into three types: the urine with sodium bicarbonate (1 mEq/kg I.V. to a total of 100
(1) neurapraxia, (2) axonotmesis, and (3) neurotmesis. Complete mEq) is a controversial measure but is recommended by some on
recovery from neurapraxia and axonotmesis can usually be the grounds that it should, in theory, reduce intratubular precipi-
achieved, but neurotmesis usually necessitates surgical interven- tation of myoglobin. If compartment syndrome is suspected, com-
tion. How quickly and successfully nerves regenerate depends on partment pressures should be measured [see Compartment
several factors, including age, type of nerve (sensory or motor), Syndrome, above].49,50
level of injury, and duration of innervation.
Careful assessment of motor and sensory function is essential
for diagnosis. Additional diagnostic information can be obtained General Management of Fractures
by means of electromyography (EMG), MRI, and nerve conduc-
FIXATION METHODS AND IMPLANT TYPES
tion studies.
In the setting of blunt trauma, surgical treatment is recom- Fracture fixation can be accomplished either nonoperatively (by
mended for closed injuries when the injured nerve shows no evi- means of external splinting) or surgically. Surgical fixation can be
dence of recovery either clinically or on electrodiagnostic studies achieved with many different techniques, which yield varying
done 3 months after the injury. It is also recommended for gunshot degrees of stability. Screws, metal wires (e.g., Kirschner or cerclage
wounds without vascular or bony problems; such wounds have rel- wires), plates, nails, and external fixators have all been used for this
atively good potential for neurologic recovery. For most open purpose. Surgical fixation methods may be broadly divided into
injuries (e.g., laceration with neurotmesis), surgical exploration at techniques of absolute stability and techniques of relative stability.4
the earliest opportunity is recommended. If possible, the nerve is Treatment of fractures with techniques of absolute stability was
reapproximated primarily and the epineurium is sutured, or (sural) widely promoted by the ASIF. Anatomic reduction and achieve-
nerve grafts are employed.4,5,46 ment of absolute stability by means of interfragmentary compres-
Physical therapy should be started soon after nerve injury to sion plating were advised for treatment of articular, metaphyseal,
maintain passive range of motion in the affected joints and pre- and diaphyseal fractures.This method reduces strain at the fracture
serve muscle strength in the unaffected muscles. Splinting of site and allows bone healing without visible callus formation (so-
affected joints may be necessary to prevent contractures and min- called direct bone healing). However, obtaining interfragmentary
imize deformities. compression usually necessitates a fairly extensive surgical
approach, which disturbs the local blood supply.
CRUSH SYNDROME
Unlike techniques of absolute stability, techniques of relative
Crush syndrome (also referred to as traumatic rhabdomyolysis) stability (e.g., intramedullary nailing, use of bridging plates across
is a clinical syndrome consisting of rhabdomyolysis, myoglobin- a comminuted fracture, and external fixation) allow small inter-
uria, and subsequent renal failure. It is caused by prolonged com- fragmentary movements to occur when a load is applied across the
pression of muscle tissue (frequently in the thigh or the calf) and is fracture site. Such movements can stimulate callus formation and
usually seen in victims of motor vehicle accidents who required a lead to union of the bone in four stages: (1) inflammation, (2) soft
long extrication procedure or in earthquake victims who are res- callus, (3) hard callus, and (4) remodeling.The various techniques
cued from beneath rubble after being trapped for several hours or of relative stability (also referred to as splinting or bridging tech-
days. Once released from entrapment, crush syndrome patients are niques) yield varying degrees of stiffness.
likely to exhibit agitation, severe pain, muscle malfunction, Both biologic factors (fracture healing) and biomechanical fac-
swelling, and other systemic symptoms.4,5,10,49,50 tors (strength and stiffness) are important for recovery after a frac-
The pathophysiologic process underlying this syndrome begins ture. Over the past two decades, clinical experience and data from
with muscle breakdown from direct pressure, impaired muscle basic studies have led to a shift in focus away from the mechanical
perfusion leading to ischemia and necrosis, and the release of myo- aspects of fracture treatment and toward the biological aspects.
globin. As long as the patient is entrapped, the ischemic muscle is Today, a common practice is so-called biologic osteosynthesis,
isolated from the circulation, and this isolation affords some pro- which means careful handling of the soft tissues to take advantage
tection against the systemic effects of the released myoglobin and of the remaining biologic support, coupled with the use of tech-
other toxic materials. Extrication and the resulting reperfusion of niques of relative stability to stimulate callus formation. Anatomic
necrotic and ischemic muscle lead to the second insult, the reper- reduction is no longer considered a goal in itself, except in the case
fusion injury. This injury is caused by the formation of toxic reac- of intra-articular fractures.4
tive oxygen metabolites, which leads to failure of ion pumps and Conventional dynamic compression plates are applied tightly
increasing permeability of cell membranes and microvasculature. against the bone.Their application can compromise the blood sup-
When large amounts of muscle are involved, the resulting fluid ply and thereby induce partial necrosis of the underlying bone.The
changes can rapidly induce shock. The large quantities of potassi- presence of avascular tissues may reduce the healing potential and
um, lactic acid, and myoglobin that are released into the circula- lower the local resistance to infection. To overcome some of these
tion can lead to renal failure, disseminated intravascular coagula- disadvantages, plates with smaller contact areas were developed.
tion, and circulatory arrest.49,50 This process has culminated in the introduction of locking com-
Treatment should begin at the time of extrication so as to antic- pression plates (e.g., LCP; Synthes, West Chester, Pennsylvania),
ipate the onset of the syndrome. The first step is initiation of I.V. which can be regarded as noncontact plates. The LCP is a plate-
fluid therapy, starting with a 2 L crystalloid bolus and continuing and-screw system in which the screws are also locked in the plate
with crystalloid infusion at a level of 500 ml/hr (the dosage must by means of an extra thread in the head of the screw; thus, the plate
be adjusted in pediatric and cardiac patients). Cardiac monitoring is no longer tightly fixed to the bone and the periosteum. Locking
is essential (T waves indicate hyperkalemia). Intravascular fluid compression plates (also referred to as locked internal fixators) are
expansion and osmotic diuresis, by maintaining high tubular vol- designed in such a way that both conventional dynamic compres-
sion techniques and bridging techniques can be used, depending the importance of the soft tissues has led to substantial changes in
on the fracture type. They may be applied via a less invasive the treatment of diaphyseal fractures. It is now widely recognized
approach using closed reduction techniques.4,5 that anatomic reduction of each fracture fragment is not always a
Intramedullary nails are placed within the medullary canal and prerequisite for restoration of normal limb function (see above).
therefore have the same biomechanical properties in both the For most long bone fractures, radial and ulnar fractures excepted,
frontal and the sagittal plane.They differ from plates in that the lat- the most important goal is restoration of the mechanical axis of the
ter are attached eccentrically to the bone. Intramedullary nails may limb without significant shortening, angulation, or rotational
be inserted in either an unreamed or a reamed fashion; both tech- deformity. Good functional results may be expected even if frac-
niques have advantages and disadvantages.With unreamed nailing, ture fragments lying between the proximal and distal main frag-
the nails are inserted without widening the medullary canal. This ments are not anatomically reduced.4,5
approach causes somewhat less operative trauma than reamed In the upper extremity, both plates and intramedullary implants
nailing, but it places some limitations on the diameter and strength are frequently used for operative fixation of fractures. In the lower
of the nail and the locking bolts. If larger-diameter nails (> 9 mm) extremity, intramedullary nails are generally preferred because
are needed, the medullary canal must be reamed to accommodate they allow early weight bearing, in contrast to plates and screws,
them. Reaming takes time, leads to increased intramedullary pres- which are more susceptible to failure. However, intramedullary
sure, and produces debris that may be embolized in the pulmonary nailing may not be suitable for shaft fractures that extend into the
circulation. The clinical consequences of reamed intramedullary metaphysis or the adjacent joint. The treatment plan may also be
nailing have not yet been fully clarified. Current evidence suggests, influenced by the local condition of the soft tissues (e.g., the pres-
however, that reamed nailing is associated with significantly lower ence or absence of contusions or wounds), the quality of the bone
rates of nonunion and implant failure than unreamed nailing (e.g., the presence or absence of osteoporosis), and the origin of
is.4,5,51 the fracture (pathologic or nonpathologic).4,5
External fixators consist of metal pins (Schanz screws) that are For intra-articular fractures, alignment alone is insufficient.
placed in the bone proximal and distal to the fracture and con- Anatomic reduction of the articular surface is required to restore
nected outside the skin by one or more rods. Most external fixa- joint congruity, and rigid fixation is necessary to allow early motion
tors are used only on one side of the limb, but in specific instances, and thereby prevent the joint stiffness resulting from prolonged
multiplanar or circular devices may be used. The stability of the immobilization. Impacted osteochondral fragments are elevated,
frame depends primarily on the stiffness of the rods, the distance and the resulting metaphyseal defect underneath is filled with can-
between the rod or rods and the bone (the smaller the distance, the cellous bone or a bone substitute. Fracture fragments may be
greater the rigidity), and the number, placement, and diameter of reduced either via direct exposure or via more limited approaches,
the fixator pins. As a general rule, two pins proximal and distal to with the assistance of an image intensifier an arthroscope, or both.
the fracture are sufficient for fixation of long bone fractures. The Regardless of which approach is followed, care must be taken not
main advantage of external fixators is that their use minimizes to devascularize bone fragments. Fixation may be achieved with
additional surgical trauma.The main disadvantages are the occur- metal wires, screws, and plates.The reconstructed articular surface
rence of pin-tract infections and the frequent lack of stability for is connected to the diaphysis with plates or, alternatively, external
definitive fracture treatment. Appropriate placement of fixator pins fixators.4,5
requires a detailed knowledge of the cross-sectional anatomy of the Nonoperative treatment usually consists of application of plas-
injured limb.4,5 ters or (less frequently) traction and may be employed as either
temporary or definitive therapy. It reduces the risk of infection and
BASIC PRINCIPLES OF TREATMENT
eliminates operative risk, but it also frequently results in a longer
Although most fractures heal readily with casting, long periods time to union, a higher risk of malunion, and a greater likelihood
of immobilization with restriction of muscle activity, joint motion, of stiffness of the involved joints. Accordingly, nonoperative man-
and weight bearing are known to lead to so-called fracture disease, agement is mostly reserved for extra-articular and minimally dis-
characterized by muscle atrophy, joint stiffness, disuse osteoporo- placed fractures.4,5
sis, and persistent edema. Accordingly, the goals of fracture treat- Autologous bone grafting remains the gold standard for improv-
ment should include not only the achievement of bony union but ing and accelerating fracture healing. In recent years, however, var-
also the early restoration of muscle function, joint mobility, and ious other methods have been developed and evaluated for this
weight bearing.4,5 purpose.There is some evidence from randomized trials indicating
Currently, there are seven main indications for operative treat- that low-intensity pulsed ultrasonography may shorten the healing
ment of fractures: time for fractures treated nonoperatively.52,53 Ultrasound treatment
does not, however, appear to confer any additional benefit after
1. Preservation of life (e.g., decreasing morbidity and mortality
intramedullary nailing with prior reaming.The discovery of specif-
through fixation of femoral shaft fractures);
ic bone growth factors (bone morphogenetic proteins [BMPs])
2. Preservation of a limb (as with open fractures, fractures associ-
was an important step forward in the understanding of bone phys-
ated with vascular injury, and fractures complicated by com-
iology and raised the possibility that these factors could be locally
partment syndrome);
applied to enhance fracture healing. However, clinical trials have
3. Articular incongruity;
not yet determined the most appropriate indications for the use of
4. Facilitation of early mobilization and rehabilitation;
BMPs in managing specific fractures or nonunions.54
5. Inability to maintain reduction with conservative treatment;
The indications for implant removal are not well established.
6. The presence of more than one fracture in the same limb (so-
There are few definitive data to guide the decision as to whether an
called floating joint); and
implant should be removed or left in place. In general, implants in
7. The presence of additional fractures in other limbs (e.g., bilat-
most adult patients may be left in place; the same is true of
eral humeral or tibial fractures).
implants in the upper extremity. When implants are removed for
Improved understanding of the biology of fracture repair and relief of pain and mitigation of presumed functional impairment
alone, the results are unpredictable and depend on both the type of shoulder dislocation is luxatio erecta, characterized by infe-
implant type and its anatomic location. Implant removal is often rior dislocation of the abducted arm. Injuries associated with
technically challenging and may lead to complications such as shoulder dislocation include injury to the axillary nerve, injury to
infection, neurovascular injury, or refracture. Current data do not the labrum (Bankart lesion), and a depression in the humeral head
support routine removal of implants to protect against allergy, car- (Hill-Sachs lesion); the last two predispose to recurrence.
cinogenesis, or metal detection.The decision for or against implant Radiographs should be obtained in AP, axillary, and Y-scapular
removal is therefore based on individual patient and surgeon pref- views to determine the position of the humeral head and detect
erences, as well as on the clinical circumstances.55,56 any fractures. Treatment consists of gentle and closed reduction.
This can usually be done in the ED; if necessary, it can be done in
the OR with the patient under general anesthesia. Reduction is fol-
Management of Upper-Extremity Injuries lowed by immobilization in a sling.5
Dislocations of the sternoclavicular joint are rare, but they are
SHOULDER
potentially life-threatening when they occur posteriorly (anterior
Fractures of the clavicle are common and are usually caused by dislocations are far less dangerous). Diagnosis of these injuries is
falling on the shoulder. Approximately 80% of clavicular fractures difficult with conventional x-rays; accordingly, CT is recommend-
occur in the middle third of the bone, 15% in the lateral third, and ed when sternoclavicular joint dislocation is suspected.
5% in the medial third. Dislocation results from traction of the Compression of the mediastinal vessels and trachea can some-
pectoral and sternocleidomastoid muscles. Neurovascular injury is times lead to respiratory and circulatory failure. In such cases,
uncommon, but the patient should always be evaluated for such urgent operative reduction, performed with an eye to potential vas-
injury nonetheless.Treatment is primarily conservative, employing cular emergencies, is warranted.5,10
a collar and cuff or a sling; union rates approach 95%. Operative Dislocations of the acromioclavicular joint result from falling on
fixation is indicated only when there is impending perforation of the shoulder and are frequently classified according to the system
the overlying skin, an associated injury to the subclavian artery and formulated by Tossy.Tossy 1 dislocations (sprains) and Tossy 2 dis-
brachial plexus, an ipsilateral scapular neck fracture (so-called locations (subluxations) are treated conservatively with a collar
floating shoulder), a dislocation greater than 2 cm (a relative rather and a cuff. For Tossy 3 dislocations (complete separations), oper-
than absolute indication), or painful nonunion. Fixation methods ative treatment may be considered, though the optimal technique
include plate osteosynthesis and intramedullary osteosynthesis.57 remains to be determined and the results of operative fixation are
Scapular fractures result from high-energy trauma and are fre- still uncertain.5
quently accompanied by life-threatening injuries to the head, the
chest, or the abdomen. CT scanning is usually required to deter- Shaft
mine the fracture pattern. Most scapular fractures can be treated Fractures of the humeral shaft typically result from direct trau-
conservatively. Severely (> 40°) dislocated scapular neck fractures ma. Depending on the level of the fracture, dislocation mainly
and dislocated intra-articular glenoid fractures are treated with results from traction placed on the deltoid or pectoral muscles.
open reduction and internal screw or plate fixation. Fractures of the middle and distal thirds of the humeral shaft can
result in injury to the radial nerve, which is the most severe func-
HUMERUS
tional complication. Most closed AO-ASIF type A1 and A2 frac-
tures can initially be treated conservatively with functional bracing
Proximal techniques (rather than hanging casts); this approach yields good
Fractures of the proximal humerus are common, especially in or excellent results in the majority of cases. Moderate angulation,
elderly women. Correct positioning of the four main bony struc- rotation, and shortening are well tolerated. Generally accepted
tures of the proximal humerus (the head, the greater tuberosity, indications for operative treatment include open fractures, AO-
the lesser tuberosity, and the shaft) and their muscle attachments ASIF type B and C fractures, associated vascular injury, multiple
is important for a good shoulder function. Consequently, fractures trauma, bilateral fractures, combined humeral shaft and forearm
of this segment of the humerus may have significant functional fractures (so-called floating elbow), pathologic fractures, sec-
consequences. Damage to the blood supply of the head may lead ondary radial nerve palsy, and nonunion.60 The standard tech-
to avascular necrosis of this part of the bone. Conservative treat- nique is open reduction and plate fixation; the main alternative is
ment with a sling is preferred for elderly patients with minimally locked intramedullary nailing, either antegrade (entering in the
displaced fractures, and early range-of-motion exercises are proximal humerus) or retrograde (entering in the distal
encouraged. Operative treatment is indicated for patients with dis- humerus).61,62 External fixation is employed in the presence of
located two-, three-, or four-part fractures and fracture-disloca- severe soft tissue injuries and in polytrauma patients as part of
tions. The optimal fixation method has not been established, but DCS.
plate osteosynthesis is frequently employed; alternatives include
intramedullary techniques and prosthetic replacement.58,59 Distal
Rehabilitation usually takes several months, and continuing Fractures of the distal humerus result from falling on the elbow
impairment of shoulder function is a common complaint. with the forearm flexed. In elderly persons, many of whom are
Shoulder (glenohumeral joint) dislocations mostly occur in osteoporotic, a fall from a standing position is often sufficient to
young persons participating in sports.The size difference between cause such a fracture, whereas in young patients, high-energy trau-
the large articular surface of the humeral head and the small sur- ma is required. Extra-articular injuries usually have a good prog-
face of the glenoid renders the shoulder particularly vulnerable to nosis. Intra-articular fractures are more difficult to manage: limita-
dislocation. The majority (95%) of patients have anterior dislocation of flexion and extension and pain often occur, even after opti-
tions, resulting from abduction and exorotation.The relatively few mal treatment. In addition to AP and lateral x-rays, it may be advis-
posterior dislocations that occur tend to be difficult to diagnose able to obtain CT scans to help clarify the fracture pattern. For
and are frequently missed initially. A particularly rare and severe minimally displaced AO-ASIF type A fractures, conservative treat-
ment is appropriate, but for all other fractures, open reduction and
plate osteosynthesis are required, frequently in conjunction with
an olecranon osteotomy to provide adequate exposure. In com-
minuted fractures, the articular surface can be difficult to reduce.
In osteoporotic bone, finding good bone stock can be a serious
problem.4,5,63,64
ELBOW
Olecranon fractures are the most common fractures in the area

of the elbow and usually are caused by falling directly on the elbow.
They frequently lead to impaired extension as a consequence of
the discontinuity between the triceps and the proximal ulna. All
dislocated olecranon fractures are treated operatively, with
Kirschner wires and a tension band employed for simple fractures
and plate osteosynthesis for comminuted fractures. Both methods
allow early functional therapy postoperatively.
Fractures of the radial head are caused by falling on the out-
stretched arm and may occur either in isolation or in combination
with an elbow dislocation, an ulnar shaft fracture (Monteggia frac-
ture), a coronoid process fracture, or a medial collateral ligament
rupture. In addition, the interosseous membrane between the ulna
and the radius may be disrupted over its entire length, thereby dis-
turbing the distal radioulnar joint at the wrist (Essex-Lopresti
injury). Fractures with dislocations smaller than 2 mm can be
treated conservatively with early range-of-motion exercises; exter-
nal support is usually unnecessary. Dislocated fractures and frac-
tures causing mechanical blockage (e.g., of pronation or supina-
tion) are mostly treated operatively, with plate or screw fixation.
When the fracture is comminuted, adequate reduction and fixation
may be impossible. If the elbow is otherwise stable, radial head
excision may be performed; if not, a radial head prosthesis may be
inserted to stabilize the joint. Active and passive range-of-motion
exercises should be started soon after the operation. Figure 6 Shown is grade II open forearm
Elbow dislocations are typically caused by falling on the out- fracture with segmental bone loss in the
stretched hand. Posterior dislocations, characterized by dorsal dis- radius, intially stabilized with debridement
placement of the radius and the ulna, are more common than ante- and external fixation. Injury is treated with
secondary plate osteosynthesis and Kirschner
rior dislocations. Associated injuries may include coronoid process
wire fixation of metacarpal fracture.
fractures and collateral ligament injuries, as well as neurovascular
injuries. Most elbow dislocations can be treated with closed reduc-
tion by applying traction with the forearm flexed 30°. After reduc- radial head dislocation (Monteggia fracture). Appropriate x-rays
tion, the stability of the elbow should be carefully evaluated. Plaster must be obtained to ensure that this injury is not missed.The radi-
immobilization should not be continued beyond 3 weeks. Opera- al head is reduced by closed or open methods during plate fixation
tive reduction is necessary only when the dislocation is associated of the ulna. Radial shaft fractures are sometimes associated with a
with an open fracture, when interposing fragments preclude ade- dislocation of the ulna in the distal radioulnar joint (Galeazzi frac-
quate closed reduction, or when neurovascular injury is present.4,5 ture). If the distal radioulnar joint remains unstable after plate fix-
ation of the radius, temporary transfixation is necessary.4,5
FOREARM
WRIST
The bones in the forearm have a complex relation with each
other and with the elbow and the wrist, and this complex relation Distal radial fractures are among the most commonly encoun-
allows numerous different combinations of flexion, extension, tered fractures. Like elbow dislocations, they are usually caused by
pronation, and supination.The mechanism of a forearm injury is a falling on the outstretched hand. The incidence rises sharply with
frequently a vehicular accident or a fall; isolated fractures of the increasing age, especially in osteoporotic women. Associated
radius or the ulna are rare and usually result from a direct blow. injuries include ulnar styloid process fractures and ligamentous
The goal of treatment is to achieve anatomic restoration of length, carpal injuries. Dislocations are classified as dorsal (Colles type) or
axial alignment, and rotation with stable fixation in a manner that volar (Smith type); the former are more common. Partial articular
permits free movement (especially pronation and supination) of fractures (AO-ASIF type B) are also referred to as dorsal or volar
the elbow and the wrist postoperatively [see Figure 6]. Only nondis- Barton fractures. Diagnostic imaging plays an important role in
placed fractures may be treated nonoperatively; all other forearm assessment; the critical radiographic parameters are radial angle,
fractures must be treated operatively. The standard technique is radial length, and dorsal angulation. Radiologic signs of instability
open reduction with plate fixation; intramedullary fixation is an include initial dorsal angulation greater than 20°, greater than 5
alternative. The radial nerve is at risk during plate fixation of the mm reduction in radial length, intra-articular involvement, and
proximal radius.65-67 metaphyseal comminution. An articular stepoff greater than 2 mm
Approximately 10% of ulnar fractures are accompanied by a is associated with a poor prognosis.
Minimally displaced AO-ASIF type A distal radial fractures and Perilunate dislocations result from high-energy trauma and
stable impacted fractures may be treated conservatively in plaster include a spectrum of severe ligamentous wrist injuries, fractures,
for 4 to 6 weeks. If necessary, this can be done after closed reduc- and dislocations characterized by dorsal dislocation of the distal
tion, though loss of reduction may occur after an initial satisfacto- carpal row, the scaphoid, and the triquetrum with respect to the
ry position has been achieved. For all other fractures, operative lunate. Perilunate dislocations may be missed initially in multiply
treatment is advised, depending on fracture type and patient sta- injured patients if the physical examination is incomplete or the x-
tus [see Figure 7]. AO-ASIF type B fractures are best treated with rays of the wrist are inadequate or not carefully examined.
open reduction and screw or plate fixation; however, optimal treat- Treatment consists of closed or open reduction; additional fixation
ment of AO-ASIF type C fractures remains to be determined. may be performed as needed, depending on the degree of stabili-
External fixation combined with Kirschner wires and plate ty achieved after reduction. Associated fractures of the radius or
osteosynthesis is frequently employed. In some cases, it may be the scaphoid are treated operatively.5
necessary to fill a subchondral or metaphyseal defect with a can-
HAND
cellous bone graft or a bone substitute. Reflex sympathetic dystro-
phy develops in some patients [see Special Considerations, Com- Fractures of the hand can result from direct blows, twisting
plications, Reflex Sympathetic Dystrophy, below].Treatment of this injuries, crush injuries, and gunshot wounds. Neurovascular sta-
syndrome can be difficult, and complete functional loss is occa- tus, wounds (e.g., bites), and tendon function should all be care-
sionally the final result.4,5,68 fully evaluated. Most fractures can be detected on posteroanterior,
Fracture of the scaphoid typically is caused by falling on the lateral, and oblique views.
outstretched or dorsally flexed hand. It tends to be difficult to Metacarpal neck fractures, most frequently of the fourth or fifth
diagnose and is easily missed. Signs such as pain, functional metacarpal (so-called boxer’s fracture), can usually be treated con-
impairment, and tenderness at the anatomic snuff box are often servatively with 3 to 4 weeks of immobilization and early range-of-
absent initially, and standard AP and lateral x-rays of the wrist may motion exercises.70 Fracture healing may result in cosmetic defor-
be insufficient to identify the injury. If special scaphoid views do mity but good function. Severely dislocated fractures are typically
not confirm the presence of a fracture, the wrist is immobilized treated with Kirschner wires or plate fixation. Most fractures of the
and x-rays are repeated after 7 to 10 days. Alternatively, CT, MRI, metacarpal shafts can be treated nonoperatively with immobiliza-
or bone scintigraphy may be performed to confirm the diagnosis.3 tion in a cast or splint for 4 weeks. If the wrist is immobilized in
Undisplaced fractures may be treated conservatively in plaster. plaster, it should be positioned in 20° of extension, with the the
Immobilization should be continued for 6 to 12 weeks to minimize metacarpophalangeal joints in 70° to 90° of flexion and the inter-
the risk that disturbance of the delicate blood supply of the phalangeal joints in complete extension to prevent shortening of
scaphoid might result in avascular necrosis or pseudarthrosis. ligaments. Rotation (as indicated by nail position) should be
Dislocated fractures (with dislocation greater than 2 mm or angu- checked frequently. Indications for operative treatment include
lation greater than 25°) are treated with screw osteosynthesis.4,5,69 angulation greater than 10° to 30°, shortening, malrotation (more
a b
Figure 7 Illustrated is treatment of distal radial fracture with (a) volar plate osteosynthesis and
(b) external fixation.
frequent in the second and fifth metacarpals), and multiple frac- protected motion. Postoperative treatment and rehabilitation of
tures. Bennet’s fracture (an intra-articular fracture of the base of tendon injuries are very important and require the services of a
the first metacarpal with a small ulnar fragment that remains special hand therapist.
attached to the second metacarpal) should be treated with reduc- A commonly encountered extensor tendon injury is so-called
tion or, if unstable, fixation with percutaneously placed Kirschner mallet finger, which results from forcible flexion of the extended
wires or screws. Other metacarpal base fractures are less frequent distal interphalangeal joint.The extensor tendon is torn off the dis-
but may also be associated with carpometacarpal dislocations. tal phalanx, with or without an intra-articular fragment of its base.
Treatment focuses on reduction of the joint and restoration of Clinically, the distal interphalangeal joint is in flexion, and active
alignment and the articular surface, if necessary by means of open extension of the distal phalanx is impossible. Most lesions can be
reduction.5,71,72 treated with a special splint that keeps the distal interphalangeal
Phalangeal fractures are common. In the distal phalanx, frac- joint in extension for 4 to 6 weeks.5
tures often result from crush injury and may be associated with
subungual hematoma (which should be drained) and soft tissue
Management of Pelvic and Acetabular Injuries
injury. The vitality of the fingertip may be compromised.
Nondisplaced fractures may be treated with immobilization in PELVIC RING
plaster or a splint for 3 weeks, followed by active range-of-motion
Pelvic fractures occur in about 3% of trauma patients. These
exercises. Dislocated fractures may be treated with closed or open
injuries can have a devastating influence on the outcome of trau-
reduction and fixation with Kirschner wires or small screws or
ma care and therefore must be identified as early as possible.
plates.71,72
Internal retroperitoneal bleeding is the main concern in the early
Dislocations of the interphalangeal joints usually are easily rec-
management of these patients because over 40% of the mortality
ognized by the obvious deformity they cause, but x-rays must still
from pelvic trauma is attributable to persistent bleeding.
be obtained to exclude fractures. Dorsal dislocations are associat-
Accordingly, the initial physical examination and the AP pelvic x-
ed with injuries to the volar plate or collateral ligaments, which
ray (which is diagnostic in 90% of cases) during the primary sur-
tend to increase instability. Treatment consists of closed or open
vey are essential for placing the focus on the potential risk of inter-
reduction, followed by testing through the range of motion to
nal bleeding. Additional inlet and outlet views (taken at a 45° angle
check stability and x-rays to ensure adequate reduction. If reduc-
from cephalad and caudal) may be useful for accurate classification
tion is unstable, transarticular Kirschner wire fixation may be
and determination of dislocation.4,5 CT scanning is performed in
necessary.5
nearly all cases but not necessarily as an emergency evaluation.The
So-called gamekeeper’s thumb is an injury to the ulnar collater-
CT scan facilitates fracture classification and provides additional
al ligament of thumb metacarpophalangeal joint that causes insta-
information on active bleeding and associated injuries.
bility at that joint; the ulnar collateral ligament frequently becomes
Administration of I.V. contrast material during CT scanning helps
dislodged between the adductor pollicis aponeurosis and its nor-
in detecting active arterial bleeding, which suggests the need for
mal position (Stener lesion). Partially unstable lesions (< 20° to
early angiographic embolization. Angiographic embolization may
30° opening at stress examination in comparison with the unin-
be lifesaving in patients with pelvic arterial bleeding.
jured side) may be treated in a plaster splint for 3 to 4 weeks.
Pelvic injuries are frequently associated with other serious
Completely unstable lesions are treated with surgical repair to pre-
injuries. Fractures of the anterior pelvic ring, especially when seen in
vent chronic instability.5
combination with blood from the urethral meatus, are an indication
TENDONS for retrograde urethrography before placement of a transurethral
catheter to detect or exclude urethral and bladder injuries. Vaginal
Injuries to the rotator cuff reduce the shoulder’s strength and
and rectal examinations are components of the standard workup for
impair its function. Most ruptures occur in cuff muscles or tendons
detecting or excluding fracture perforations and abnormalities of
that are already affected by degenerative changes. Operative treat-
prostate position (indicative of urethral injury).
ment is advised for young patients and for patients who have expe-
Posterior pelvic ring injuries may be accompanied by sacral
rienced substantial ruptures as a result of recent trauma.
plexus nerve injuries. Perineal and groin wounds often are in con-
Rupture of the distal biceps tendon occurs mainly in middle-
tinuity with fracture components and pose a serious threat of fur-
aged men.The tendon is torn off the radial tuberosity during flex-
ther complications. With open pelvic injuries, early surgical
ion against resistance. The muscle belly is visibly retracted proxi-
debridement and fecal deviation must be considered.
mally, and flexion and supination are reduced by 30% to 40%. In
The AO-Tile classification of pelvic ring and acetabular frac-
cases where the diagnosis is not clear, MRI or ultrasonography
tures is based on the degree of pelvic stability or instability. The
may be helpful.Treatment consists of reattaching the tendon to the
pelvis is divided into an anterior section (comprising the symphysis
radius with suture anchors or drill holes.
pubis and the pubic rami) and a posterior section (comprising the
In the case of tendon injuries around the wrist and the hand,
ilium, the sacroiliac joint complex, and the sacrum).4 Determina-
appropriate clinical testing and diagnosis depend on a solid knowl-
tion of whether and to what extent the posterior section is dis-
edge of the exact anatomy and function of the various tendons.The
placed is crucial for estimating the stability of the injury. Depend-
extensor tendons are located just under the skin, directly on the
ing on the degree of posterior bony or ligamentous instability,
bone, on the back of the hands and the fingers; their superficial
pelvic ring injuries may be classified into three types as follows:
location makes them easily injured even by a minor cut. The flex-
or tendons pass through fibrous rings called pulleys, which guide 1. Type A: injuries where the mechanical stability of the pelvic
the tendons and keep them close to the bones; because of the more ring is intact—the most common type, seen in 50% to 70% of
complex anatomy, flexor tendon injuries are usually more chal- pelvic fracture patients.
lenging than extensor tendon injuries. Partial injuries with intact 2. Type B: injuries characterized by partial posterior stability (i.e.,
function may be treated conservatively, but most injuries, especial- injuries that are rotationally unstable but vertically stable)—
ly sharp lacerations, are treated with surgical repair followed by seen in 20% to 30% of pelvic fracture patients.
3. Type C: injuries characterized by combined anterior and pos- symphysis may be treated conservatively. If symphyseal dislocation is
terior instability (i.e., injuries that are both rotationally and ver- less than 2.5 cm, anterior plate fixation of the symphysis is usually
tically unstable)—seen in 10% to 20% of pelvic fracture sufficient. If the patient cannot undergo formal internal fixation, an
patients. external fixator (which may have been applied initially for bleeding
control) is a reasonable alternative for definitive treatment. However,
Another system used to categorize pelvic fractures is the Young- the discomfort and the complications (e.g., infection) caused by
Burgess classification, which is based on the force vectors causing external fixator pins motivate many surgeons to convert to internal
the fracture. In this system, pelvic ring fractures are divided into plate fixation after the initial stabilization phase. In the setting of an
the following four major groups: (1) lateral compression, (2) emergency laparotomy, early anterior plate fixation may be consid-
anteroposterior compression, (3) vertical shear, and (4) combined ered during the same laparotomy, provided that patient is or has
mechanical injury.The stability or instability of the fracture can be been rendered physiologically stable.Type B2 (lateral compression)
determined on the basis of knowledge of the ligamentous anatomy injuries with minimal anterior dislocation often have good intrinsic
of the pelvis coupled with assessment of the fracture pattern and stability and can frequently be treated conservatively.
the direction of the injuring force.4,5 For type C injuries, both anterior and posterior stabilization is
Provisional stabilization is advised after manual reduction of required. Of the many techniques currently in use, plate fixation of
pelvic ring disruption, especially in open-book fractures with sig- the anterior pelvic ring combined with either percutaneous sacroil-
nificant dislocation. External fixation is one means of achieving iac screws or plate fixation of the posterior pelvis provides the best
provisional stabilization; however, it is more time consuming than mechanical stability. The main goals are to restore the anatomy
applying a sheet wrap or a similar device for temporary stabiliza- and prevent any leg-length discrepancy while encouraging allow-
tion. For this reason, many institutions prefer the latter approach ing early mobilization of the patient to prevent the complications
during initial management in the ED. The Pelvic C-Clamp of prolonged bed rest.4,5,73-75
(Synthes, West Chester, Pennsylvania) is also employed for exter- Percutaneous placement of iliosacral screws under fluoroscopic
nal stabilization, primarily in hemodynamically unstable patients guidance is already the preferred technique for stabilization of the
with unstable (i.e., type B or C) pelvic ring injuries. This device majority of unstable sacroiliac injuries. The continuing develop-
acts by exerting direct compression on the posterior part of the ment and growing availability of modern surgical tools (e.g., com-
pelvic ring, thereby reducing the intrapelvic volume, compressing puter-assisted intraoperative navigation) are providing ever more
fracture parts, and providing stability. Application of this device opportunities for minimally invasive approaches to pelvic fracture
should also be considered if operative retroperitoneal pelvic pack- fixation. Nevertheless, stabilization of the pelvis through open sur-
ing is necessary. gical reduction and internal fixation using standard plate and
Definitive treatment of pelvic injuries depends on the type of screw techniques are still proper alternatives and are the treatment
injury, the classification (stability), the local soft tissue situation, of choice for many pelvic ring fractures.
and the general condition of the patient [see Figure 8].Type A frac-
tures are stable and usually need not be treated operatively. ACETABULUM
Functional treatment, with early ambulation and weight bearing as Traumatic acetabular fractures may occur either in isolation or
tolerated, usually suffices. as part of a pelvic ring injury [see Figure 8a]. On occasion, they
Type B1 (open-book) injuries with minimal dislocation of the occur in combination with hip dislocation; in such cases, urgent
a b
Figure 8 Shown are (a) plate osteosynthesis for combined pelvic ring injury and left-side acetabular fracture
in a multiply injured patient and (b) treatment of type C unstable pelvic ring injury with initial angioem-
bolization (coils visible) and external fixation, followed by secondary percutaneous placement of sacroiliac and
pubic screws.
reduction of the dislocated hip is essential for restoring blood flow fixation method or misinterpretation of the fracture configuration.
to the femoral head. For adequate fracture classification, x-rays Fractures of the femoral head are the most devastating of hip
must be obtained in Judet views (oblique views taken with the injuries and must be handled as surgical emergencies. They are
beam stationary and with the patient rolled 45° to both sides along generally classified according to Pipkin’s system. Because substan-
the vertical axis). CT scanning with axial and three-dimensional tial force is required to produce femoral head fractures, they are
reconstructions can greatly clarify the extent of the injury and help often seen in association with hip joint dislocations and acetabular
identify the number and size of fracture fragments. An accurate fractures, most commonly in multiply injured patients who were
neurologic examination that includes assessment of the integrity of involved in motor vehicle accidents. The diagnosis is made on the
the sciatic nerve should also be part of the initial workup. basis of pelvic and acetabular x-rays, supplemented by CT scans.
Until the 1960s, the vast majority of patients with acetabular Concomitant hip dislocations (most often posterior) should ideal-
fractures were treated conservatively. Thanks to the impressive ly be reduced with the patient under general anesthesia and with
efforts of Letournel and Judet (who also introduced the most fre- muscle relaxation achieved by upward traction with the hip in 90°
quently used classification system), operative treatment has of flexion.80 If possible, this should be done in the ED to minimize
become standard for dislocated acetabular fractures.76,77 The most delay in restoring blood flow to the femoral head. After reduction,
important goal of operative treatment is to restore the articular sur- the stability of the joint is tested clinically, and CT scanning is per-
face so that a congruent hip joint can be obtained. Achievement of formed to assess impaction fractures, loose fragments in the hip
this goal nearly always requires open reduction and internal fixation joint, and the integrity of the acetabulum.
with plates or screws through anterior or posterior approaches. Most femoral head fractures are treated operatively if the
Extensive experience on the part of the operating team is necessary patient’s condition permits. For optimal results, this should be
to ensure optimal long-term results. After the operation, the patient done within 24 to 48 hours after the injury, if possible. Closed
should be able to take part in non–weight-bearing exercises. treatment of dislocated fractures yields uniformly poor results.
The majority of acetabular fractures can be treated in a delayed Internal fixation of these injuries is technically demanding and
fashion between 3 and 14 days after the injury. Acute operative should allow early passive and active motion exercises postopera-
fracture treatment may be indicated if a dislocated hip cannot be tively. Indomethacin is administered to prevent heterotopic ossifi-
reduced, if redislocation of the hip cannot be prevented, or if inter- cation around the hip. Weight bearing is allowed after 10 to 12
position of intra-articular fracture fragments occurs. In many weeks. In some patients, particularly physiologically older patients
instances, however, initial skeletal traction (if indicated after hip with major fractures, it may be best to insert a hip prosthesis pri-
reduction) will be applied. marily. Although operative treatment is usually necessary to pro-
Adequate prophylaxis of deep vein thrombosis (DVT) is essen- vide the best chance of recovery, the magnitude of the initial trau-
tial for both patients with pelvic fractures and those with acetabu- ma is generally such that good results can be obtained in only 50%
lar fractures. Functional outcome after acetabular fracture surgery to 70% of cases.4,5,81
is determined by many factors, the most important of which are A typical patient with an intracapsular (femoral neck) fracture
anatomic fracture reduction, the development of osteoarthritis, presents with a shortened, externally rotated, and abducted lower
avascular necrosis, and heterotopic ossification.4,5,77-79 extremity.These fractures are often classified according to Garden’s
system.Treatment is determined by the fracture type and associat-
ed patient factors. Especially in young patients, because of the risk
Management of Lower-Extremity Injuries
of nonunion and avascular necrosis, dislocated femoral neck frac-
FEMUR tures should preferably be treated on an emergency basis within 12
hours after the injury.82 In otherwise healthy and ambulatory
Proximal (Hip Fracture) patients, incomplete and impacted fractures (intact trabeculae of
Fracture of the proximal femur (hip fracture) is one of the most the inferior neck; Garden 1) may be managed with conservative
common conditions seen by orthopedic and trauma surgeons. It is treatment, consisting of early mobilization with crutches or a walk-
particularly common in the elderly. Substantial force is required to er (to the extent permitted by the pain experienced) and supervised
fracture a hip in a young person, whereas a minor trauma or fall by a physical therapist. Secondary dislocation occurs in 10% to
may be sufficient to do so in an elderly osteoporotic woman. 50% of cases, leading to secondary operative treatment. Complete
Almost 90% of patients with proximal femoral fractures are older but undislocated fractures (Garden 2) are mostly treated opera-
than 65 years. Between 5% and 10% of these elderly patients die tively with cannulated screws or a sliding hip screw (e.g., Dynamic
during hospital admission; 25% die within the first year after the Hip Screw [DHS]; Synthes, West Chester, Pennsylvania). Sliding
accident. hip screws allow controlled compression of the fracture to be
Hip fractures are typically classified into four broad categories obtained during weight bearing as the lag screw slides into the
according to their anatomic site: (1) femoral head fractures, (2) plate. Complete fractures with partial (Garden 3) or complete dis-
intracapsular (femoral neck) fractures, (3) intertrochanteric frac- placement (Garden 4) are treated by means of early anatomic
tures, and (4) subtrochanteric fractures. Within these broad cate- reduction with fixation to eliminate the risk of displacement and
gories, they may be further divided into subcategories according to permit rapid mobilization.When the patient is physiologically older
various classification systems (see below). Such classifications can than 70 years, placement of a primary hip prosthesis is often indi-
be helpful in guiding decision making with respect to treatment, cated instead of internal fixation; however, this procedure is associ-
which necessarily differs from one type of hip fracture to another.4,5 ated with higher perioperative morbidity and mortality.4,5,81,83
In general, the choice of treatment is influenced by a range of Trochanteric fractures are the most common fractures of the
patient-related factors that includes age, the presence and severity proximal femur. They do not threaten the blood supply to the
of comorbid medical conditions, previous mobility, cognitive sta- femoral head, because they occur below the extracapsular ring of
tus, fracture classification, and the status (i.e., preserved or dis- vessels. Trochanteric fractures are classified according to the AO-
rupted) of the all-important blood supply to the femoral head. Fail- ASIF system. Almost all patients with such fractures are candidates
ure of treatment frequently results from inappropriate choice of a for internal fixation. The main exceptions are elderly patients who
a b
Figure 9 Shown are (a) fixation of AO-ASIF type A1 fracture with the Dynamic
Hip Screw and (b) fixation of AO-ASIF type A2 fracture with the Proximal
Femoral Nail.
had significant arthritis of the hip before sustaining the fracture; for femoral shaft; a simple fall seldom results in this type of fracture
these patients, placement of a hip prosthesis is an alternative. unless the bone has been weakened by osteoporosis or other dis-
The lesser trochanter provides crucial support for the medial ease.A patient with a femoral shaft fracture should therefore be con-
femoral cortex; thus, assessment of its integrity is important for sidered a victim of high-energy trauma and evaluated accordingly.
determining the stability of the fracture, which, in turn, helps Most fractures of the femoral shaft are easily recognized clini-
determine treatment. The main treatment options are cally on the basis of pain and abnormal position or movement.
extramedullary and intramedullary implants. Extramedullary Because of the shape of the thigh, more than 1 L of blood may be
implants include sliding hip screws (see above), which are relative- lost into this space with little or no external indication.
ly easy to insert and also allow open reduction of the fracture if Neurovascular injuries are relatively uncommon in this setting;
necessary. These implants are most suitable for stable (AO-ASIF however, when the fracture is in the distal third of the femoral shaft,
type A1) fractures [see Figure 9a]. For unstable (AO-ASIF type A2 injury to either the superficial femoral artery or the popliteal artery
and A3) intertrochanteric fractures, intramedullary fixation is the may ensue as a consequence of the tethering of these vessels against
treatment of choice because of the favorable position of the the shaft at the level of the adductor canal. Femoral shaft fractures
implants in the biomechanical loading axis of the femur. Examples are often associated with injuries to knee ligaments, which are dif-
include the Proximal Femoral Nail (PFN; Synthes, West Chester, ficult to assess in the presence of the femoral fracture.Thus, when
Pennsylvania) [see Figure 9b], the Intramedullary Hip Screw the patient is under anesthesia for treatment of the fracture, the sta-
(IMHS; Smith & Nephew, London, England), and the Gamma bility of the knee should be assessed as well. Imaging consists of AP
Nail (Stryker, Kalamazoo, Michigan).The operative technique for and lateral x-rays, with the hip and knee joints included.
intramedullary fixation is more complex and unforgiving than that In the ED, a fractured femur is immobilized with a vacuum
for extramedullary fixation, and various complications may arise, splint or a Thomas splint. This measure reduces blood loss and
including malpositioning and femoral shaft fractures during inser- lessens patient discomfort, and the splints need not be removed for
tion. Intramedullary implants are usually inserted percutaneously x-rays to be taken. Ideally, femoral shaft fractures should be treat-
on a traction table with one or more screws in the femoral head ed within 12 to 24 hours after the injury; preoperative skeletal trac-
and one or more distal locking screws. Internal fixation of trochan- tion is therefore superfluous. The main goal is stable fixation that
teric fractures should allow mobilization from postoperative day 1, yields correct length, rotation, and alignment, with full weight
preferably with full weight bearing or the use of a walker.4,5,84 bearing possible within a few days of the operation.
Subtrochanteric (AO-ASIF type A3) fractures are inherently Femoral shaft fractures of AO-ASIF types A to C are best treat-
unstable. Operative treatment may be difficult because high bend- ed with locked intramedullary nailing [see Figure 10]. In isolated
ing forces in the region (resulting from the angular shape of the instances, a plate or an external fixator may be indicated. Nailing
proximal femur) often lead to implant failure before union. The lowers the incidence of respiratory distress syndrome, blood loss,
preferred management approach is intramedullary nailing; the use and tissue trauma and reduces the patient’s need for narcotics. In
of angled blade plates is an alternative, especially in young patients the setting of DCS, femoral fractures are initially stabilized by
who require anatomic reduction.4,5 means of external fixation. The external fixator can then be
exchanged for an intramedullary nail 2 to 10 days later without a
Shaft significant increase in complications.12,13,85 Nailing can be per-
In most adults, considerable force is necessary to fracture the formed with the patient supine on a fracture table or in a lateral
a b c
d e
Figure 10 Illustrated (a
through e) is treatment of
comminuted AO-ASIF type
C femoral fracture with
intramedullary nailing. No
attempt was made to reduce
fracture fragments in order
to preserve their vasculariza-
tion. Healing was uneventful,
with complete restoration of
function.
decubitus position with closed reduction (or, if necessary, open intramedullary nailing or plating, depending on the surgeon’s pref-
reduction) of the fracture. Most nails are inserted in an antegrade erence. Open reduction with extensive techniques for applying
manner through the greater trochanter or piriform fossa, though angled blade plates, condylar plates, sliding hip screws, and similar
retrograde nailing through the intercondylar notch is becoming devices is currently being replaced by less invasive plating tech-
increasingly popular for distal shaft fractures. Reaming is generally niques using screws that are locked into the plate. An example of
advised because it reduces the rate of nonunion.51 the latter is the Less Invasive Stabilization System (LISS; Synthes,
Most complications with femoral shaft fractures are secondary West Chester, Pennsylvania), which allows submuscular fixation
to technical problems at the time of nailing and can therefore be and percutaneous placement of self-drilling unicortical fixed-angle
prevented by paying close attention to technical details (in partic- screws.The focus with this system is more on correction of length
ular, the entry point of the nail and correct rotation). In rare and alignment and less on anatomic reduction.
instances, embolization of debris from reaming may lead to fat Intercondylar fractures are treated with anatomic reduction and
embolism syndrome (FES) [see Special Considerations, Complica- screw fixation of the articular surface to allow early motion and there-
tions, Fat Embolism Syndrome, below]. Infections occur mostly in by facilitate cartilage healing. Either open methods or image intensi-
open fractures and fractures where there is substantial soft tissue fier-assisted closed methods may be employed. The reconstructed
involvement. Compartment syndrome of the thigh may occur after articular surface is then connected en bloc to the femoral shaft with
femoral shaft fracture, albeit infrequently; it should be suspected if one of the previously described techniques (usually plating).4,5,86
severe swelling is present.4,5
KNEE
Distal
Supracondylar (AO-ASIF type A) and intercondylar (AO-ASIF Patellar Fracture
type B and C) fractures of the distal femur typically occur in young Knee injuries are common in multiply injured patients, in large
patients who have sustained high-energy trauma or in elderly part because of the vulnerability of this joint to dashboard injuries
patients with osteoporotic bone. Careful assessment of neurovas- in automobile accidents and to direct trauma in motorcycle acci-
cular status is important. X-rays focused on the knee should be dents. Patellar fractures usually result from a fall on the knee, a
supplemented with x-rays of the femoral and tibial shafts. CT can sudden forceful contraction of the quadriceps muscle with knee
provide additional information on the fracture pattern and help in flexion, or a combination of the two. Other injuries (e.g., cruciate
preoperative planning. Standard treatment consists of operative ligament failure and femoral fracture) may be present as well.The
reduction and internal fixation, followed by partial–weight-bearing most important task in the examination is to confirm that the
or non–weight-bearing active or passive exercises. extensor mechanism is intact by asking the patient to raise the leg
Supracondylar fractures can be treated with retrograde with the knee fully extended. X-rays should include AP, lateral, and
(optionally) tangential views. optimal results, whereas others recommend primary immobiliza-
Transverse and stellate fractures with minimal (< 1 to 2 mm) tion followed, if necessary, by late reconstructions.4,5,90
displacement and an intact extensor mechanism may be treated
conservatively by keeping the joint in a cast for 6 weeks, with Ligamentous Injury and Meniscal Tearing
weight bearing allowed. All other fractures are treated by open Distortions of the knee are common injuries; most involve
reduction with internal fixation, typically with Kirschner wires and varus, valgus, or rotational deformities. The history should focus
tension bands or cerclage wires. Postoperatively, early active on the mechanism of injury, the type and location of pain, any
motion and partial weight bearing are allowed. Severely commin- associated symptoms, the amount of immediate dysfunction, the
uted patellar fractures may be irreparable; in such instances, a par- presence and onset of joint edema, and any history of past knee
tial or total patellectomy with reconstruction of the extensor appa- problems. The physical examination should include inspection,
ratus may be required. Ligamentous patellar injuries (e.g., to the active motion, and stress testing to detect instability. Hemarthrosis
quadriceps tendon or the patellar tendon) are treated by means of is a sign of possible cruciate ligament injury. If pain and swelling
operative repair and reinsertion to the patella.4,5 preclude reliable examination, the examination should be repeated
in 5 to 7 days. Collateral ligament injuries are graded on a scale of
Dislocation I to III. A grade I injury is a sprain (with stretching but no tearing
Knee dislocations, though potentially severe injuries, are gener- of the ligament, local tenderness, minimal edema, and no gross
ally rare, with only a few small series having been reported. They instability on stress testing), a grade II injury is a partial ligament
result primarily from motor vehicle and pedestrian accidents, falls, tear (with moderate local tenderness and mild instability on stress
and sports activities, though they also occur spontaneously in mor- testing), and a grade III injury is a complete tear (with discomfort
bidly obese persons.Their severity is determined by the complexi- on manipulation, a variable amount of edema, and clear instabili-
ty of the ligamentous injury and any associated trauma, including ty on stress testing).
popliteal artery and vein injury (20% to 30% of cases) and per- X-rays of the knee are obtained to detect any fractures of the tib-
oneal nerve injury (25% to 35%). Failure to recognize vascular ial plateau or the intercondylar eminence. The number of unnec-
injury can lead to muscle necrosis and amputation. It is therefore essary x-rays may be substantially and safely reduced by applying
essential that reduction of knee dislocations be carried out imme- the so-called Ottawa knee rule. This rule specifies the following
diately, either before arrival at the hospital or in the ED, followed indications for x-rays: age 55 years or older, tenderness at the head
by vascular examination and x-rays. Anterior dislocation (30% to of the fibula, isolated tenderness of the patella, inability to flex the
40% of cases) is often caused by severe knee hyperextension, knee 90°, and inability to walk four weight-bearing steps immedi-
whereas posterior dislocation (25% to 30%) occurs with the appli- ately after the injury and in the ED. MRI is useful for detecting lig-
cation of force to the proximal tibia in an anterior-to-posterior amentous, meniscal, and cartilage injuries but is rarely indicated
direction, as in a dashboard-type injury or a high-energy fall on a on an emergency basis.
flexed knee. Treatment depends on the patient’s age and activity level and
Physical examination reveals gross deformity around the knee should always include appropriate reeducation and strengthening
with swelling and immobility. Occasionally, the knee will have relo- of the relevant muscles (hamstrings and quadriceps). Grade I and
cated spontaneously before the patient arrives at the ED. Attention II collateral ligament injuries (which are usually medial) may be
should be focused on the presence or absence of hard signs of vas- treated conservatively with early active motion, with or without a
cular injury [see 7:17 Injures to the Peripheral Blood Vessels]; if pre- knee brace. Grade III medial collateral ligament injuries may be
ferred, the ankle-brachial index (ABI), duplex scanning, or both treated in a knee brace for 6 weeks, but grade III lateral collateral
may be employed in addition.5,37 Although many authors recom- ligament injuries must be treated surgically because conservative
mend mandatory arteriography or operative exploration for all treatment frequently leads to chronic instability. Anterior cruciate
knee dislocations, this recommendation is increasingly being ques- ligament ruptures are increasingly being treated by operative
tioned.87-89 The current literature indicates that the absence of hard means in serious athletes and other physically active persons. The
signs reliably excludes a significant arterial injury that necessitates ligament is arthroscopically reconstructed with a section of the
operative repair.The presence of hard signs of vascular injury, how- patellar tendon or the semitendinous tendon. Isolated posterior
ever, is an indication for arteriography; because about 25% of cruciate ligament ruptures, which are considerably less common,
patients with hard signs actually have no vascular injury, arteriog- are primarily treated nonoperatively.4,5,91
raphy serves to prevent many unnecessary vascular explorations. Meniscal tears occur mainly in physically active persons, though
Another potentially valid (and timesaving) approach may be to they may also result from simple distortions experienced during
take those with hard signs directly to the OR and obtain an on- activities of daily living, especially if the meniscus has previously
table angiogram. In some instances, noninvasive tests may be able undergone some degeneration. Complaints include mild pain,
to distinguish patients who have vascular injures requiring repair swelling, grinding, locking, and “giving way.” Clinical diagnosis is
from those who do not. aided by provocative tests (e.g., the McMurray and Appley tests),
Asymptomatic intimal injuries visualized by angiography do not but when symptoms persist, MRI is often performed. Mild menis-
call for surgical exploration, and the clinical value of interventional cal tears may be treated conservatively, whereas symptomatic
radiology techniques (e.g., stent placement) in this context is ques- lesions usually call for surgical treatment. In general, meniscal
tionable. If there is a vascular injury that requires surgical repair, an repair is indicated when the tear is in the vascular outer one third
external fixator that spans the knee joint should be quickly placed. of the meniscus, and partial excision is indicated when the injury
Restoration of circulation has absolute priority in this situation; the is in the avascular inner two thirds.5
amputation rate exceeds 80% when vascular repairs are done more
TIBIA
than 8 hours after injury. Operative repair of nerve injuries is con-
troversial. Optimal treatment of multiple ligament ruptures is also
subject to debate. Many authors recommend early operative liga- Proximal
mentous repair followed by functional bracing and mobilization for Tibial plateau fractures are intra-articular fractures that mostly
result from indirect varus or valgus trauma. The amount of dis- with an above-the-knee cast for 2 to 4 weeks, followed by functional
placement and comminution is determined by the magnitude and bracing for 10 to 16 weeks. Bracing relies on the intact soft tissues,
direction of the forces applied. High-energy fractures may be asso- primarily the interosseous membrane, to prevent shortening and
ciated with severe soft tissue injuries, as well as ligamentous and dislocation.93 Displaced and unstable AO-ASIF type A, B, and C
meniscal tears. It is important to recognize that severe proximal tib- fractures, as well as all open fractures, are treated operatively. The
ial fractures can represent a reduced fracture dislocation of the severity of any associated soft tissue injury is a crucial factor in
knee, and thus, the neurologic and vascular concerns that accom- deciding how to manage of tibial shaft fractures. The standard
pany knee dislocations can apply to these fractures as well [see treatment for such fractures—closed reduction with reamed, inter-
Knee, Dislocation, above]. locking intramedullary nailing—has a high success rate and a low
Tibial plateau fractures are characterized by local pain, swelling complication rate [see Figure 11]. In those unusual circumstances in
from hemarthrosis, and, in some cases, instability of the knee joint. which the fracture pattern does not permit insertion of an
Aspiration of a tense hemarthrosis is sometimes required to intramedullary rod (e.g., certain fractures in the proximal or distal
decompress the joint and relieve pain. Only 6% of patients with third of the shaft), plate fixation may be employed instead; unfor-
knee trauma have a fracture.The need for x-rays is generally deter- tunately, this procedure is associated with a high rate of
mined according to the Ottawa knee rule [see Knee, Ligamentous nonunion.4,5,51
Injury and Meniscal Tearing, above].92 If a fracture is confirmed, For open fractures associated with complex wounds, the stan-
CT scanning with axial, coronal, and sagittal reconstructions is dard treatment has been external fixation, which permits stabiliza-
done to delineate the severity and orientation of the fracture lines. tion of the fracture, affords ready access to large open wounds, and
This measure also helps the physician decide whether operative or facilitates nursing care. Currently, however, nailing appears be
nonoperative treatment is indicated and, if the former, which oper- superior to external fixation for grade 1 and 2 open fractures: the
ative approach should be taken. If the condition of the soft tissues infection rate is no higher, the complication rate is lower, and the
precludes early definitive operative treatment, a plaster splint or functional end results are better. Grade 3 open fractures are highly
temporary external fixation may be employed to allow the soft tis- complex injuries, and an expert team that includes a plastic sur-
sues time to heal or to give the surgeon time to plan an operative geon is required for optimal management. Aggressive irrigation and
procedure for soft tissue coverage. debridement are followed by either external fixation or
Proximal tibial fractures are classified according to the AO- intramedullary nailing, depending on the state of the surrounding
ASIF system or the Schatzker system. Extra-articular AO-ASIF soft tissue factors, the fracture pattern, time-related factors, and the
type A1 and A2 fractures and minimally (< 2 mm) displaced surgeon’s preference. If secondary soft tissue procedures involving
intra-articular fractures (AO-ASIF type B and C) may be treat- a pedicle or a free flap are warranted, they should be planned at an
ed conservatively; all others should be treated operatively. early stage in treatment. In multiply injured patients who require
Operative treatment consists of anatomic reduction of the artic- DCS, tibial shaft fractures are initially stabilized with external fixa-
ular surface, either under direct vision (arthrotomy) or via a less tion, with care taken to place the fixator pins strategically, in antic-
invasive approach (with arthroscopic or fluoroscopic assistance). ipation of subsequent soft tissue coverage procedures. Once the
Reduction is held with screws, plates, or both, and often, the use patient is physiologically stable, the fixator may be removed and
of iliac bone grafts or bone substitutes (e.g., calcium phosphates) intramedullary nailing performed. In these patients, a combination
is required to maintain the elevation of the articular surface. The of retrograde femoral nailing and antegrade tibial nailing done
articular “block” is connected to the tibial shaft by means of through a single knee incision offers an elegant and less invasive
plates and screws; if soft tissue injuries preclude plating, special means of stabilizing a floating knee.
external fixation devices (i.e., ring fixators with tensioned wires) One of the most severe complications that may develop after a
may be employed instead. Fixed-angle plating systems that allow tibial fracture is compartment syndrome [see 7:17 Injuries to the
less invasive insertion methods are also gaining popularity for use Peripheral BloodVessels].When the fracture is in the distal third of the
in the proximal tibia. Early motion is appropriate after operation, shaft, delayed union or nonunion is a particular risk as a conse-
with weight bearing allowed after 8 to 12 weeks. Disabling com- quence of the limited vascularization provided by the predomi-
plications include infection, posttraumatic arthritis, and instabil- nantly posterior soft tissue envelope.4,5
ity of the knee.4,5
Distal
Shaft Fractures of the distal tibia mostly result either from vertical
Fractures of the tibial shaft are among the most common serious loading that drives the talus into the tibia (as in a fall from a height
fractures. The subcutaneous location of the tibia affords little pro- or a motor vehicle accident) or from low-energy trauma with tor-
tection from direct violence, and high-energy fractures are associ- sion (as in skiing). Intra-articular fractures in this region are called
ated with longer healing times.Tibial fractures can be fraught with tibial plafond (ceiling) or pilon fractures. Pilon fractures are fre-
complications (e.g., compartment syndrome, nonunion, delayed quently accompanied by severe soft tissue swelling and comminu-
union, malunion, and infection), and in their most severe manifes- tion of the articular surface and the metaphysis; the fibula may or
tations, they can end in amputation. Tibial shaft fractures are easi- may not be fractured. Standard AP and lateral x-rays are obtained
ly diagnosed clinically in the ED. Examination includes palpation in conjunction with CT scans to define the fracture pattern and aid
for signs of possible compartment syndrome and assessment of the in preoperative planning.The goals of treatment are to restore ankle
neurovascular status. If the fracture is grossly angulated or joint integrity, congruency, and stability; to achieve bony union;
malaligned, gentle restoration of axial alignment helps relieve vas- and to allow functional painless motion. In cases where there is
cular kinking and compromise. The extremity should be splinted, substantial soft tissue involvement, staged surgery may be advis-
and appropriate x-rays should then be obtained to allow full assess- able. A safe option is to apply a bridging external fixator from the
ment of the fracture. midtibia to the foot, leaving enough distance between the fixator
Selected closed fractures without dislocation and minimally dis- pins to allow future incisions in the distal tibia; this may be done
placed AO-ASIF type A fractures may be treated conservatively with or without primary percutaneous screw fixation of the joint
a b
Figure 11 Shown (a, b) is treatment of closed AO-ASIF type A1 tibial fracture with reamed
intramedullary nailing.
surface and with or without primary fixation of the fibula to restore provides additional stabilization for an unstable distal tibial shaft
the length of the ankle. fracture; however, rendering the fibula stable may diminish the
Fractures that are not accompanied by dislocation (mostly AO- cyclic compression that occurs with weight bearing at the site of
ASIF type A1) may be treated conservatively in a cast for 8 weeks. the tibial fracture and thus may delay healing. For this reason, in
All other distal tibial fractures generally require operative treat- most cases of combined tibial and fibular fracture, the fibula is not
ment, the basic principles of which resemble those appropriate for stabilized.5
proximal tibial fractures. Because of the typical swelling and the
ACHILLES TENDON
frequent presence of fracture blisters, optimal timing of the proce-
dure is critical. For extra-articular (AO-ASIF type A) fractures, a Achilles tendon ruptures are mainly caused either by sudden
minimally invasive approach involving percutaneous insertion of a forceful dorsiflexion of the foot with the knee extended (placing the
plate with locking screws (e.g., the LCP) may be feasible. For intra- soleus and gastrocnemius muscles on maximal stretch) or by sud-
articular (AO-ASIF type B and C) fractures, anatomic reduction den takeoff during athletics. They are frequently seen in weekend
of the articular surface and internal fixation are required, prefer- athletes, as well as in more regular participants in active sports
ably performed by an experienced surgeon. As a rule, the fibula is (e.g., football, volleyball, tennis, and squash). A common scenario
fixed first through a lateral incision, and the tibia is then fixed via is one in which the patient wrongly believes that someone has hit
an anterior or medial approach. Dissection should be minimized to him or her on the heel; sometimes, the patient hears a snap as well.
prevent further soft tissue injury. Any debris present in the joint is On physical examination, a visible or palpable dent is apparent in
removed. After reconstruction of the articular surface, a connection the tendon 2 to 6 cm above the calcaneus. The Thompson test is
with the tibial shaft is made, most frequently with a plate and useful for confirming or ruling out an Achilles tendon rupture. For
screws or with a hybrid ring fixator. With most AO-ASIF type C this test, the patient is placed in the prone position with both feet
distal tibial fractures, the use of a bone graft or bone substitute is extending past the end of the examining table. If squeezing of the
required to support the articular surface. After the procedure, the calf muscles on the affected side does not result in plantar flexion
patient is allowed to engage in active movement without weight of the foot, the tendon is ruptured; if this maneuver does result in
bearing for 8 to 12 weeks.The outcome of treatment of pilon frac- plantar flexion, the tendon is intact. If the patient does not present
tures depends primarily on the quality of the articular reduction until several days after the injury, diagnosis may be more difficult.
and the recovery of the soft tissues. Such fractures frequently give In such cases, ultrasonography or MRI may be helpful.
rise to severe posttraumatic arthritic pain, and delayed ankle fusion Treatment may be nonoperative (i.e., immobilization in plantar
may be required.4,5 flexion) in certain patients, but it is operative in most. Operative
treatment consists of surgical repair of the tendon either via full
FIBULA
exposure of the tendon or via a minimally invasive approach (e.g.,
suture anchors); the latter may be preferable for minimizing wound
Shaft healing problems. After the procedure, the injured area is kept in a
Generally, fibular shaft fractures may be ignored. Such fractures soft cast for 6 weeks, during which period the patient is allowed
heal readily, sometimes so readily that they interfere with the union active movement with weight bearing. Surgical treatment substan-
of associated tibial fractures. Isolated midshaft fibular fractures that tially reduces the incidence of recurrent ruptures; however, it is also
do not involve the ankle joint may be treated symptomatically, associated with an increased risk of wound healing problems and
often without a cast. In some instances, plating the fibular fracture surgical site infection.5,94
ANKLE
provided and immobilization instituted.5
Fracture and Dislocation Ligamentous Injury
Ankle fractures are usually caused by indirect trauma. They are Ankle ligament injuries are among the most common injuries
generally categorized according to the AO-ASIF classification sys- seen in the ED.They often occur during sports activities as a result
tem, which also guides treatment decisions.The factors that deter- of inversion during plantar flexion of the ankle. Approximately
mine the type of fracture present include age, bone density, the 85% of ligamentous ankle injuries involve one or another of the
position of the foot at the time of injury (pronation or supination), three lateral ligaments: the anterior talofibular ligament, the calca-
and the direction of the forces that acted on the joint to produce neofibular ligament, and the posterior talofibular ligament.
the injury (adduction, abduction, exorotation, or axial loading). Approximately 65% of ankle sprains resulting from inversion occur
The history and physical examination reveal pain, swelling, func- in the anterior talofibular ligament alone. Ankle sprains are com-
tional impairment, and inability to bear weight. Conventional x- monly classified into three grades: grade I is a sprain with stretch-
rays usually suffice for diagnosis. A true AP (mortise) view requires ing of the ligament, grade II is a partial ligament tear, and grade III
20° of internal rotation for adequate assessment of the joint. If the is a complete tear. This classification does not, however, guide
fracture is particularly complex, CT scanning should be performed treatment. Diagnosis is based on the history and the physical
to obtain additional information. The two main factors to consid- examination (including the anterior drawer test). X-rays are
er in the management of ankle fractures are the congruency of the obtained if a fracture is suspected. The number of unnecessary x-
ankle joint medially, laterally, and superiorly (i.e., with respect to rays can be markedly and safely reduced by applying the so-called
the tibia, the fibula, and the talus) and the presence of soft tissue Ottawa ankle rule [see Figure 12], which is analogous to the Ottawa
injury (because there is little muscle coverage in this area). Even knee rule described earlier [see Knee, Ligamentous Injury and
small disturbances of ankle congruity (e.g., widening of the mor- Meniscal Tearing, above].96
tise) can lead to overloading of the cartilage and predispose to The main treatment options for ankle ligament injuries are
posttraumatic arthritis. immobilization in plaster, functional treatment (early mobilization
Type A fractures are transverse lateral malleolar fractures that with the joint in tape or a soft cast), and surgical repair. Current
occur distal to the syndesmosis, at or just below the level of the evidence indicates that functional treatment is the recommended
ankle joint. They may be treated either conservatively in a plaster strategy for most patients.97,98 Approximately 20% of patients
cast or functionally in a soft cast for 4 to 6 weeks with full weight experience varying levels of recurrent or chronic symptoms.
bearing allowed.
FOOT
Type B fractures are oblique or spiral fractures of the lateral
malleolus that occur at the level of the syndesmosis, with or with- The foot is a complex system consisting of numerous bones, lig-
out a fracture of the medial malleolus.Whereas nondislocated type aments, and tendons. Accordingly, many different types of foot
B fractures may be treated conservatively, all other type B fractures injury are seen. The history plays an important role in identifying
are treated by means of open reduction and internal fixation with the mechanism of injury. Foot injuries do occur as isolated events,
a plate or screws, followed by protected weight bearing. The best but they also frequently occur in conjunction with distant injuries
time for operative treatment is within the 8 hours following admis- and thus may easily be missed initially in cases of polytrauma.
sion. After 24 hours, edema increases, and surgery is best post- Physical examination includes assessment of the soft tissues of the
poned until 5 to 7 days later, when the condition of the soft tissue foot and ankle, the degree of pain felt on compression, the stabili-
has improved. In the meantime, the fracture or dislocation is ty of the injured area, and the neurovascular status of the foot.
reduced, and a splint is applied. Conventional x-rays are often supplemented with CT scans; MRI
Type C fractures occur above the syndesmosis. Sometimes, a and bone scintigraphy are also sometimes employed, though less
fracture is located near the fibular head proximally. In such cases, frequently.4,5 The pain, swelling, functional impairment, and defor-
the interosseous membrane and the syndesmosis are ruptured mity associated with foot injuries can markedly limit the patient’s
between the fibular fracture and the ankle joint (Maisonneuve frac- mobility. In recent years, it has become clear that function can be
ture).This type of injury is easily missed if a careful examination is improved by restoring the normal anatomy and avoiding pro-
not performed and the appropriate proximal x-ray obtained. Type longed immobilization in plaster.
C fractures are generally treated surgically with plating or with one
or two fibulotibial syndesmotic positioning screws, which allow the Talus
syndesmosis to heal with a correct length and position relative to The talus plays an important role in the transmission of force to
the talus of the fibula. the rest of the foot, with 60% of its surface covered by cartilage.
Malleolar fractures are frequently associated with fractures of This cartilaginous covering, in combination with a delicate blood
the posterior lip of the tibial plafond (trimalleolar fractures). Large supply, makes talus fractures complex injuries. Fractures and dis-
fragments (> 20% of articular surface) should be reduced and locations of the talus typically result from high-energy trauma (as
fixed to prevent posterior dislocation of the talus. Early complica- in motor vehicle accidents or falls). Most talus fractures are intra-
tions include inadequate reduction and fixation, wound problems, articular; sometimes, the only damage consists of an osteochondral
and infection. Long-term results are primarily determined by the flake (e.g., from an ankle sprain).
presence and extent of cartilage damage and by the congruency of Most talus fractures are treated operatively. Ideally, surgical
the ankle joint. Approximately 30% of patients experience persis- treatment should be carried out as early as possible, especially if the
tent symptoms around the ankle.4,5,95 fracture involves the talar neck. Screw fixation may be accom-
Isolated ankle dislocations without fractures are rare; 30% of plished either via open reduction or percutaneously (if displace-
these injuries are associated with an open wound extending into ment is minimal). After the operation, active motion is allowed,
the joint. A dislocated ankle should immediately be reduced— and weight bearing is started after 8 to 12 weeks. The outcome of
before x-rays are taken if possible—to minimize further neurovas- treatment is determined primarily by the presence or absence of
cular compromise. After closed or open reduction, wound care is open wounds, the fracture type, and the status of the remaining
LATERAL VIEW MEDIAL VIEW
6 cm A. Posterior Edge C. Posterior Edge or 6 cm

or Tip of Lateral Malleolus Tip of Medial Malleolus
Navicular Bone
B. Base of 5th D. Navicular Bone

Metatarsal
Figure 12 Illustrated is the Ottawa ankle rule. According to this rule, an ankle or foot x-ray series
is required only if (1) palpation of the marked areas is painful or (2) the patient is completely unable
to bear his or her own weight both immediately after the injury and for four steps in the ED.
blood supply. Avascular necrosis, infection, and posttraumatic and can lead to prolonged deformity, pain, and functional impair-
arthritis can lead to severe disability.4,5,99 ment. Restoration of the anatomy both medially and laterally is
important for a good outcome.
Calcaneus The majority of nondislocated fractures, extra-articular frac-
The calcaneus is the most frequently fractured bone in the foot. tures, and ligament avulsion fractures of the midfoot can be treat-
Fractures of the calcaneus are primarily caused by falling or jump- ed nonoperatively in plaster or with functional therapy and early
ing from a height and thus are commonly seen in combination motion. Dislocated fractures are generally treated operatively with
with other injuries (e.g., spine fractures). Examination typically screw or plate fixation unless such treatment is precluded by severe
reveals marked swelling of the foot, with or without deformity. comminution. Fractures in Lisfranc’s joint mainly result from
Lateral x-rays of the foot show a reduction in Böhler’s angle (the high-energy trauma and are often associated with dislocation of
posterior angle formed by the intersection of a line from the pos- one or more metatarsal bones. Such fractures are treated by means
terior to the middle facet with a line from the anterior to the mid- of operative reduction and fixation with Kirschner wires or
dle facet) from the normal range of 20° to 40°. Conventional x- screws.4,5,102,103
rays are always supplemented with CT scans to delineate the
extent of the fracture. Metatarsals and Toes
Most extra-articular and nondislocated intra-articular fractures Most metatarsal fractures result from direct trauma (e.g., from
can be treated conservatively with non–weight-bearing mobiliza- a heavy object falling on the foot); however, they can also occur
tion of the ankle and the foot over a period of 6 to 12 weeks; there with chronic repetitive loading in the absence of obvious trauma
is no need for a splint or a cast. Optimal treatment of intra-articu- (so-called stress or march fracture).
lar fractures—in particular, the role of surgery—remains subject to For the most part, fractures of the second through fourth
debate, however. Depending on the fracture configuration, reduc- metatarsals and nondislocated fractures of the first and fifth
tion and internal fixation of the joint surfaces may be accom- metatarsals can be treated nonoperatively by using a plaster cast or
plished either via an open approach or percutaneously. The same a heavy supportive shoe for 4 to 6 weeks.With the majority of dis-
measures recommended as conservative treatment are then car- placed fractures, closed reduction can be achieved, but mainte-
ried out as postoperative treatment. Whether this strategy yields nance of the reduction requires internal fixation; malunion can
better functional results than conservative treatment is not clear. disturb ambulation. Many fractures of the lesser metatarsals and
However, there is currently a trend toward operative treatment in subcapital fractures can be treated with percutaneous pinning.
situations where anatomic reconstruction of the subtalar and cal- Fractures with joint involvement and multiple fragments frequent-
caneocuboidal joints can be achieved. Smoking, advanced age, ly necessitate treatment with open reduction and plate fixation.
diabetes, and noncompliance are relative contraindications to sur- Fractures of the base of the fifth metatarsal form a special group.
gical management. A substantial percentage of patients heal with The mechanism of injury is identical to that seen in ankle sprains.
malunion or experience posttraumatic arthritis.These patients are These fractures are generally divided into two types: avulsion frac-
candidates for arthrodesis of the subtalar joint.4,5,100,101 tures (involving the insertion of the peroneus brevis tendon) and
transverse fractures of the base of the fifth metatarsal (Jones frac-
Midfoot ture). Both types may be treated nonoperatively if displacement is
The midfoot contains the navicular bone, the cuboid bone, and minimal, but delayed healing is common with Jones fractures.
the three cuneiform bones (medial, intermediate, and lateral). Operative treatment consists of tension-band wiring or screw or
Proximally, the navicular and the cuboid articulate with the talus plate fixation.4,5,104
and the calcaneus (Chopart’s joint); distally, the cuboid and the Fractures and dislocations of the toes result from direct trauma.
cuneiforms articulate with the metatarsals (Lisfranc’s joint). Virtually all toe fractures can be treated conservatively by taping the
Fractures and ligamentous injuries in these joints are easily missed injured toe to an adjacent, uninjured toe (so-called buddy tape). On
rare occasions, reduction and Kirschner wire fixation of a dislocat- symptoms of clinical FES usually begin within 24 to 48 hours after
ed toe fracture are indicated.Toe dislocations are reduced with trac- trauma. Treatment is primarily prophylactic and supportive, con-
tion and are treated in much the same way as toe fractures.5 sisting of early fracture fixation, careful volume replacement, anal-
gesia, and respiratory support. The role of corticosteroids in this
setting is controversial.4,5,108,109
Special Considerations
Thromboembolism
GERIATRIC TRAUMA
Both symptomatic and asymptomatic DVT can pose serious
Musculoskeletal injuries in the elderly are a rapidly growing problems in trauma patients. DVT is an important cause of pul-
health problem and cause considerable morbidity and mortality. monary embolism (PE) and often results in major morbidity or
Advanced age, increased risk of falling, and reduced bone mineral death.The incidence of DVT ranges from 4% in patients with con-
density are the most important risk factors for the occurrence of servatively treated lower-extremity injuries to between 20% and
osteoporotic fractures. Although many standard principles of 35% in patients with pelvic and acetabular injuries and patients
extremity trauma management apply to the elderly, there are also with hip fractures. All trauma patients should therefore receive
certain concerns that are specific to this population. Hence, in DVT prophylaxis. Once a thromboembolic event has occurred, the
evaluating an elderly person who has sustained an extremity injury, patient should be immediately be treated with I.V. anticoagulants
it is essential to assess the entire patient, not just the affected bone according to local protocols. Prevention and treatment of DVT
or joint. and PE are discussed in greater detail elsewhere [see 6:6 Venous
One issue is that injured elderly persons often have one or more Thromboembolism].4,5,10,110-113
comorbid conditions, the presence of which increases periopera-
tive risk. Advances in medical and anesthetic techniques have Infection
made it safe for many patients to undergo surgical procedures that Infections that develop after osteosynthesis are nearly always
previously would have been contraindicated; however, the timing caused by exogenous bacteria. Contamination may occur in the
of surgery can still pose problems. Ideally, sufficient time should be course of the injury (as with an open fracture), during surgical
taken to ensure that patients receive optimal preoperative prepara- treatment, or postoperatively (as a result of disturbed wound heal-
tion, but such preparation should be provided with the under- ing). Most infections manifest themselves within the first 7 days
standing that delaying surgery unnecessarily will increase mortali- after the operation. Some become apparent only after a longer
ty. Inadequate nutrition is common in the elderly and should period has elapsed; these are often preceded by an unnoticed low-
receive appropriate attention.The presence of osteoporosis can be grade infection. The infection types most frequently associated
confirmed by measuring bone mineral density (e.g., with dual- with osteosynthesis are implant-related infections (involving colo-
energy x-ray absorptiometry). Treatment of osteoporosis consists nization of fixation materials), osteomyelitis (a bone infection), and
of a combination of physical exercise, dietary supplementation infectious arthritis. Diagnosis is based primarily on clinical signs
(with calcium and vitamin D), and administration of biphos- (e.g., redness, fever, and pain), laboratory studies (e.g., C-reactive
ponates (e.g., alendronate). Elderly patients have special needs protein level and leukocyte count), and bacteriologic tests. In
with regard to rehabilitation, in that dependence or immobility patients with late-developing infections, x-rays, CT, and MRI can
may necessitate institutional care.105-107 provide additional useful information.Treatment consists of surgi-
cal debridement, open or closed wound management, and supple-
REHABILITATION
mental local or systemic antibiotic coverage. For cases of chronic
The care of a patient with musculoskeletal injuries does not stop osteomyelitis, advanced soft-tissue coverage procedures are fre-
when the last operation is performed. Adequate rehabilitation is quently required. Implant removal is generally unnecessary as long
critical for ensuring the best possible functional outcome. Physical as the implant provides stable fixation.
therapists, occupational therapists, speech trainers, dietitians, Gas gangrene is the most serious infection seen in traumatic
social workers, and psychologists may all play roles in this process. wounds; Clostridium perfringens is the classic causative pathogen.
To ensure optimal continuity of treatment from the hospital to the Other gas-forming organisms common seen include coliforms,
rehabilitation center, rehabilitation experts should be involved anaerobic streptococci, and Bacteroides. Pain is the initial symptom
early after the admission of a patients who has sustained severe of gas gangrene, followed by edema and exudation of a thin, dark
pelvic or extremity trauma.4,5 fluid. The wound acquires a bronze discoloration and a musty
smell, and crepitations develop in the muscles. Symptoms progress
COMPLICATIONS
rapidly, and profound shock and MODS usually ensue.The diag-
Systemic complications of pelvic and extremity trauma include nosis is made on clinical grounds, supported by Gram’s staining.
FES, ARDS, hemorrhagic complications, crush syndrome, and Successful treatment depends on early diagnosis, radical surgical
thromboembolism. Severe local complications include compart- debridement, fasciotomy, and I.V. antibiotic therapy.4,5,114
ment syndrome, acute and chronic infection, infected nonunion,
malunion, and posttraumatic reflex sympathetic dystrophy. Delayed Union, Nonunion, and Malunion
At present, there is no consensus among surgeons on how best
Fat Embolism Syndrome to assess fracture healing—and, therefore, no consensus on precise-
FES is most commonly associated with fractures of long bones ly what constitutes delayed union, nonunion, or malunion. In gen-
of the lower extremity.The classic clinical triad consists of respira- eral, delayed union refers to a fracture that heals more slowly than
tory distress, cerebral dysfunction, and petechial rash. The patho- the average. “Average” depends on the fracture’s location and type,
physiology is not clear, but there is some evidence to suggest that but 3 months is a frequently accepted time limit for delayed union.
extravasation of fat particles from long bone fractures may play an Nonunion refers to a failure of bone healing that results from an
important part. Furthermore, early stabilization of long bone frac- arrested growth process; 6 months is the usual time limit.
tures has been shown to decrease the incidence of FES. Signs and Nonunion has numerous potential causes, but the most important
factors leading to nonunion are disturbance of the blood supply rotation, or angulation.The degree of malunion that is acceptable
and insufficient fracture stability. The blood supply is disturbed with respect to function and cosmesis varies with the age of the
both by the injury itself and by the surgical procedure performed patient and the location of the fracture.4,5
to treat the injury. Instability results from inadequate fixation tech-
nique, a suboptimal implant choice, or implant failure. In some Reflex Sympathetic Dystrophy
nonunions, a false joint with a fibrocartilaginous cavity lined with Posttraumatic reflex sympathetic dystrophy (also referred to as
synovium is formed (a condition also referred to as pseudarthro- complex regional pain syndrome) is a poorly understood compli-
sis). Treatment of hypertrophic nonunions focuses primarily on cation that may develop in any of the extremities after an operation
achieving adequate stability, whereas treatment of atrophic or even minor trauma. It is capable of causing severe disabili-
nonunions requires not only achieving stability but also reversing ty4,5,115,116 Symptoms include unexplained diffuse pain, skin
the atrophy to the extent possible.The gold standard for treatment changes, edema, temperature changes, and functional impair-
of atrophic nonunions is placement of a cancellous autologous ment. The optimal treatment regimen has not been established;
bone graft, which has the advantage of being osteogenic, osteoin- common therapeutic measures include free radical scavenger
ductive, and osteoconductive. Unfortunately, the morbidity from treatment (e.g., with systemic acetylcysteine and local dimethyl
cancellous bone harvesting can be considerable. sulfoxide cream), administration of vitamin C, analgesia, vasodi-
Malunion is a deformity characterized by abnormal length, latation, and careful physical therapy.
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56. Brown OL, Dirschl DR, Obremskey WT: 1980
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57. Zlowodzki M, Zelle BA, Cole PA, et al; Evidence- of reduction and clinical results in patients man- lateral ankle ligament injuries in adults. Cochrane
Based Orthopaedic Trauma Working Group: aged operatively within three weeks after the injury. Database Syst Rev (3):CD003762, 2002
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99. Vallier HA, Nork SE, Benirschke SK, et al:
tematic review of 2144 fractures: on behalf of the 79. Giannoudis PV, Grotz MR, Papakostidis C, et al: Surgical treatment of talar body fractures. J Bone
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100. Bridgman SA, Dunn KM, McBride DJ, et al:
58. Handoll HHG, Gibson JNA, Madhok R: 87:2, 2005
Interventions for treating calcaneal fractures.
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tures in adults. Cochrane Database Syst Rev Functional outcome of patients with femoral head 2000
(4):CD000434, 2003 fractures associated with hip dislocations. Clin
101. Rammelt S, Zwipp H: Calcaneus fractures: facts,
59. Helmy N, Hintermann B: New trends in the treat- Orthop Relat Res 377:44, 2000
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Relat Res 442:100, 2006 ation implants for intracapsular proximal femoral
fractures in adults. Cochrane Database Syst Rev 102. Rammelt S, Grass R, Schikore H, et al: Injuries of
60. Shao YC, Harwood P, Grotz MR, et al: Radial the Chopart joint. Unfallchirurg 105:371, 2002
nerve palsy associated with fractures of the shaft of (4):CD001467, 2001
the humerus: a systematic review. J Bone Joint Surg 82. Bottle A, Aylin P: Mortality associated with delay 103. Sands AK, Grose A: Lisfranc injuries. Injury
Br 87:1647, 2005 in operation after hip fracture: observational study. 35(suppl 2):SB71, 2004
61. Chapman JR, Henley MB, Agel J, et al: BMJ 332:947, 2006 104. Rammelt S, Heineck J, Zwipp H: Metatarsal frac-
Randomized prospective study of humeral shaft 83. Parker MJ, Gurusamy K: Internal fixation versus tures. Injury 35(suppl 2):SB77, 2004
fracture fixation: intramedullary nails versus plates. arthroplasty for intracapsular proximal femoral 105. Gillespie LD, Gillespie WJ, Robertson MC, et al:
J Orthop Trauma 14:162, 2000 fractures in adults. Cochrane Database Syst Rev Interventions for preventing falls in elderly people.
Cochrane Database Syst Rev (4):CD000340, Practice management guidelines for the preven- tic challenge with new imaging options. J Trauma
2003 tion of venous thromboembolism in trauma 52:1210, 2002
106. Jacobs DG, Jacobs DO, Kudsk KA, et al; EAST patients: the EAST practice management guide- 115. Zollinger PE, Tuinebreijer WE, Kreis RW, et al:
Practice Management Guidelines Work Group: lines work group. J Trauma 53:142, 2002 Effect of vitamin C on frequency of reflex sympa-
Practice management guidelines for nutritional 111. Kock H, Schmit-Neuerburg KP, Hanke J, et al: thetic dystrophy in wrist fractures: a randomised
support of the trauma patient. J Trauma 57:660, Thromboprophylaxis with low-molecular-weight trial. Lancet 354:2025, 1999
2004 heparin in outpatients with plaster cast immobili- 116. Stanton-Hicks M, Janig W, Hassenbusch S, et al:
107. Jacobs DG, Plaisier BR, Barie PS, et al; EAST sation of the leg. Lancet 346:459, 1995 Reflex sympathetic dystrophy: changing concepts
Practice Management Guidelines Work Group: 112. Wille-Jørgensen P, Jorgensen LN, Crawford M: and taxonomy. Pain 63:127, 1995
Practice management guidelines for geriatric trau- Asymptomatic postoperative deep vein thrombosis
ma: the EAST Practice Management Guidelines and the development of postthrombotic syn-
Work Group. J Trauma 54:391, 2003 drome: a systemic review and meta-analysis.
108. Habashi NM, Andrews PL, Scalea TM: Thromb Haemost 93:236, 2005 Acknowledgments
Therapeutic aspects of fat embolism syndrome. 113. Amaragiri SV, Lees TA: Elastic compression stock- Figures 1, 2, and 12 Thom Graves, CMI.
Injury 37(suppl 4):S68, 2006 ings for prevention of deep vein thrombosis. The authors would like to thank Gregory J. Jurkovich,
109. White T, Petrisor BA, Bhandari M: Prevention of Cochrane Database Syst Rev (3):CD001484, M.D., F.A.C.S. (Harborview Medical Center, Seattle,
fat embolism syndrome. Injury 37(suppl 4):S59, 2000 Washington), and W.R. Smith, M.D. (Denver Health
2006 114. Gross T, Kaim AH, Regazzoni P, et al: Current Medical Center, Denver, Colorado), for their review-
110. Rogers FB, Cipolle MD, Velmahos G, et al: concepts in posttraumatic osteomyelitis: a diagnosing of the manuscript.
7 TRAUMA AND THERMAL INJURY 13 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 1
13 MANAGEMENT OF THE PATIENT

WITH THERMAL INJURIES
Nicole S. Gibran, M.D., F.A.C.S., and David M. Heimbach, M.D., F.A.C.S.
Optimal care of the burn patient requires not only specialized cleaned with sterile saline. In fact, burns can be effectively washed
equipment but also, more important, a team of dedicated sur- during a daily shower or bath with regular tap water and nonper-
geons, nurses, therapists, nutritionists, pharmacists, social work- fumed soap. A second misconception is that the patient must
ers, psychologists, and operating room staff. Burn care was one of scrub the wound to debride all the superficial exudates. Simply
the first specialties to adopt a multidisciplinary approach, and over wiping the wound with a soapy washcloth to remove the topical
the past 30 years, burn centers have decreased burn mortality by ointment and wipe away the bacteria that have accumulated over
coordinating prehospital patient management, resuscitation meth- the past day provides adequate care. Intact blisters can be left as a
ods, and surgical and critical care of patients with major burns. protective wound cover if they do not prevent movement of a joint.
Detailed practice guidelines for burn patients, as well as lists of the Dressings must allow full range of motion.
resources needed in a burn center, have been developed.1,2 Physical therapy is an essential component of burn manage-
ment. A common misconception is that burns over joints should
be immobilized to promote healing. Actually, immobilization of
Where to Treat Burn Patients extremities leads to swelling, which worsens burn wound pain and
Patients with critical burns, as defined by the American Burn increases the risk of wound infection. Patients with hand burns
Association [see Table 1], should be transferred to a specialized must be taught exercises to maintain range of motion. Likewise,
burn center as soon as possible after their initial assessment and patients with foot burns must ambulate without assistive devices,
resuscitation. A community general or plastic surgeon with an so that normal muscle contraction can facilitate lymphatic
interest in burns could manage moderate burns that do not drainage of the lower extremity. Patients must be taught to elevate
involve functionally significant body sites. However, even patients burned extremities when they are not actively exercising.
with small burns benefit from the expertise of a specialized burn Inadequate pain management is a frequent reason for return
care team. Furthermore, the burn center’s focused approach facil- visits to the emergency department or readmission to the hospital.
itates patient and family education, reentry into society, long-term Often, inadequate pain control results from poor patient under-
rehabilitation needs, and reconstructive surgical needs. standing of how to care for the burn (e.g., excessive scrubbing dur-
ing wound care or inactivity and subsequent swelling). Although a
OUTPATIENT VERSUS INPATIENT MANAGEMENT
healing partial-thickness burn may become more painful as the
Outpatient management may be appropriate for small burns epithelial buds begin to emerge and healing progresses [see 7:14
(1% to 5% of total body surface area [TBSA]) that do not involve Management of the BurnWound], an acute increase in stinging pain
joints or vital structures. However, successful outcomes in such may be the first sign of a superficial wound infection. This is an
cases require a well-organized plan and clear communication with indication that the burn should be evaluated for signs of infection,
the patient and family. Many outpatient management plans fail including erythema and breakdown of a previously epithelized
because insufficient teaching during a short visit to an emergency wound; cellulitis may or may not surround an infected burn.
department leads to inadequate pain control, wound infection, Systemic antibiotics and a change in the topical antimicrobial
and limited movement. agent are indicated in this situation.
Three important reasons for hospitalizing a patient with a burn Socioeconomic issues can be important contraindications to
injury are wound care, physical therapy, and pain management. A
short hospital stay immediately after the injury gives the burn team
the opportunity to teach the patient how to properly clean and
dress the burn; this is especially important for burns to the extrem- Table 1 American Burn Association Criteria
ities. A therapist should assess patient movement and educate the for Burn Injuries That Warrant Referral
patient about expected activity levels and exercise programs. to a Burn Unit
Background pain (pain experienced with ordinary daily activities)
and procedural pain (pain experienced during wound care) should Partial-thickness burns of greater than 10% of total body
be carefully assessed, and analgesic medications should be titrated surface area
to the individual patient’s pain levels. Third-degree burns
Electrical burns, including lightning injury
Complex burn wound management is discussed in detail else-
Chemical burns
where [see 7:14 Management of the Burn Wound]. For outpatient Inhalation injury
management, however, simplicity is the key to success. Patients Burn injury in patients with preexisting medical disorders that could
and their families are unlikely to manage complicated dressing complicate management, prolong recovery, or increase mortality
plans. For outpatient burn care, once-daily dressing changes are Burns with concomitant trauma
adequate. A common misconception is that these wounds must be
Table 2 Criteria for Outpatient Management mate of need; individual patients may have higher or lower fluid
of Burn Patients requirements, depending on their overall condition and comor-
bidity. Continuous monitoring and reliance on objective clinical
Outpatient Management Outpatient Management outcomes must dictate patient management.
Appropriate Inappropriate The reliability of the Parkland formula directly depends on
accurate assessment of burn depth and percentage of TBSA
Abused patients affected.5 There are two formulas for quick estimation of burn
Demented patients size. One is the commonly used Rule of Nines: each arm is con-
Patients with small burns* who have
demonstrated understanding of Intoxicated patients sidered to be 9% of TBSA, each leg 18%, the anterior trunk 18%,
wound care, pain control, and Homeless patients
therapy the posterior trunk 18%, and the head 9% [see Figure 1]. Another
Patients with comorbid conditions
Patients with a language barrier
easy method involves using the patient’s full palm, including
digits, to represent 1% of TBSA. First-degree burns [see 7:14
*1%–5% of total body surface area. Management of the BurnWound] should not be included in the cal-
culation of burned areas.
Despite improvements in invasive monitoring techniques, the
outpatient management of a burn wound [see Table 2]. Any sug- most reliable measures of adequate tissue perfusion for burn
gestion of abuse—of a child or an adult—mandates admission for resuscitation continue to be mean arterial pressure (MAP) and
full evaluation of the home situation by the burn team; if the his- adequate urine output (UOP). MAP should be maintained above
tory and the burn distribution are consistent with a nonacciden- 60 mm Hg to ensure adequate cerebral perfusion. For an other-
tal injury or potential neglect, the patient must be referred to pro- wise healthy adult, a UOP of 30 ml/hr should be adequate; for a
tective services. Likewise, suggestion of a self-induced burn injury child, 1.0 to 1.5 ml/kg/hr should suffice. No evidence supports the
should trigger admission for psychological evaluation. For exam- use of pulmonary arterial (PA) catheter measurements for routine
ple, the presence of multiple small cigarette burns in various phas- resuscitation; in fact, reliance on PA catheters may lead to over-
es of healing is an absolute indication for admission to the hospi- resuscitation and contribute to the development of fluid-related
tal for psychological evaluation, even though the burns themselves complications (see below). Use of diuretics and inotropes should
may be easily cared for at home with small adhesive bandages. be restricted to patients with underlying comorbidity, especially
Although language barriers are not an absolute indication for hos- preexisting cardiac disease. Use of inotropes will not stop the leak
pital admission, there must be assurance that patients fully under- of plasma into the extravascular space but may lead to ischemia in
stand the treatment plan before they leave the emergency depart- the wound, resulting in conversion of a partial-thickness wound
ment. Underinsured and homeless patients may not have the into a full-thickness wound. Use of mannitol may be appropriate
resources to care for a wound outside the hospital and should be for patients with myoglobinuria who require an osmotic diuretic
admitted for initial wound care and planning for transfer to a facil- to maintain a UOP of 100 ml/hr [see 7:15 Miscellaneous Burns and
ity where they have access to a daily shower. Finally, the success Cold Injuries].
of outpatient burn wound management depends on the ability to
arrange a follow-up visit with an outpatient health care provider
who can assess the outcome.
For patients with large burns, transition from inpatient to out-
patient status is based on the same principles listed above. When 9%
burn pain can be controlled with oral medication and the patient
and family can provide wound care, perform range-of-motion
exercises, and manage splints and other assistive devices, outpa-
tient management is appropriate. In some cases, daily or weekly 18%
outpatient therapy sessions to maintain range of motion may be FRONT
included. If there are concerns about nonhealing wounds, weekly
follow-up visits with the burn surgeon may be indicated initially. 18%
BACK
Because of possible long-term sequelae—scarring, contractures,
and rehabilitation difficulties [see 7:16 Rehabilitation of the Burn 9% 9%
Patient]—the burn team should follow burn patients for 1 to 2
years after injury; longer follow-up may be necessary for patients 1%
with persistent contractures and scar formation. Prolonged fol-
low-up is especially important with young children, who may
encounter difficulties as they grow and may therefore require peri-
18% 18%
odic monitoring until adulthood.
Figure 1 The size of a

Fluid Management
burn can be estimated by
In the late 1960s, Charles Baxter developed objective criteria means of the Rule of
for resuscitation of the thermally injured patient.3,4 The Baxter Nines, which assigns per-
formula (also known as the Parkland formula) calls for the infu- centages of total body
sion, over 24 hours, of 3 to 4 ml of crystalloid per percentage of surface to the head, the
TBSA burned. Half of this volume is delivered during the first 8 extremities, and the front
and back of the torso.
hours after injury, and the other half is delivered over the subse-
quent 16 hours. It is important to remember that this is an esti-
Table 3 Acute Physiologic Changes during Burn Resuscitation
Signs of Signs of
Measurement Comment Goal Underresuscitation Overresuscitation
Fluid input generally exceeds

output during the early post- Urine output: adults, 30 ml/hr; Urine output > 30 ml/hr; hyper-
Fluid volume children < 20 kg, 1.0–1.5 Low urine output osmolar diuresis from hyper-
burn period as edema
develops ml/kg/hr glycemia must be excluded
An accurate dry weight is Weight will increase because

Body weight necessary for estimation of intravascular leak and Massive weight gain from
Weight approaches dry weight
of resuscitation fluid resuscitation volume anasarca
requirements
Body temperature Hyperthermia may indicate a Normothermia — —

hyperdynamic state
Dysrhythmias are uncommon Dysrhythmias may reflect poor

Electrocardiographic status in young patients but may Tachycardia may reflect
Normal sinus rhythm oxygenation, electrolyte
complicate management of intravascular contraction
imbalance, or pH abnormality
older patients
Although the first 24 hours after a burn is usually considered the gested that 12% of patients would require more than 4.3
resuscitative phase of a burn injury, stabilization of the flux of medi- ml/kg/%TBSA resuscitation fluid, subsequent reports suggest that
ators and closure of capillary leaks in fact take place on a continu- more than 55% of patients receive this amount of fluid.8 Excessive
um, occurring gradually from 12 to 48 hours after the burn injury. fluid resuscitation increases the risk of complications, including
As capillary leakage resolves, the amount of fluids needed to main- poor tissue perfusion, compartment syndrome involving the abdo-
tain a MAP of 60 mm Hg and a UOP of 30 ml/hr should progres- men or extremities, pulmonary edema, and pleural effusion.
sively decrease. A patient with both a large, deep burn and a pro- Abdominal compartment syndrome (ACS) is an increasingly
found inhalation injury or a patient in whom resuscitation has been well-recognized posttraumatic complication that occurs in pa-
delayed may require significantly more fluid than predicted by the tients who require extensive fluid resuscitation. Increased abdom-
Parkland formula to maintain blood pressure and UOP. inal pressure decreases lung compliance and impedes lung expan-
Colloid administration (albumin or fresh frozen plasma) after sion, resulting in elevated airway pressures and hypoventilation.
the capillary leak has closed (12 to 72 hours) may facilitate resus- The classic presentation includes high peak airway pressures,
citation in the patient with persistent low urine output and hy- decreased venous return, oliguria, and intra-abdominal pressures
potension despite adequate crystalloid delivery. In such cases, the exceeding 25 mm Hg.10 Sustained intra-abdominal hypertension
formula used is 5% albumin, 0.3 to 0.5 ml/kg/% TBSA burned is often fatal. Bedside decompressive laparotomy can alleviate ACS
over 24 hours. Alternatively, plasmapheresis may reduce intra- and can be performed safely through burn wounds,11 and its use
venous fluid requirements in patients who are not responding to should be considered in patients with hemodynamic instability,
resuscitation.6 Indications for plasmapheresis include a sustained hypoventilation, and elevated abdominal pressures. Whether the
MAP of less than 60 mm Hg and a UOP less than 30 ml/hr in a patient survives, however, depends on the comorbid conditions
patient with ongoing fluid needs that exceed twice the estimated that led to the requirement for large resuscitative volumes.
volume requirements. Early plasmapheresis (12 to 24 hours after
injury) may decrease the incidence of complications from admin-
istration of excessive fluid (see below).Why plasmapheresis works Airway Management
is unknown, but theoretically, the process should remove inflam- Abnormal pulmonary function commonly complicates the man-
matory mediators that cause vasodilatation and capillary leak. agement of thermally injured patients. It may result from inhala-
Once resuscitation is complete (24 to 48 hours after injury), tion injury or from the systemic response to the burn. Under-
insensible losses and hyperthermia associated with a hyperdy- standing the management of pulmonary dysfunction in the ther-
namic state may indicate the need for ongoing fluid administra- mally injured patient requires a working knowledge of pulmonary
tion. The route of administration can be intravenous or, prefera- function measurements and of pulmonary pathophysiology [see
bly, enteral. Reliable daily weights can be extremely valuable Tables 5 and 6].
for detection and measurement of insensible fluid loss or fluid
INHALATION INJURY
retention.
Along with MAP and UOP, several laboratory variables can be Inhalation injuries occur in approximately one third of all major
used to ensure that patients are receiving appropriate amounts of burns, and mortality is more than double that of cutaneous
resuscitation fluid [see Tables 3 and 4]. burns.12-14 Curiously, isolated inhalation injuries do not result in
high mortality.15 Presumably, the combination of inhalation injury
COMPLICATIONS OF FLUID ADMINISTRATION
and cutaneous thermal injury creates a double insult in which
Before the development of current resuscitation formulas, inad- recurrent or persistent bacteremia aggravates the pulmonary
equate resuscitation was a common cause of death in burn injury.
patients, as a result of decreased tissue perfusion and subsequent Three distinct components of inhalation injury exist: carbon
multiorgan failure.7 In addition, this ischemia caused conversion monoxide (CO) poisoning, upper airway thermal burns, and
of the burn to a deeper injury, thereby increasing surgical require- inhalation of products of combustion. Diagnosis of an inhalation
ments. However, there are also complications associated with injury requires a thorough history of the circumstances sur-
overresuscitation, or so-called fluid creep.8,9 Whereas Baxter sug- rounding the injury and is often suggested by fire in a closed
Table 4 Acute Biochemical and Hematologic Changes during Burn Resuscitation

Signs of Signs of
Measurement Comment Goal Underresuscitation Overresuscitation
Normal baseline values rule out preexist-

Serum creatinine and ing renal disease, which reduces urine Rising values may reflect
blood urea nitrogen output reliability as an index of tissue Normal values underresuscitation or acute May be normal
perfusion tubular necrosis
Significant blood loss from incorrectly May be elevated with severe

Hematocrit and performed surgical interventions such intravascular depletion; May be low in patients with
Should approach normal excessive intravascular
hemoglobin as escharotomies or central venous line this is typical with delayed
placement may lower values resuscitation volumes
The initial WBC may vary, depending on

the stress response and cell margina-
tion; the absolute value is not particu- May decrease, but this general-
White blood cell count ly represents margination of
larly useful during the early postburn Normal values May increase
(WBC) circulating neutrophils into the
period; once leukopoiesis increases,
neutropenia resolves without treatment wound
with stimulatory factors
Increased release of catecholamines in Hyperglycemia, which may Hypoglycemia, especially in

Levels maintained at
Blood glucose burn patients may lead to hyperglyce- misleadingly increase urine infants (< 20 kg), who have
≤ 120 mg/dl
mia; diabetic patients may require insulin output decreased glycogen stores
Electrolyte status depends on the type

of crystalloid used for resuscitation;
hypernatremia and hyponatremia
Electrolytes can be avoided by resuscitation with Normal electrolyte levels — —
lactated Ringer solution; use of normal
saline should be avoided because it
can lead to hyperchloremic acidosis
Myoglobinemia may result if

Decreased albumin level Myoglobinemia may result excessive resuscitation leads
Patients with very deep burns or electri-
Plasma protein and within the first 8 hr from prolonged underresus- to compartment syndrome;
cal burns may have elevated plasma
myoglobin levels after burn injury may citation and tissue ischemia escharotomy should be
myoglobin levels
be normal performed to minimize
rhabdomyolysis
Unrecognized compartment
Prolonged shock and underre- syndrome and delayed
Prothrombin time, suscitation may lead to dis- escharotomy may cause tis-
Initial values are useful to determine
partial thromboplas- seminated intravascular sue ischemia and dissemi-
whether the patient has preexisting Normal
tin time, and platelet coagulation; coagulation fac- nated intravascular coagula-
hepatic or hematologic disease
count tors and platelets may be tion; a dropping platelet
needed in such cases count may indicate heparin-
induced thrombocytopenia
space, carbonaceous sputum, and an elevated carboxyhemoglo- cardiac dysrhythmia (three cases), and eustachian tube occlusion
bin level (> 15%). (two cases).18 Consensus is growing that when cardiac arrest com-
plicates inhalation injury, the result is uniformly fatal regardless of
Carbon Monoxide Poisoning aggressive therapy, including hyperbaric oxygen therapy.19
CO injury is the most commonly recognized form of inhalation
injury and the most common cause of death in inhalation injury. Upper Airway Thermal Injury
Clinical signs and symptoms of CO toxicity correlate with arterial Direct thermal damage tends to occur in the upper airway
carboxyhemoglobin levels, which can be used to quickly and pre- rather than in the lower airway because the oropharyngeal cavity
cisely determine the degree of CO intoxication [see Table 7]. CO has a substantial capacity to absorb heat. Upper airway thermal
intoxication can be easily treated with 100% inhaled oxygen, injury constitutes an important indication for intubation, because
which rapidly accelerates the dissociation of CO from hemoglobin it is mandatory to control the airway before airway edema devel-
[see Table 8]. Hyperbaric oxygen therapy has been touted as a supe- ops during resuscitation.
rior treatment for quickly reducing carboxyhemoglobin levels,16 The diagnosis of upper airway thermal injury is achieved with
but the data are controversial and the studies are generally poorly direct laryngoscopic visualization of the oropharyngeal cavity. The
controlled.17 Hyperbaric oxygen therapy may be appropriate in a decision whether to intubate should be based on visual evidence
patient with impaired neurologic status and a markedly elevated of pharyngeal burns or swelling or carbonaceous sputum coming
carboxyhemoglobin level (≥ 25%). However, the risks (including from below the level of the vocal cords. If a patient is phonating
barotrauma) associated with isolation in a hyperbaric chamber without stridor, intubation can often be delayed. Singed facial and
may be too significant for a burn patient (≥ 10% TBSA) undergo- nasal hair does not constitute an adequate independent indication
ing resuscitation. In one study of 10 patients with combined for intubation.
inhalation injury and burns treated acutely with hyperbaric oxy- Treatment of upper airway injuries includes hospital admission
gen, seven patients survived but the complications included aspi- for observation and provision of humidified oxygen, pulmonary
ration (two cases), cardiac arrest (two cases), hypovolemia with toilet, bronchodilators as needed, and prophylactic endotracheal
metabolic acidosis (three cases), respiratory acidosis (four cases), intubation as indicated. Upper airway thermal burns usually man-
ifest within 48 hours after injury, and airway swelling can be Table 6 Mechanisms of Pulmonary Dysfunction
expected to peak at 12 to 24 hours after injury. A patient with a and Indications for Mechanical Ventilation
true upper airway burn will likely require airway protection for 72
hours. A short course of steroids may facilitate earlier resolution of Mechanism Best Indicator
airway edema in a patient with small cutaneous burns, but a
patient with a burn larger than 20% TBSA should not be treated Inadequate alveolar ventilation PaCO2 and pH
with steroids because of the risk of infection and failure to heal.
Inadequate lung expansion Tidal volume, respiratory rate, VC
The decision whether to extubate can be based on pulmonary
weaning criteria but also on the presence of an air leak around the Inadequate respiratory muscle
strength MIF; MVV; VC
endotracheal tube.
VE required to keep PCO2 normal;
Lower Airway Burn Injury Excessive work of breathing
VD/VT; respiratory rate
Burn injury to the tracheobronchial tree and the lung
Unstable ventilatory drive Breathing pattern, clinical setting
parenchyma results from combustion products in smoke [see
Table 9] and, under unique conditions, inhaled steam. Numerous Severe hypoxemia
P(A-a)O2; PaO2/PAO2; PaO2/FIO2;
Qs/Qt
irritants in smoke or the vaporized chemical reagents in steam
can cause direct mucosal injury, leading to mucosal slough and MIF—maximum inspiratory force MVV—maximum voluntary ventilation
bronchial edema, bronchoconstriction, and bronchial obstruc- P(A-a)O2—alveolar-to-arterial PO2 gradient PaO2/FIO2—ratio of arterial PO2 to inspired O2
tion. Tracheo-bronchial mucosal damage also leads to neutro- Qs/Qt—intrapulmonary right-to-left shunt fraction VC—vital capacity VD/VT —dead
space fraction VE —minute ventilation
phil chemotaxis and release of inflammatory mediators into the
lung parenchyma, accentuating the injury with exudate forma-
tion and microvascular permeability. Together, these may prog- citation failures in burn victims with concomitant inhalation
ress to pulmonary edema, pneumonia, and acute respiratory dis- injury.
tress syndrome (ARDS). Reduced myocardial contractility sec- Inhalation injury can often be a clinical diagnosis.14 Lower air-
ondary to smoke-toxin inhalation may also contribute to resus- way injury can be confirmed by bronchoscopy or xenon-133 ven-
tilation-perfusion scan,20 but these modalities do not change ther-
apeutic choices or clinical outcome.21
Table 5 Measures of Pulmonary Function
ACUTE LUNG INJURY AND ACUTE RESPIRATORY DISTRESS
SYNDROME
Abnormal Values
Measurement Normal Values Indicating Need for Understanding of the pathophysiology of ARDS has improved
Mechanical Ventilation since its initial description in the late 1960s,22 and ARDS-relat-
ed deaths were lower in the period 1995 through 1998 than in
Tidal volume (VT ), ml/kg 5–8 <5
the period 1990 through 1994; however, 40% to 70% of patients
Vital capacity (VC), ml/kg 65–75 < 10; < 15* with ARDS still die of the disease.23 ARDS is an independent
Forced expiratory volume in
risk factor for death in burn patients.24 Mortality in burn
1 sec (FEV1), ml/kg 50–60 < 10 patients with ARDS is attributable to overwhelming sepsis and
Functional residual capacity
80–100 < 50
(FRC), % of predicted value
Table 7 Clinical Manifestations of Carbon
Respiratory rate (f),
12–20 > 35
Monoxide Poisoning
breaths/min
Maximum inspiratory force Carboxyhemoglobin Level (%) Clinical Manifestations

(MIF), cm H2O 80–100 < 20; < 25; < 30*
< 10 None
Minute ventilation (VE), L/min 5–6 > 10
15–25 Nausea, headache
Maximum voluntary ventila-
tion (MVV), L/min 120–180 < 20; < (2 × VE)*
30–40 Confusion, stupor, weakness
Dead space fraction (VD/VT), % 0.25–0.40 > 0.60 40–60 Coma
PaCO2, mm Hg 36–44 > 50; > 55* > 60 Death
75–100 (breath- < 50 (room air);
PaO2, mm Hg ing room air) < 70 (mask O2)*
Alveolar-to-arterial PO2 gradi- 25–65 (breathing

Table 8 Half-life of Carbon Monoxide–Hemoglobin
> 350; > 450*
ent [P(A-a)O2], mm Hg 100% O2) Bonds with Inhalation Therapy
Arterial-alveolar PO2 ratio
0.75 < 0.15
(PaO2/PAO2) Carboxyhemoglobin Half-life Treatment Modality
Arterial PO2–inspired O2 4 hr Room air
350–450 < 200
(PaO2/FIO2), mm Hg
45–60 min 100% oxygen
Intrapulmonary right-to-left > 20%; > 25%;
≤ 5%
shunt fraction (Qs/Qt), % > 30%* 100% oxygen at 2 atm (hyperbaric
20 min
oxygen)
*More than one value indicates lack of uniform agreement in the literature.
Table 9 Clinical Findings Associated with Specific lung neutrophil sequestration, and platelet activation through
Inhaled Products of Combustion alterations in microvascular permeability. Clinical studies have
correlated infection—but not isolated inhalation injury—with
Product of
increased IL-2 levels, which reemphasizes the potential signifi-
Source Clinical Effect cance of the double insult inflicted by the combination of a burn
Combustion
and an inhalation injury.31 Some data suggest that relative imbal-
Carbon monoxide
Poor tissue oxygen ances in levels of inflammatory mediators may be more important
Organic matter delivery than absolute values.
Carbon dioxide Narcosis
An important cell in the inflammatory cycle is the pulmonary
Wood, paper, anhy-
Airway mucosal irrita- alveolar macrophage, a phagocytic cell that produces reactive oxy-
Nitrogen oxides (NO, tion, pulmonary
drous ammonia NO2) gen intermediates (ROIs) as a means of killing microorganisms. In
edema, dizziness
animal models, addition of a burn injury to a smoke insult exag-
Polyvinyl chloride Hydrogen chlorine
Airway mucosal gerates lipid peroxidation and hypoproteinemia, implicating reac-
(plastics) irritation tive oxygen species in the pathophysiology of ARDS. With sys-
Wool, silk, polyurethane Respiratory failure, temic inflammation, unchecked ROI production may lead to local
Hydrogen cyanide
(nylon) headache, coma tissue injury. ROIs damage cells by direct oxidative injury to cel-
Petroleum products Carbon monoxide,
lular proteins and nucleic acids, as well as by inducing lipid per-
Airway mucosal irrita- oxidation, which leads to the destruction of the cell membrane.
(gasoline, kerosene, nitrogen oxide,
tion, coma
propane, plastics) benzene ROIs are generated under conditions of ischemia-reperfusion (as
Airway mucosal irrita- with failed resuscitations), which occurs when the flow of oxy-
Wood, cotton, paper Aldehydes tion, lung parenchyma genated blood is restored to ischemic tissue such as unexcised
damage eschar. During ischemia, there is increased activity of xanthine oxi-
Airway mucosal dase and increased hypoxanthine production; when reperfusion
Polyurethane (nylon) Ammonia
irritation reintroduces oxygen, the xanthine oxidase and hypoxanthine gen-
erate ROIs, which cause more tissue injury.
multiple organ failure rather than to respiratory failure alone.25 Management of ARDS
Clinically, ARDS is characterized by pulmonary edema, refrac- In spite of 30 years of advances in ARDS treatment, patients
tory hypoxemia, diffuse pulmonary infiltrates, and altered lung with ARDS still must depend on mechanical respiratory sup-
compliance. Pathologically, it is distinguished by diffuse alveolar port—not treatment—as the primary therapeutic intervention
epithelial damage with microvascular permeability and subse- while the alveolar epithelium repairs itself, the capillary perme-
quent inflammatory cell infiltration into the lung parenchyma, ability resolves, and the lung heals. Restricting fluids to prevent
interstitial and alveolar edema, hyaline membrane formation, and, further edema formation has increased survival. The most encour-
ultimately, fibrosis. aging strategy to prevent lung injury and increase survival has
The development of ARDS is presaged by high fluid resuscita- been low tidal volume mechanical ventilation, commonly called
tion requirements, reflecting increased microvascular permeability lung protective ventilation, with or without high levels of positive
and leading to increased pulmonary edema. ARDS commonly end-expiratory pressure.32 Pharmacologic approaches to treating
develops within 7 days after injury. The likelihood of death is sig- ARDS in burn patients parallel those used in other critically ill sur-
nificantly increased in patients with a multiple organ dysfunction gical patients and are addressed elsewhere [see 8:4 Pulmonary
score of 8 or higher and a lung injury score of 2.76 or higher. In Insufficiency].
one review, burn patients with inhalation injury had a 73% inci- For most patients with pulmonary complications from thermal
dence of respiratory failure (with hypoxemia, multiple pulmonary injury, conventional ventilatory approaches will be adequate.
infections, or prolonged ventilator support) and a 20% incidence However, the population at risk for development of ARDS may
of ARDS, whereas patients without inhalation injury had a 5% need more sophisticated management to reduce barotrauma and
incidence of respiratory failure and a 2% incidence of ARDS.24 pulmonary infection in the minimally compliant lung with in-
Advanced age is also an important risk factor for the development creased airway pressures. In the past, conventional ventilator man-
of ARDS—indeed, one small retrospective study has suggested agement of inhalation injury and ARDS, which emphasizes nor-
that age is the only independent major predisposing factor for malization of blood gases, promoted high rates of barotrauma—
ARDS.26 Curiously, acute lung injury rarely develops in patients that is, ventilator-induced lung injury that is physiologically and
with inhalation injury but without cutaneous burns.27,28 histopathologically indistinguishable from ARDS itself. Over-
distention and cyclic inflation of injured lung exacerbates under-
Inflammatory Mediators in ARDS with Burn Injuries
lying lung injury and perpetuates systemic inflammation. These
Local and systemic inflammatory mediators released in effects can be minimized by maintaining low tidal volumes and
response to burn injury include platelet-activating factor, inter- peak pressures and by applying positive end-expiratory pressure.
leukins (IL-1, IL-2, IL-6, and IL-8), prostaglandin, thromboxane, Hence, the use of alternative modes of ventilation (e.g., volume-
leukotrienes, hematopoietic growth factors (granulocyte- limited ventilation with or without inverse-ratio ventilation, prone
macrophage colony-stimulating factor, macrophage colony-stimu- positioning, and tracheal gas insufflation) has increased in patients
lating factor, and granulocyte colony-stimulating factor), cell at risk for ARDS. No single approach is likely to benefit all pa-
adhesion molecules (intercellular cell adhesion molecule–1, tients, and adjustment of ventilatory controls must be based on
endothelial-leukocyte adhesion molecule–1, and vascular cell individual clinical responses.
adhesion molecule–1), and nitric oxide (NO).29,30 Systemic levels
of circulating tumor necrosis factor–α (TNF-α) and IL-1 correlate Lung-protective ventilation Lung-protective ventilation
with ARDS severity. IL-2 promotes multisystem organ edema, utilizes low inspiratory volumes (4 to 6 ml/kg) to keep peak inspi-
ratory pressures below 40 cm H2O. This strategy is limited by the ance of tracheobronchial casts that occlude the airway and predis-
accumulation of carbon dioxide (so-called permissive hyper- pose to pulmonary infection. Although HFPV is usually described
capnia), although respiratory acidosis with a pH as low as 7.20 is as rescue therapy for patients in whom conventional therapy has
tolerated. failed, there is some evidence that it can reduce mortality and the
The ARDS Network Study found that ARDS patients ventilat- incidence of pneumonia in patients with inhalation injury.39,40
ed with low tidal volumes had a 22% lower mortality than patients Improved oxygenation and pulmonary toilet has been reported
ventilated with conventional means.32,33 The volume-preset, assist- in patients treated early with HFPV,41 which suggests that a larg-
control mode is recommended for tidal volume control, and the er-scale prospective trial is warranted to determine whether the
respiratory rate should be slowly increased as tidal volume is benefits of HFPV justify the added cost and effort of maintain-
reduced to maintain minute ventilation and prevent acute hyper- ing multiple types of ventilators and credentialing for respiratory
capnia. Tidal volume can be increased for severe acidosis (pH ≤ therapists.
7.15).Ventilator inspiratory flow should be optimized to minimize A similar method, high-frequency oscillatory ventilation, may
dyspnea. If dyspnea results in asynchronous breaths, sedation may have no impact on burn mortality. However, it may have a role in
be necessary or the tidal volume can be titrated to 7 to 8 ml/kg, the supportive management of burn patients with severe oxygena-
provided that peak inspiratory pressures are below 40 cm H2O. tion failure that is unresponsive to conventional ventilation.42
Pressure support levels between 5 and 20 cm H2O can be titrated
to keep the respiratory rate below 35 breaths/min and may be use- Nitric oxide inhalation Endogenously produced NO plays
ful for weaning. an important role in the changes in systemic and pulmonary
One study of children with burns found that low tidal volume microvascular permeability seen in an animal model of combined
ventilation was associated with low incidences of ventilator- smoke inhalation and third-degree burn.30 Clinically, inhaled NO
induced lung injury and respiratory-related deaths,34 which sup- may be useful in burn patients with severe acute lung injury in
ports the use of this modality in thermally injured patients. In fact, whom conventional ventilatory support is failing.43 The safety of
in patients with large burns and inhalation injury, it may be war- inhaled NO in these patients is indicated by low methemoglobin
ranted to use low tidal volume ventilation before ARDS develops. levels and absence of hypotension attributable to the NO. Strong,
The early resuscitative phase may be the optimal time to initiate immediate, and sustained improvement in the PaO2/FIO2 and
this approach. reduction in pulmonary arterial mean pressure in response to NO
seem to correlate with survival. However, the use of inhaled NO
Prone positioning Changing a patient’s position from has been reported in only small numbers of burn patients, and a
supine to prone is emerging as a simple and inexpensive strategy prospective study is warranted.
to improve gas exchange in acutely injured lungs. Studies report
that despite concerns about airway protection, this is a safe inter- Corticosteroids The use of corticosteroids in the treatment of
vention that may improve the ratio of arterial oxygen pressure to burns is problematic because of the negative effect these agents
fraction of inspired oxygen (PaO2/FIO2) early in the course of have on wound healing. Nevertheless, there is some evidence that
ARDS.35 Some data suggest that prone positioning in conjunction rescue treatment with corticosteroids in the late chronic fibropro-
with NO administration may improve arterial oxygenation.36 liferative phase of ARDS may decrease mortality and lower the
However, no clinical trials have examined the use of prone posi- PaO2/FIO2.44 Ongoing multicenter studies in patients with small
tioning in burn patients. If prone positioning has a significant burns and inhalation injury are under way.
effect, this positive result presumably would be evident during
TRACHEOSTOMY VERSUS ENDOTRACHEAL INTUBATION
operative procedures when a patient with an acute lung injury is
placed in this position (e.g., for excision of a posterior torso burn). Transmural airway inflammation from inhaled gases and heat
Furthermore, prone positioning may be relatively contraindicated necessitates endotracheal airway protection, yet the use of endo-
in a patient with a burned head who is at extreme risk for loss of tracheal tubes in such cases may be complicated by tracheal pres-
control of the airway because of facial swelling and difficulty secur- sure necrosis. Hence, survivors of inhalation injury may develop
ing an endotracheal tube. laryngotracheal strictures. One report suggests that there is a 5.5%
incidence of tracheal stenosis in patients with burns and inhalation
Extracorporeal membrane oxgyenation Few centers have injury.45 The relative risks and benefits of tracheostomies and
experience with extracorporeal membrane oxygenation (ECMO), endotracheal intubation have been debated since the early 1970s.
and published information on its use for the treatment of ARDS Each modality has its own advantages and complications.
in patients with inhalation injury and burns is mostly confined to Nasotracheal intubation is the least advantageous form of airway
anecdotal case reports.37 Given its experimental nature and its protection because of its association with paranasal sinusitis,46 as
high cost, ECMO is reserved for patients in whom other ventila- well as pressure necrosis of the alar rim of the burned nose, which
tory modalities fail. Although ECMO has been shown to increase is nearly impossible to reconstruct. Therefore, nasotracheal intu-
survival in some children with large burns and severe acute lung bation should be avoided unless absolutely necessary.
injury, patients with higher ventilator requirements before under- Tracheostomies are also associated with complications, includ-
going ECMO generally do not survive, suggesting that if ECMO ing tracheal malacia, tracheal stenosis, trachea–innominate artery
is to be successful, it must be instituted early to prevent barotrau- fistulas, tracheoesophageal fistulas, and posttracheostomy dyspha-
ma and irreversible lung injury.38 Early implementation of per- gia.47 However, complications associated with tracheostomy may
missive hypercapnia may be equally effective. relate to previous long-term endotracheal intubation and to the
underlying pathophysiology, suggesting that if tracheostomy is to
High-frequency percussive ventilation High-frequency be done, it should be done early on; furthermore, the tracheosto-
percussive ventilation (HFPV) is another strategy for maintaining my tube should be removed at the earliest possible time. In a 1985
low peak pulmonary pressure and preventing alveolar overdisten- study of airway management, tracheal stenosis and tracheal scar
tion. HFPV has the added advantage of facilitating mucosal clear- granuloma formation were reported to be more frequent and
more severe after tracheostomy than after translaryngeal intuba-

tion.48 As expected, the duration of tube placement significantly
Table 10 Formulas for Estimating Caloric
affected the development of permanent damage, leading to the
conclusion that initial respiratory support with translaryngeal Needs in Burn Patients
tubes is preferable for up to 3 weeks. Burn patients who undergo
HARRIS-BENEDICT FORMULA
tracheostomy before postburn day 10 may have a lower incidence
Basal energy expenditure (BEE)* × activity factor† =
of subglottic stenosis with no difference in pneumonia incidence, calories needed daily
when compared with orally intubated patients.49 Nevertheless, tra- CURRERI FORMULA
cheostomy has been reported to provide no benefit for early extu- 25 kcal / kg + 40 kcal / %TBSA burned = calories needed daily
bation or overall outcome for burn patients.50 One major consid-
eration in deciding whether to perform a tracheostomy has been *Women: BEE = 65.5 + 9.6(weight in kg) +1.8 (height in cm) – 4.7
(age in years).
the presence of eschar at the insertion site, which complicates tra- Men: BEE = 66.5 + 13.8(weight in kg) + 5.0 (height in cm) – 6.8
cheostomy-site care and increases the risk of airway infection. (age in years).
Percutaneous dilatational tracheostomy may provide a reasonable, †For burns, the activity factor is 2, which may overestimate caloric needs for
less invasive approach for patients who are likely to need pro- patients with smaller burns.
TBSA—total body surface area
longed ventilatory support.51 This procedure can be safely per-
formed at the bedside, at one quarter the cost of a conventional
tracheostomy. Given ongoing controversies over the relative risks
and benefits of endotracheal intubation and tracheostomy in burn any type of trauma, primarily because the disease is so devastating
patients and the rarity of complications from intubation in our and its prevention so simple. There are a few cases in modern
own practice, we perform tracheostomies only when multiple medical literature of tetanus in patients who had received immu-
attempts at extubation have failed; these failures usually occur nization during childhood.56
because the patients cannot protect their airway. For many years, all patients admitted with burn injuries received
antibiotic prophylaxis against gram-positive organisms. This prac-
tice often led to the development of gram-negative bacterial infec-
Temperature Regulation tions or, even worse, fungal infections. Studies have now verified
Because the burn patient has lost the barrier function of the that prophylactic antibiotics not only are unnecessary but may well
skin, temperature regulation is an important goal of successful be contraindicated in patients with burns.57 Therefore, treatment
management. Keeping a patient warm and dry is a major goal dur- of infections in patients with burns should be based on clinical
ing resuscitation, especially during the pre–burn center transport judgment and supportive laboratory and radiologic findings.
of patients. This includes maintaining a warm ambient tempera- The wound is a primary source of infection for patients with
ture. Large evaporative losses52 combined with administration of burns [see 7:14 Management of the Burn Wound]. The mainstay of
large volumes of intravenous fluids that are at room temperature both prevention and treatment is daily washing with soap and
or colder may accentuate the hypovolemia, which will complicate water and application of a topical broad-spectrum antimicrobial
the patient’s overall course and may lead to disseminated intravas- agent. As soon as it becomes evident that a burn wound will not
cular coagulopathy. Mild hyperthermia may occur in the first 24 heal, excision and grafting should be performed. Preferably, the
hours as a result of pyrogen release or increased metabolic rate53 decision to proceed with surgery should be made before postburn
and may cause tachycardia that misleadingly suggests hypovo- day 21. For patients who undergo surgery, perioperative antibi-
lemia. Because infection is unlikely early on, especially within the otics may reduce postoperative wound infection.57
first 72 hours after injury, elevated temperatures should be treated
with antipyrogens to control the energy expenditure associated Nutrition
with increased catabolism.54 About 72 hours after injury, patients
with thermal injuries commonly develop a hyperdynamic state, the In the early 1970s, Curreri and others recognized that patients
systemic inflammatory response syndrome (SIRS), which is char- with major thermal injury experience hypermetabolism, with an
acterized by tachycardia, hypotension, and hyperthermia—classic increased basal metabolic rate, increased oxygen consumption,
signs of sepsis that in this case do not have an infectious source. negative nitrogen balance, and weight loss; hence, these patients
Although patients with burns are likely to have elevated tem- have exaggerated caloric requirements.58 Furthermore, inade-
peratures and may even have elevated white blood cell counts, quate caloric intake can be associated with delayed wound heal-
fevers in burn patients are not reliable indicators of infections.55 ing, decreased immune competence, and cellular dysfunction.
At least one study has demonstrated that in pediatric burn A patient with a large burn may lose as much as 30 g of nitro-
patients, physical examination is the most reliable tool for evaluat- gen a day because of protein catabolism. Not only is urinary excre-
ing the source of fever.55 tion of urea nitrogen increased, but large amounts of nitrogen are
lost from the wound itself.Therefore, total urea nitrogen levels do
not accurately reflect all nitrogen losses in burn patients.59 A
Infection Control patient with a small burn (≤ 10% TBSA) may lose nitrogen at a
Infection is a major potential problem for patients with large rate of 0.02 g/kg/day. A moderate burn (11% to 29% TBSA) may
thermal injuries. In one review, up to 100% of such patients be associated with nitrogen losses equaling 0.05 g/kg/day. A large
developed an infection from one or more sources during the hos- burn (≥ 30% TBSA) may result in the loss of as much as 0.12
pital stay. It is important to apply sound epidemiologic practice g/kg/day, which may be equivalent to daily losses of 190 g of pro-
to treating infections, both to limit development of opportunis- tein or about 300 g of muscle.
tic infections in individual patients and to achieve good infection Catabolism generally continues until wounds have healed.
control in the burn unit itself. However, once a patient becomes anabolic, preburn muscle takes
Tetanus prophylaxis has been standard for patients admitted for three times as long to regain as it took to lose.60,61 Therefore, a
patient in whom it takes 1 month for burn wounds and donor sites feeding.73 Hence, for burn patients with high caloric needs, the
to heal may need 3 or more months to regain preburn weight and benefit of decreased aspiration with transpyloric feeds may only be
muscle mass. These statistics underscore the importance of accu- theoretical and may be offset by the delay in feeding for confirma-
rately estimating each patient’s caloric needs during hospitalization of tube placement; such confirmation is necessary because
tion. Over the years, a number of equations have been developed these tubes can easily flip back into the stomach.
to estimate calorie needs [see Table 10]. Probably the most widely Continuation of tube feedings during surgery in intubated
used formula is the Harris-Benedict equation, which estimates patients who require multiple operations is a safe way to maximize
basal energy expenditure according to gender, age, height, and caloric intake and decrease wound infection. There is no need to
weight. The basal energy expenditure is then multiplied by an stop feedings for anesthesia induction and endotracheal intuba-
activity factor that reflects the severity of injury or the degree of ill- tion74; however, intraoperative positioning, especially if the patient
ness; for burns, this multiplier is 2, the maximal factor for this for- will be prone during surgery, may necessitate stopping feedings
mula.The limitation of the Harris-Benedict equation is that it may preoperatively. Mayes and colleagues have presented data that
overestimate caloric needs for patients with burns smaller than support continuation of tube feedings in critically ill burn patients
40% TBSA. A formula specific for patients with burns is the undergoing decompressive laparotomy.75
Curreri formula,62 which is based on patient weight and burn size;
GLUCOSE LEVELS
this formula may overestimate caloric needs for patients with large
burns and therefore is best used for patients with burns less than The adverse effects of hyperglycemia on wound healing and
40% TBSA.63,64 morbidity highlight the importance of maintaining blood glucose
Ongoing evaluation of metabolic status of the burn patient is levels at 80 to 110 mg/dl.76 In pediatric burn patients, poor glucose
necessary to take into account changes in wound size and clinical control has been associated with bacteremia, reduced skin-graft
condition. Metabolic demands decrease with burn healing or graft- take, and higher mortality.77
ing; on the other hand, donor sites create new wounds, which may
ALBUMIN LEVELS
increase catabolic rates. Development of infection or ARDS great-
ly increases catabolism and may alter caloric needs.65 Simple Burn patients characteristically have hypoalbuminemia that per-
assessment of nitrogen requirements can be determined by mea- sists until wounds are healed and the rehabilitation phase of recov-
suring 24-hour total urea nitrogen levels in the urine. However, this ery has begun. In fact, patients with large burns have serum albu-
does not account for nitrogen lost from the wound itself. Serum min levels that average 1.7 g/dl and never exceed 2.5 g/dl.66
albumin levels are notoriously unreliable markers of adequate Management of hypoalbuminemia is controversial, but there is
nutrition because they lag behind clinical progress; they are espe- general agreement that once burn resuscitation is complete, infu-
cially known to be low in patients with burns larger than 20% sion of exogenous albumin to serum levels above 1.5 g/dl does not
TBSA.66 Transthyretin (also known as prealbumin, although it is affect burn patient length of stay, complication rate, or mortality.78
not related to albumin in structure or function) levels correlate NUTRITIONAL SUPPLEMENTS
more closely with catabolic status,67 and a trend over several weeks
may indicate whether the patient’s caloric needs are being met.68 Specialized nutritional formulas with purported effects on
C-reactive protein levels also provide an indication of the patient’s metabolic rate and immunologic status have garnered a great deal
general inflammatory state; high levels may correlate with increased of interest as adjuncts in the management of critically ill and
catabolism.67 For intubated patients, indirect calorimetry may be injured patients.79 Much of the information on nutritional require-
helpful in measuring caloric needs but may not be more exact than ments for critically ill patients was derived from an animal burn
the Curreri formula.69 The so-called metabolic cart is a portable model,80 however, and studies on the efficacy of specialized nutri-
gas analyzer that quantifies volumes of inspired O2 and expired tional supplements in humans have generated contradictory data.
CO2 and calculates nutritional requirements according to the fol- A randomized trial of nutritional formulas that were intended to
lowing formula: enhance immune status and that included essential amino acids
and omega-3 fatty acids showed no clinical advantage in burn
kcal/day = ([3.9 × VO2] + [1.1 × VCO2]) × 1.44 patients.81 However, another study demonstrated that glutamine
This result can also be indirectly measured in patients with pul- supplementation in adult burn patients resulted in significantly
monary artery catheters in place by using the Fick equation: lower mortality and infection rates.82 Other nutritional or meta-
bolically active supplements that have demonstrated promise in
kcal/day = cardiac output × (arterial PO2 − venous PO2) × 10 × 6.96 promoting anabolism in burn patients include insulin, recombi-
ENTERAL NUTRITION
nant human growth factor, the anabolic steroid oxandrolone, and
propranolol.83 Oxandrolone in particular has produced marked
As early as 1976, the benefits of enteral nutrition over parenter- improvements in weight gain, return to function, and length of
al nutrition had already been identified for patients with function- hospital stay.84 Early administration of antioxidant supplementa-
al gastrointestinal systems.70 The problems of prolonged ileus and tion with α-tocopherol and ascorbic acid has been shown to reduce
Curling stress ulcers in burn patients have been largely eliminated the incidence of organ failure and shorten ICU length of stay in
by early feeding.71 Multiple studies have shown that patients with critically ill surgical patients.85 Whether this is true for burn
major thermal injury can receive adequate calories within 72 hours patients remains to be demonstrated, but the relative low cost and
after injury.72 At the University of Washington burn center, tube the low risk of complications make this an attractive intervention
feeding is started a median of 5 hours after admission. for burn patients at risk for ARDS.
There is ongoing debate about the benefits of gastric feeding
versus duodenal feeding. Although feeding distal to the pylorus
should pose less aspiration risk, one study found evidence of enter- Anemia
al formula in pulmonary secretions of 7% of patients receiving gas- Because acute blood loss is uncommon in a patient with an iso-
tric feeds compared with 13% of patients receiving transpyloric lated burn injury, a rapidly decreasing hematocrit during resusci-
tation should prompt an evaluation for associated injuries. oral narcotics or transmucosal fentanyl citrate90 work well for
Procedures during resuscitation, such as central venous line place- wound care; I.V. morphine or fentanyl is used for uncontrolled
ment or escharotomies, should not be associated with significant pain. For outpatients, oxycodone (5 to 15 mg) works well for daily
blood loss. wound care.
Anemia was a major problem in burn management before early Anxiety related to wound care is an underdiagnosed and under-
excision and grafting became commonplace. As excision tech- treated source of discomfort that is often construed as pain, espe-
niques have become more sophisticated [see 7:14 Management of cially in children. Therefore, patients with large burns requiring
the Burn Wound], operative blood loss has decreased, as has the wound care once or twice a day should be evaluated to determine
need for transfusion.86,87 Nevertheless, excision and grafting may whether they would benefit from a short-acting anxiolytic agent
be associated with large blood loss, and the operating team must for procedures.
be prepared for intraoperative blood transfusion. Learning to accurately assess pain in burn patients can help pre-
Decisions about transfusion must be based on the patient’s age, vent complications related to excessive narcotic use, such as pro-
overall condition, and comorbidity. The risks of viral transmission longed sedation, delirium, and, more urgently, loss of airway con-
and transfusion reactions, as well as the cost, must also be careful- trol. This is especially true in young children and elderly patients,
ly considered. For an otherwise healthy patient who does not need who may have decreased ability to tolerate narcotics.91,92
surgery, a hematocrit as low as 20% may be tolerated. However, Nonpharmacologic approaches are also an important compo-
patients with inhalation injury or ARDS may benefit from the nent of pain management in burn patients. Hypnosis—adminis-
greater oxygen-carrying capacity afforded by a higher hematocrit. tered either by trained health care providers or, more efficiently, by
Patients with large burns and anticipated blood loss during hospi- patients themselves—has proved to be a useful tool for reducing
talization should probably receive iron supplements. narcotic use in patients with burns.93 Another distraction modali-
Given that the literature contains some indication that erythro- ty that has shown promise and garnered significant publicity has
poietin levels may be elevated in patients with large burns, the ben- been virtual reality. Although it is not a standard of care for all
efit of exogenous erythropoietin is debatable.88 At least one pro- patients admitted with burn injuries, preliminary observations
spective study suggests that administration of recombinant eryth- suggest that use of virtual reality can enhance patient comfort dur-
ropoietin in acutely burned patients does not prevent anemia or ing wound care and intense therapy.
decrease transfusion requirements.89 Discomfort in the healed wound may persist for months after
injury. In general, narcotics do not control such symptoms; exer-
cise and deep massage are more effective. Itching can be a perva-
Pain Management sive long-term symptom for which there is no reliable topical or
Pain management for patients with burn injuries can be chal- systemic therapy. Diphenhydramine, cyproheptadine, or cetirizine
lenging.The simplest approaches work best; polypharmacy is like- may relieve itching. There are also promising data on the use of
ly to confuse both patient and health care providers and should doxepin ointment as a topical treatment for itching of healed
therefore be avoided. Burn patients experience several different wounds.94 Keeping the wound moist with a topical salve may be as
classes of pain: background, breakthrough, and procedural. Each effective as other pharmacologic approaches.
responds to a different approach.
Background pain is the discomfort that burn patients experi-
ence throughout the day and night. It is best treated with long-act- Deep Vein Thrombosis Prophylaxis
ing pain relievers. For a hospitalized patient with large burns, The incidence of deep vein thrombosis (DVT) and, thus, the
methadone or controlled-release morphine sulfate may be the need for DVT prophylaxis in patients with thermal injury have
most appropriate choice for background pain. In an outpatient never been clearly defined. Whereas some studies report DVT in
with a small burn, a nonsteroidal anti-inflammatory drug (NSAID) as many as 25% of all hospitalized burn patients and advocate
may be optimal; if excision and grafting are planned, the NSAID DVT prophylaxis,95 others report that thromboembolism is re-
should be stopped at least 7 days before surgery to permit recov- sponsible for only 0.14% of deaths in burn patients and does not
ery of platelet function. warrant the potential complications of anticoagulation therapy.96
Breakthrough pain results when activities of daily living exacer- At the University of Washington burn center, a quality-assurance
bate burn-wound discomfort. Short-acting narcotics or aceta- review found that in patients with burns larger than 20% TBSA,
minophen are used to alleviate breakthrough pain. Persistent clinically evident thromboembolic disease occurred in 9% of those
breakthrough pain indicates that the dose of the long-acting med- who received prophylaxis with unfractionated heparin and in 18%
ication should be increased. of those who received low-molecular-weight heparin. On the basis
Procedural pain is the discomfort that patients experience dur- of these data, patients with burns larger than 20% TBSA receive
ing wound care and dressing changes. This usually requires treat- prophylaxis with subcutaneous unfractionated heparin, 5,000 U
ment with a short-acting narcotic. For inpatients with larger burns, twice a day.
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7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE BURN WOUNS — 1
14 MANAGEMENT OF THE
BURN WOUND
Matthew B. Klein, M.D., David Heimbach, M.D., F.A.C.S., and Nicole Gibran, M.D., F.A.C.S.
Advances in resuscitation and critical care have significantly The fibroblast is the principal cell of the dermis and is respon-
improved survival after thermal injury. Ultimately, survival sible for synthesis and degradation of fibrous and elastic dermal
remains contingent on effective wound management and com- proteins. The dermis also contains various inflammatory cells
plete wound closure. Current approaches to burn management (derived from bone marrow stem cells), mast cells, and cells asso-
are based on an understanding of the biology and physiology of ciated with vascular, lymphatic, and nervous tissue.
human skin and the pathophysiology of the burn wound. The BMZ is a complex region of extracellular matrix con-
necting the basal cells of the epidermis with the papillary dermis.
At the light-microscopic level, the dermal-epidermal junction
Anatomic and Physiologic Considerations consists of protrusions of dermal connective tissue known as
dermal papillae, which interdigitate with epidermal projections
BIOLOGY OF SKIN
known as rete ridges. The structure of the BMZ is best appreci-
Skin consists of two distinct layers, the epidermis and the dermis; ated on electron microscopy, where it appears as a trilaminar
these layers are integrated by a structure known as the basement zone consisting of a central electron-dense region (the lamina
membrane zone (BMZ) [see Figure 1]. The epidermis is the outer densa) flanked on both sides by regions of lower electron densi-
layer and acts as the barrier between body tissues and the environ- ty [see Figure 2]. Within the basal cells of the epidermis are mul-
ment. This layer protects against infection, ultraviolet light, and tiple sites of attachment to the basal lamina, which are known as
evaporation of fluids and provides thermal regulation. The epider- hemidesmosomes. On the dermal side of the basal lamina are
mis is derived from fetal ectoderm and thus, like other ectodermal numerous anchoring fibrils, which reach from the lamina into
derivatives, is capable of regeneration. Repair of epidermal wounds the connective tissue of the dermis.1 The BMZ plays a significant
is achieved through regeneration of epidermal cells both from the role in burn wound healing: epithelialized wounds undergo blis-
perimeter of the wound and from the adnexal structures of the epi-
dermis (i.e., hair follicles, sweat glands, and sebaceous glands).
Accordingly, pure epidermal injuries heal without scarring.1
The principal cell of the epidermis is the keratinocyte. These
cells are arranged into five progressively differentiated layers, or
strata: the stratum basale, the stratum spinosum, the stratum
granulosum, the stratum lucidum, and the stratum corneum.The
outermost of these layers—the relatively impermeable stratum
corneum—provides the barrier mechanism that protects the
underlying tissues. Besides keratinocytes, the epidermis contains
cells from other embryologic layers that carry out specific func-
Epidermis
tions. Melanocytes, derived from fetal neuroectoderm, produce
melanosomes, which become pigmented as a result of the forma-
tion of melanin through the action of the enzyme tyrosinase. Papillary
Melanin provides the skin with its pigment and absorbs harmful Dermis
ultraviolet radiation. Langerhans cells, derived from bone marrow
cells, play a critical role in the immune function of the skin.These
Dermis
cells recognize, phagocytize, process, and present foreign antigens
and, through their expression of class II antigens, initiate the rejec-
tion process in skin transplantation.1
In contrast to the epidermis, the dermis is a complex network Reticular
comprising cellular and acellular components. This layer provides Dermis
skin with its durability and elasticity. Structurally, the dermis con-
sists of two sublayers, a superficial one (the papillary dermis) and a
deeper one (the reticular dermis). Collagen is the major structural Subcutaneous
matrix molecule, constituting approximately 70% of the skin’s dry Tissue
weight. Elastic fibers account for approximately 2% of the skin’s
dry weight and play an important role in maintaining the integrity
of the skin after mechanical perturbation.1 Glycosaminoglycans
(GAGs), the third major extracellular component of the dermis, Figure 1 Cross-sectional diagram shows the two distinct layers
regulate intracellular and intercellular events by binding to, releas- of the skin—the epidermis and the dermis (papillary and reticu-
ing, and neutralizing cytokines and growth factors.2,3 lar)—and the underlying subcutaneous fat.
Table 1 Overview of Burn Wound Management
Basal Keratinocyte Burn Wound Type Clinical Features Management
Cell Superficial Erythematous, painful Soothing, moisturizing

Membrane lotions (i.e., aloe)
Silver sulfadiazine;
BP230 BP180 α6 β4 Partial-thickness Blistered, pink, moist, greasy gauze once
painful epithelial buds are
Hemidesmosome present
Silver sulfadiazine dress-

ings daily; surgical
Deep partial-thickness Dry, mottled pink-and- excision and grafting if
white, less painful not going to heal within
3 wk
Intermediate Lamina
Filament Lucida Silver sulfadiazine; early
Full-thickness Dry, leathery, black or
excision and skin
Laminin 5 white, painless
Lamina grafting
Densa B
Type IV
Collagen
ed.The zone of coagulation is surrounded by the zone of stasis, an
Anchoring Sublamina area characterized by vasoconstriction and ischemia. Tissue in this
Fibril (Type VII Densa zone is initially viable; however, it may convert to coagulation as a
Collagen)
consequence of the development of edema, infection, and
decreased perfusion.4 With good wound perfusion, tissue in the
zone of stasis generally remains viable. Surrounding the zone of sta-
Figure 2 The basement membrane zone (BMZ) integrates the sis is the zone of hyperemia, an area characterized by vasodilation
epidermis with the underlying dermis. On electron microscopy, resulting from the release of inflammatory mediators from resident
the BMZ has three layers: a central electron-dense region known cutaneous cells.Tissue in this zone typically remains viable.
as the lamina densa and two regions of lower electron density to
either side of this central region.
Clinical Evaluation and Initial Care of Burn Wound
tering until the anchoring structures of the BMZ mature and After admission to the burn center, the burn wound is cleaned
provide protection from shearing. with soap and water, blisters and debris are removed, and the
extent and depth of the wound are assessed. Management of tar
PATHOPHYSIOLOGY OF THERMAL INJURY burns warrants special mention.When tar that has been heated to
Jackson’s classification of burn wounds remains the foundation maintain a liquid form comes into contact with skin, it can trans-
of our understanding of the pathophysiology of thermal injury to fer sufficient energy to cause a significant burn injury. As the tar
the skin.4 In this classification, there are three zones of tissue injury cools on the skin, it solidifies, thereby becoming difficult to
resulting from a burn [see Figure 3].The central, most severely dam- remove. Solvents such as petrolatum, petrolatum-based oint-
aged area is called the zone of coagulation because the cells in this ments, lanolin, and Medi-Sol (Orange-Sol, Inc., Gilbert, Arizona)
area are coagulated or necrotic.Tissue in this zone must be debrid- are useful for tar removal. For optimal effect, 10 to 15 minutes
should be allowed after solvent application before removal of the
tar is attempted. Repeat applications may be necessary for com-
plete removal.
ASSESSMENT OF BURN DEPTH
Thermal injury can damage the epidermis alone, the epidermis

along with a portion of the dermis, or the entire skin and can even
extend into the underlying subcutaneous tissue.The depth of the
injury affects the subsequent healing of the wound; thus, assess-
ment of burn wound depth is important for selection of wound
dressings and, ultimately, for determination of the need for
surgery [see Table 1].
Superficial burns involve only the epidermis.They typically are
erythematous and painful, much as a sunburn would be. Most
such burns heal within 3 to 4 days, without scarring. The usual
treatment is a soothing moisturizing lotion (e.g., one containing
aloe vera), which both optimizes the rate of reepithelialization and
provides comfort to the patient.
Partial-thickness burns extend through the epidermis and into
Figure 3 A burn wound is characterized by three zones of the papillary dermis. Blistering is their hallmark [see Figure 4].
injury: A represents the zone of coagulation, B the zone of stasis, These burns can be further categorized as superficial or deep.
and C the zone of hyperemia. Superficial partial-thickness burns are typically pink, moist, and
Figure 4 Shown at left is a shallow scald burn with the pink, moist appearance typical of a superficial par-
tial-thickness burn wound. Such injuries typically heal without the need for excision and grafting. A superfi-
cial partial-thickness burn (right, a), which involves only the papillary dermis, is visually distinct from a deep
partial-thickness burn (right, b), which is mottled in appearance, extends into the reticular dermis, and is
more likely to require excision and grafting.
painful.They usually heal within 2 to 3 weeks, without scarring or escharotomies are necessary. In general, escharotomies are
functional impairment. Deep partial-thickness wounds extend into required only for circumferential full-thickness extremity burns in
the reticular layer of the dermis.They are typically a mottled pink- which distal perfusion has been compromised or for chest burns
and-white, dry, and variably painful. In some cases, they may be in which eschar poses an external mechanical barrier to respira-
difficult to distinguish from full-thickness burns. Deep partial- tion. Escharotomies can be performed at the bedside with either a
thickness burn wounds, if they do not become infected, typically scalpel or an electrocautery. They should extend through the
heal in 3 to 8 weeks, with severe scarring, contraction, and loss of eschar only, not through the muscle fascia. Adequate release is sig-
function.Therefore, if a partial-thickness burn has not healed by 3 naled by separation of the eschar, improved distal perfusion, and,
weeks, surgical excision and skin grafting may be required. sometimes, a popping sound. Because an escharotomy is a super-
Full-thickness burn wounds extend through the entire dermis ficial incision through dead tissue, only minimal doses of anal-
and into the subcutaneous tissue. These burns are typically white gesics and anxiolytics are required.
or black, dry, and painless [see Figure 5]. Some full-thickness burns
DAILY BURN WOUND CARE
appear red, but they can be distinguished from superficial burns
because they are not moist and do not blanch with pressure. The use of hydrotherapy tanks, previously a standard compo-
Because all skin appendages are burned away, full-thickness burns nent of burn unit wound care, has fallen from favor somewhat
can heal only by contraction or migration of keratinocytes from because of the risks of cross-contamination between one burn
the periphery of the wound. Accordingly, all full-thickness burns, wound area and another. It is preferable to place the patient on a
unless they are quite small (e.g., the size of a quarter or smaller),
must be treated with excision and grafting.
As a rule, both superficial and full-thickness burns are easily rec-
ognized, and treatment decisions are relatively straightforward. It is
frequently difficult, however, to determine the ultimate fate of
intermediate partial-thickness burns soon after injury. For this rea-
son, these wounds are often referred to as indeterminate-thickness
wounds. Over the course of the first several postburn days, it usu-
ally becomes easier to determine which indeterminate-thickness
wounds are likely to heal in a timely manner, without the need for
grafting.
Various techniques for accurately and readily assessing burn
depth have been described, including the use of vital dyes, laser
flowmetry, thermography, and magnetic resonance imaging, but
none of these has ever been shown to yield a more precise deter-
mination of burn depth than clinical evaluation by an experienced
burn care provider.5
DETERMINATION OF NEED FOR ESCHAROTOMY
Burn wound eschar consists of dead skin, has the consistency of Figure 5 Shown is a full-thickness flame burn with a character-
leather, and may restrict limb perfusion by creating a nonelastic istic brown, leathery appearance. Such wounds require excision
exoskeleton. A key issue in assessing burn wounds is whether and subsequent skin grafting.
Topical Burn Wound Treatment

GENERAL PRINCIPLES
Because thermal injury disrupts the protective barrier function

of the skin, dressings are needed to protect the body against envi-
ronmental flora. Burn dressings also protect against evaporative
heat loss.The ideal burn dressing would be inexpensive and com-
fortable and would not require frequent changing. Daily dressing
changes allow the burn care provider not only to apply clean dress-
ings but also to clean the wounds and debride fragments of sepa-
rated eschar and devitalized tissue.
Numerous topical agents and dressings are available for use in
burn patients; we limit our discussion to the ones that are most
commonly employed and have proved most effective. Selection of
an appropriate dressing for a given wound is governed by the spe-
cific goals of management.With purely superficial wounds, the goal
is to create a moist environment that will optimize reepithelializa-
tion. Typically, this is achieved by applying ointments or lotions.
With partial-thickness and full-thickness wounds, however, it is
necessary to include agents that protect against microbial coloniza-
tion (see below). Once a partial-thickness burn demonstrates evi-
dence of epithelialization, dressings should be changed to a regi-
men that facilitates healing (e.g., greasy gauze with ointment).
ANTIMICROBIAL AGENTS
It must be emphasized that systemic antibiotic prophylaxis plays

no role in the management of acute burn wounds and provides no
protection against microbial colonization of burn eschar6; in fact,
use of prophylactic antibiotics in burn patients increases the risk
that opportunistic infections will develop. Because eschar has no
microcirculation, it is impossible for systemically administered
Figure 6 Shower tables are generally preferred to Hubbard
tanks for burn wound care. A clean plastic drape can be used to antibiotics to reach the eschar surface, where colonization occurs.
cover the shower table during patient care. Therefore, topical preparations, which are capable of supplying
high concentrations of antimicrobial agents at the wound surface,
must be used. In the early postburn period, the dominant coloniz-
shower table, which is inclined so that water runs off the wounds ing organisms are staphylococci and streptococci—typical skin
and into a drain [see Figure 6]. Smaller wounds can often be man- flora. Over time, however, the burn wound becomes colonized with
aged with bedside wound care after a shower. Washing with tap gram-negative organisms.5 Thus, topical antimicrobial agents used
water and regular soap suffices for daily burn wound cleansing. It in early burn care should have broad-spectrum coverage to mini-
is important to be cognizant of the need to provide adequate seda- mize colonization of the wound, but they need not be able to pen-
tion and analgesia while performing daily wound care—a particu- etrate the burn eschar deeply.
larly challenging task with infants and elderly patients. Of the antimicrobial agents used in this setting [see Table 2], sil-
Table 2 Topical Antimicrobial Agents Used in Burn Care
Agent Antimicrobial Coverage Advantages Disadvantages/Precautions
Bacitracin Gram-positive bacterial Soothes and moisturizes; good for facial Not appropriate for deeper wounds
care and epithelializing wounds
Broad-spectrum antibacterial; Penetrates eschar well; available as solu- Painful on application; causes metabolic
Mafenide acidosis (via carbonic anhydrase
anticlostridial tion or cream
inhibition)
Mupirocin Anti-MRSA Effective against MRSA Narrow (poor gram-negative) antimicro-

bial coverage
Provides fungal prophylaxis with swish-

Nystatin Antifungal (Candida) May interfere with activity of mafenide
and-swallow solution
Penetrates eschar poorly; causes

Effective for both prophylaxis and treat-
Silver nitrate Broad-spectrum antibacterial hyponatremia; stains linen and dress-
ment of wound infection
ings; induces methemoglobinemia
Broad-spectrum antibacterial; Soothes on application and causes no Penetrates eschar poorly; causes
Silver sulfadiazine
antipseudomonal pain leukopenia
ver sulfadiazine is the one most commonly employed for partial- grafts. With burn wounds, the Acticoat dressing is typically
thickness and full-thickness burns. Silver sulfadiazine is soothing on changed every 3 days.The reduced frequency of dressing changes
application and is active against a broad spectrum of microorgan- simplifies burn care somewhat but can hinder evaluation of evolv-
isms. Because it does not penetrate eschar, very little is systemical- ing partial-thickness burns. With donor sites, Acticoat can be left
ly absorbed; therefore, it is ineffective against already established in place until the underlying partial-thickness wound heals.
burn wound infections.Wounds treated with silver sulfadiazine may Typically, an adhesive tape such as Hypafix (Smith & Nephew) is
form a tenacious yellow-gray pseudoeschar, which can be mistak- used to secure the dressing to the donor site for 7 days. Once the
en for true eschar.This pseudoeschar develops when silver sulfadi- tape has been removed, the Acticoat usually is sufficiently adher-
azine combines with the wound exudates; it can be gently debrid- ent to allow patients to shower daily and towel-dry the dressing
ed during daily wound care. It has been suggested that silver sulfa- until it eventually peels off the healed wound.The development of
diazine may be responsible for the leukopenia that sometimes Acticoat has led to the introduction of several other silver-based
develops during the first week after a major burn. This attribution dressings.
may not be entirely accurate, however, given that this leukopenia Bacitracin, neomycin, and polymyxin B have all been used for
may also develop in patients treated with silver nitrate. It is possible coverage of superficial wounds in conjunction with Xeroform or
that the leukopenia results not from either agent but from the mar- petrolatum gauze to accelerate epithelialization and minimize col-
gination of neutrophils secondary to the pathophysiology of the onization. These ointments also are commonly administered sev-
burn injury itself. In any case, the leukopenia is typically self-limit- eral times daily in the care of superficial face burns. Mupirocin has
ed and necessitates no change in therapy. Patients with a history of proved effective in treating methicillin-resistant Staphylococcus
sulfa allergy typically do not have adverse reactions to silver sulfa- aureus (MRSA) colonization; however, because of the potential for
diazine; however, if there is concern about a possible reaction, a test the development of bacterial resistance, it should be employed
patch can be applied to a small area of the wound. If the patient is only in MRSA-positive wounds.
allergic, silver sulfadiazine will cause pain on application or, in
some case, a rash.
Mafenide acetate is also commonly used in the management of Surgical Burn Wound Management
burn wounds. It provides excellent coverage against gram-negative As noted [see Clinical Evaluation and Initial Care of Burn
organisms, but it is not as active against staphylococci and has no Wound, Assessment of Burn Depth, above], superficial burns and
antifungal activity. Unlike silver sulfadiazine, mafenide penetrates superficial partial-thickness burns typically heal without any need
eschar very well, and this ability makes it effective in treating as for surgical excision and grafting. Dressing changes and daily
well as preventing burn wound infections. Mafenide does, howev- wound care can remove necrotic debris and provide an environ-
er, have some drawbacks. Because it is a potent carbonic anhy- ment conducive to healing in a timely fashion (2 to 3 weeks), with
drase inhibitor, regular use and the consequent ongoing systemic minimal scarring. For deep partial-thickness and full-thickness
absorption can lead to metabolic acidosis. In addition, because it burns, however, operative debridement with subsequent skin graft
is so well absorbed, twice-daily administration is necessary. Finally, coverage is necessary. Timely removal of eschar is critical for suc-
topical application of mafenide, particularly to partial-thickness cessful management. Surgical excision removes necrotic tissue
burns, is painful, which limits its utility in the routine management that serves as a nidus for microbial proliferation and the develop-
of burn wounds. Mafenide is frequently used on the ears and the ment of burn wound sepsis.8
nose because of its ability to penetrate eschar and protect against
EARLY EXCISION AND GRAFTING
suppurative chondritis; however, silver sulfadiazine appears to be
equally effective in this setting.7 Mafenide is available both as a Surgical excision of burn wounds is a concept whose impor-
cream and as a solution. The solution is useful as a topical agent tance was not fully appreciated until the 1970s. Previously, the
for skin grafts when the wound bed is considered likely to benefit usual practice was to leave eschar intact over the wound surface,
from postoperative antimicrobial treatment. the idea being that proteolytic enzymes produced by migrating
Silver nitrate provides broad-spectrum antimicrobial coverage, neutrophils and bacteria within the contaminated eschar would
including good activity against staphylococci and gram-negative cause a natural separation of the eschar from the wound bed
organisms (e.g., Pseudomonas). It is relatively painless on adminis- (sloughing) and that the resulting granulating wound would serve
tration and must be reapplied every 4 hours to keep the dressings as the bed for grafting.9 The rationale for delaying surgical man-
moist. It does not readily penetrate eschar. Silver nitrate is used in agement was it would presumably allow the burn care provider
the form of a 0.5% solution, which is bacteriostatic but is not toxic time to determine which wounds would heal spontaneously and
to epithelial cells.The hypotonic formulation (it is reconstituted in which would have to be covered with skin grafts. It has since
water) can cause osmolar dilution, resulting in hyponatremia and become clear, however, that in cases of extensive burn injury,
hypochloremia.Therefore, careful electrolyte monitoring and dili- delayed management results in more extensive bacterial coloniza-
gent replacement are necessary. In rare cases, use of silver nitrate tion, as well as an increased likelihood of burn wound sepsis, mul-
solution can also lead to methemoglobinemia; if this condition is tiple organ failure, and, ultimately, death.9
detected, administration of silver nitrate should be discontinued. Early excision and skin grafting of small burn wounds were first
A principal disadvantage of silver nitrate solution is that it stains described by Lusgarten in 1891. After the Cocoanut Grove fire in
everything it touches black. 1942, Cope suggested that patients treated with early excision and
Acticoat (Smith & Nephew, London, England), a relatively new grafting had better overall outcomes.10 In 1960, Jackson and asso-
antimicrobial dressing, consists of a polyethylene mesh impreg- ciates reported discouraging results with early burn wound exci-
nated with elemental silver. Silver has unique antimicrobial prop- sion,11 and it was not until 10 years later, when Janzekovic report-
erties and works by disrupting bacterial cellular respiration. ed good results with surgical burn wound excision,12 that enthusi-
Acticoat has been successfully used for coverage of partial-thick- asm for early excision was rekindled. As clinical experience with
ness burns, as well as for coverage of donor sites and meshed skin early excision was accumulated, the benefits became clear.
Since Janzekovic’s report, studies have repeatedly shown that

early wound excision and closure improve survival, reduce the
infection rate, and shorten hospital stay.13-24 Other studies have
demonstrated that early removal of dead and severely damaged
tissue interrupts and attenuates the systemic inflammatory
response syndrome (SIRS).8,25 Early excision of deep burn
wounds also appears to decrease hypertrophic scarring. Similarly,
early excision and grafting have been shown to be beneficial for
burns of indeterminate depth as well. In one study of patients with
burns covering less than 20% of their total body surface area
(TBSA), early excision and grafting reduced length of stay, cost of
care, and time away from work in comparison with nonoperative
treatment.17
Wound Excision
Early staged excision, beginning as early as postburn day 3 if
feasible, is now conventional treatment for major burns.
Operations are spaced 2 to 3 days apart until all eschar is removed
and full wound coverage is achieved. Debrided wounds can be
temporarily covered with biologic dressings or cadaveric allograft Figure 7 Fascial excision involves excision of the burned skin and
until autogenous donor sites are available. the underlying subcutaneous tissue down to the level of the muscle
Generally, the decision whether to perform operative wound fascia. It is typically performed with the electrocautery. As shown
excision is guided by whether spontaneous wound healing is like- (arrows), the edges should be tacked down to minimize the ledge at
ly to occur in a timely fashion (i.e., within 2 to 3 weeks after the the edge where normal tissue adjoins the exposed fascia.
burn). Burn wounds over joint surfaces, however, should undergo
excision and grafting sooner so as to minimize healing by wound
contraction, which can ultimately lead to disabling contractures.
In patients with extensive burns, hemodynamic and pulmonary
status must be considered in deciding on the timing of operation.
Any critically ill burn patient will have some degree of respiratory
dysfunction, but the patient should at least be capable of being
safely transported from the ICU to the operating room and back.
The risk of hypothermia and the need for blood transfusion must
be anticipated before operation and clearly communicated to the
anesthesiologist.
There are two main technical approaches to surgical excision of
the burn wound: fascial excision and tangential excision. Fascial
excision, as the name suggests, involves excising the burned tissue
and the underlying subcutaneous tissue down to the muscle fascia
[see Figure 7]. A major advantage of fascial excision is that it yields
an easily defined plane that is well vascularized and therefore can
readily accept a graft. In addition, bleeding is generally easier to
control at the fascial level of dissection because the vessels are eas-
ier to identify and coagulate. Furthermore, the entire excision can Figure 8 Tangential excision of the burn wound is carried out
be performed with the electrocautery, and blood loss is thereby with a Watson knife (as shown here) or a Weck/Goulian blade.
Eschar is tangentially excised until healthy, bleeding tissue that
minimized. The principal drawback of this approach is that the
is suitable for skin grafting is reached.
excision inevitably includes some healthy, viable subcutaneous tis-
sue. Another disadvantage is that the removal of subcutaneous tis-
sue may create an unaesthetic contour deformity. Regardless of which excision technique is used, tourniquets can
Tangential excision, as the name suggests, involves sequentially be placed on extremities to minimize blood loss, and the extremi-
excising the layers of eschar in a tangential fashion until a layer of ties can be suspended from OR ceiling hooks [see Figure 9] to pro-
viable bleeding tissue capable of supporting a skin graft is encoun- vide access to their entire circumference.
tered [see Figure 8].26,27 The goal is to remove only the nonviable A water jet–powered instrument (VersaJet Hydrosurgery
tissue, particularly in the case of deep dermal wounds. Typically, System; HydroCision, Andover, Massachusetts) is available that
tangential excision is performed with a handheld knife (a Watson can be used for tangential burn wound excision.This device offers
knife or a Weck/Goulian blade). A back-and-forth carving motion an easy and relatively precise way of excising eschar and is partic-
is used, and very little force is applied.The guard on the knife can ularly useful for excising nonviable tissue from the concave sur-
be used to control the depth of excision.The appearance of diffuse faces of the hands and feet, as well as the eyelids and ears.
punctate bleeding signals that viable tissue has been reached. The To minimize hematoma formation and graft loss, it is critical
main disadvantages of tangential excision are that (1) it may be that adequate hemostasis be achieved before the placement of skin
difficult to control the diffuse bleeding from the wound bed, and grafts, cadaveric grafts, or skin substitutes. Telfa pads (Kendall,
(2) it may be difficult to assess the suitability of the underlying fat Mansfield, Massachusetts) soaked in an epinephrine solution
for accepting a graft. (1:10,000) are a mainstay of hemostasis, combined with topical
dermis harvested with the graft. The thinner the skin graft, the
greater the degree of contraction that occurs at the recipient site
after engraftment. Although thicker grafts have the advantage of
contracting less, they leave a greater dermal deficit at the donor
site, which can lengthen the time needed for healing and increase
the risk of hypertrophic scarring at that site.
Full-thickness skin grafts can be harvested either through use of
a dermatome or through direct excision of skin from the flank, the
groin crease, the hypothenar eminence, or the forearm and can be
used for coverage of small defects of the hand or the face. Standard
(intermediate) split-thickness grafts are typically harvested at a
thickness of 0.010 to 0.012 in.Thin (0.006 in.) split-thickness skin
grafts are generally used in conjunction with skin substitutes,
whereas thick (0.018–0.025 in.) split-thickness grafts are typically
used in grafting of the hand and the face.The thickness of the graft
depends both on the dermatome setting and on the pressure the
harvester applies to the dermatome during harvesting.30
Donor site selection for split-thickness skin grafts is based on
the distribution of the burn. The anterolateral thigh, when avail-
able, is the donor site of choice for most adult patients: it can be
harvested in the supine position, it can easily be left open to the air
so the donor-site dressing can dry, and it can be covered by shorts
if desired.When larger grafts are needed or the thighs are burned,
Figure 9 Extremities can be suspended from OR ceiling hooks the back, the buttocks, and the abdomen can serve as donor sites.
to facilitate exposure for burn excision and grafting. Subcutaneous infiltration of a physiologic salt solution yields a
smooth, firm surface that facilitates the harvesting of these areas.
If this is done, the anesthesiologist should be informed that addi-
pressure and cauterization when necessary. A fibrinogen thrombin tional fluid is being administered. In children, the buttocks and the
delivery system (Tisseel Fibrin Sealant; Baxter, Deerfield, Illinois) scalp are commonly employed as donor sites. Once healed, these
is commercially available that improves the ability to control sites are usually inconspicuous: the buttock donor site can be har-
bleeding after excision. vested in such a way that it can be covered by a bikini, and the
scalp donor site is typically covered by regrown hair. It is impor-
Skin Grafting tant to reassure the patient’s parents that if the graft is harvested
The best replacement for lost skin is clearly skin itself.The first appropriately, the donor site will not exhibit alopecia and the
known report of skin grafting comes from the Sushruta Samhita, recipient site will not grow hair. Generally, however, these sites are
an ancient Indian surgical treatise that may date back as far as the sufficient only for the grafting of small wounds.
seventh century B.C.This text describes the use of both skin flaps Skin grafts can be applied as sheet (or unmeshed) grafts, or they
and grafts for the repair of mutilations of the nose, the ears, and can be meshed at ratios ranging from 1:1 to 4:1 [see 3:7 Surface
the lips. The Indian method of grafting was first introduced to Reconstruction Procedures]. Meshing allows the egress of serum and
Western medicine by English surgeons, who observed it during blood from wounds, thereby minimizing the risk that hematomas
the late 18th century.28 or seromas will form that could compromise graft survival. In
It was not until 1804 that successful transplantation of free skin addition, meshed grafts can be expanded or stretched to cover
grafts was reported by Baronio of Milan, who successfully grafted larger surface areas. When grafts are meshed at ratios of 3:1 or
large pieces of autogenous skin onto different sites on sheep.28 In higher, allograft skin or another biologic dressing can be applied
1869, F. J. C. Guyon and Jacques Reverdin, in a report to the over them to prevent the interstices from becoming desiccated
Societe Imperiale de Chirurgie, described the use of a small epi- before they close.20 Because of the lack of dermis in the interstices,
dermal graft, which became known as the pinch graft. This tech- widely expanded mesh always scars, takes a long time to close, and
nique did not, however, gain wide recognition until 1870, when results in permanent unattractive mesh marks. In our center, wide-
successful experiments in skin grafting for the treatment of burn ly spread mesh is never used unless it is grafted onto a dermal tem-
patients were performed by George David Pollock.29 In 1872, plate to minimize scarring (see below).
Ollier described the use of both full-thickness and split-thickness Sheet grafts should be used on the face, the neck, the hands [see
skin grafts and realized the possibility of covering large areas with Figure 10], and, whenever possible, on the forearms and the legs. In
such grafts if a satisfactory method of cutting them could be these exposed areas, the superior cosmetic and functional results
devised.28 obtainable with sheet grafts make such grafts preferable. Because
Currently, a 95% success rate is the standard of care for skin sheet grafts have no interstices, they must be closely monitored and
grafting. To achieve this level of success requires adequate wound periodically rolled with a cotton-tipped applicator to drain any fluid
bed preparation (see above), careful selection of suitable donor collection. Any serous or bloody blebs that form beneath the graft
sites, and appropriate postoperative care. should be incised with a No. 11 scalpel and drained expeditiously.
Skin grafts are broadly classified as either full-thickness or split- A common practice known as pie-crusting, which involves making
thickness grafts, depending on whether they contain the full thick- incisions in a sheet graft at the time of surgery, actually does not
ness of the dermis or a partial thickness [see 3:7 Surface yield much improvement in graft survival, because blebs often form
Reconstruction Procedures]. Split-thickness grafts are further catego- in areas without incisions. Use of fibrin sealant at the time of graft-
rized as thin, intermediate, or thick, depending on the amount of ing may lower the incidence of blebs.
Figure 10 Sheet grafts are the gold

standard for skin grafting of the face,
the neck, and, whenever possible, the
forearms and the legs. This 1-month
follow-up demonstrates the aesthetic
superiority of sheet grafts.
Graft and Donor Site Dressings

ally best managed by draining them with a clean pin, reapplying
Once the graft is secured in place, a dressing may be applied to the epithelial layer to the wound surface, and covering the site with
protect it from shearing, as well as to accelerate closure of meshed adhesive bandages.The bandages can be soaked off in the shower
graft interstices. Numerous options for graft dressings exist, to ensure that the adhesive causes no additional injury.
including wet dressings and greasy gauze.The use of a nonadher- Inclusion cysts may develop in healed grafts that were placed
ent dressing such as Conformant 2 (Smith & Nephew) along with over excised wound beds that still contained a thin layer of dermis
an outer antimicrobial wet dressing allows the overlying dressings with adnexal structures. The secretions from the adnexal struc-
to be periodically removed without dislodging the graft from the tures collect beneath the skin graft to form the cysts. Inclusion
wound bed. Bolsters consisting of cotton and greasy gauze are cysts are treated by unroofing the affected area with a needle.
employed to help grafts conform to concave wound surfaces, and A condition known as sponge deformity (so called because the
splinting of extremities may be necessary for safe graft immobi- skin looks like a bridge of coral sponge [see Figure 11]) may occur
lization, especially over joints. The Vacuum Assisted Closure sys- if a skin graft is placed over a wound that heals underneath the
tem (Kinetic Concepts Inc., San Antonio,Texas) is another option graft in multiple small areas, with or without sloughing of the over-
for promoting graft healing. Alternatively, an Unna boot can be lying graft.32 Where the graft does not slough, a bridge forms.This
placed on both the upper and the lower extremity to immobilize unsightly deformity can be treated by incising the bridges over the
the graft and provide vascular support, allowing mobilization of healed tissue with sharp scissors.
the extremity in the immediate postoperative period.31 Healed donor sites, skin grafts, and ungrafted burns can also
Sheet grafts can be either left open to the air to allow continu- break down as a result of infection—a process referred to as melt-
ous monitoring and rolling (depending on the patient) or wrapped ing. Such melting can occur quite rapidly: a graft or healed wound
with dry dressings, which can be removed if necessary to allow that demonstrates complete take one day may exhibit significant
interval inspection and deblebbing. breakdown the next day.Wound cultures should be obtained from
There are also various options for donor-site dressings. The these areas, and the open sites should be treated with topical antibi-
ideal donor-site dressing would not only minimize pain and infec- otic ointment and, if the problem worsens, systemic antibiotics.
tion but also be cost-effective. Greasy gauze and Acticoat are often Malignant degeneration can occur in healed burn wounds
employed for this purpose. Typically, these dressings are left in decades after the initial injury.These tumors—known as Marjolin
place until the donor site reepithelializes, at which time the dress- ulcers—are usually squamous cell carcinomas and are more
ing is easily separated from the healed wound. Op-Site, a trans- aggressive than typical skin cancers.33 Marjolin ulcers have a high
parent polyvinyl adherent film, is also commonly used. With Op- metastatic potential and are associated with a high mortality. New
Site, the underlying wound is easily examined without removal of or chronic ulcers in burn wounds should raise the suspicion of
the dressing; however, intermittent drainage of the wound fluid malignancy and be considered an indication for biopsy.
that accumulates is necessary. Op-Site does not work well over
joint surfaces and concave or convex areas (e.g., the back). Silver BIOLOGIC DRESSINGS AND SKIN SUBSTITUTES
sulfadiazine in a diaper is an excellent covering for buttock donor As noted [see Early Excision and Grafting, above], conventional
sites in children; dressing changes can be done with each diaper burn wound management dictates early, aggressive excision of
change. burn wound eschar to minimize the chances of sepsis or progres-
sion of burn wound depth.15,17,34-36 In some cases, the body sur-
Postoperative Wound Care face area to be excised is larger than can be covered by autografts
Even with complete graft take and timely donor-site reepithe- from the available donor sites.The solution is to strategically select
lialization, several wound management issues may still arise in the areas for autograft coverage and then temporarily cover the
early postoperative period. Physical therapy and scar management remaining open areas with biologic dressings. Donor sites typical-
are discussed in more detail elsewhere [see 7:16 Rehabilitation of the ly reepithelialize within about 2 weeks, after which time they can
Burn Patient]. Blisters are common on newly healed donor sites be reharvested, allowing temporary dressings to be serially
and ungrafted wounds. The new epithelial layer of these wounds removed and covered with new autograft.37
lacks the connections to the underlying wound bed normally pro- Biologic dressings perform several important functions. By
vided by the BMZ, which protect the epidermis from shearing. adhering to the wound bed, they provide a physical covering that
During the months it takes for these structures to reconstitute, controls water vapor transmission, thus minimizing loss of water,
their absence frequently leads to blistering.These blisters are usu- electrolytes, and proteins and preventing desiccation and macera-
tion of wounded tissue (which can lead to extension of the depth definitive closure of large burn wounds.11 In 1985, Heck and asso-
of injury). In addition, biologic dressings help prevent microbial ciates constructed the first deliberate combination of allogeneic
invasion from the environment.38 dermis with autologous epidermis.36 This basic idea was subse-
quently expanded on by Cuono and colleagues, who used cryo-
Allograft and Xenograft Skin preserved allogeneic dermis as a bed for autologous keratinocyte
Although the technique of skin grafting is thousands of years cultures.45,46 These investigators demonstrated long-term survival
old, skin grafting between individuals was not reported until the and documented the reconstitution of a normal-appearing BMZ
late 19th century. In 1869, Reverdin published a report on the with anchoring fibrils.
transplantation of small epidermal grafts from his own arm onto a Use of allograft skin as a temporary cover or as the permanent
patient’s burn wound.28 In 1881, Girdner described transplanta- dermal replacement in the composite technique does have several
tion of skin grafts from a cadaver to a burn patient and reported a drawbacks, including the limited availability of suitable skin, the
75% immediate take rate. It was widely noted that these grafts ini- variable quality of the skin obtained, the substantial cost of allograft
tially performed well but survived for only 6 to 8 weeks.28 The procurement and preservation, and the significant potential for dis-
mechanisms underlying the rejection of these grafts were eventu- ease transmission.47 In addition, the cryopreservation process sig-
ally elucidated by the efforts of Sir Peter Medawar, who received nificantly compromises the viability, and therefore the efficacy, of
the Nobel Prize in 1960 for his seminal work on defining the basis the allograft.38
of allograft rejection and tolerance induction. Xenografts from a number of species have also been used as
The use of allograft was popularized by James Barrett Brown in biologic dressings. Porcine xenograft has been used in the man-
the 1940s and 1950s,39 and with the subsequent development of agement of exfoliative skin disorders (e.g., toxic epidermal necrol-
skin banking, allograft became the standard temporary graft for ysis) as well as for temporary wound coverage after excision and
excised burn wounds when sufficient autograft is unavailable or before definitive autografting.48
autografting is not indicated.40 Since the 1980s, research efforts have focused on the develop-
Ultimately, allograft skin is always rejected unless the donor and ment of skin replacements that could serve as either a temporary
the recipient are immunologically identical. The rejection process or a permanent substitute for human skin. Conceptually, any skin
usually begins within 10 days in an immunologically competent replacement must recapitulate the native skin biology—that is, it
host, but allografts can be tolerated for up to 1 month in a host must include an epidermal component, a dermal component, and
who is severely immunocompromised (e.g., as a result of extensive a BMZ equivalent linking the two.
burn injury).9,41 The use of immunosuppressive agents such as
cyclosporine has led to the achievement of prolonged allograft tol- Cultured Epidermal Autografts
erance,14,42-44 but it also exposes the burn patient to the risks inher-
Replacement of the epidermis alone was successfully accom-
ent in prolonged systemic immunosuppression.
plished in the 1970s with the development of cultured epidermal
In addition to providing temporary wound closure, allograft has
autografts (CEAs). In 1975, Rheinwald and Green reported the
been used as an overlay for meshed autograft with the aim of
accelerating epithelialization of the interstices. Allograft has also successful isolation and culture of epidermal keratinocytes,49 and
been used to cover donor sites after autograft harvesting and to several years later, O’Connor and coworkers reported the first
cover wounds after excision as a means of assessing the suitability clinical use of CEAs to cover burn wounds.9 In 1984, Gallico and
of a bed for autograft placement.15 associates described the use of CEAs to resurface the burn
Recognition of the weaker immunogenicity of the dermal layer wounds of two children who had sustained injuries over 95% of
of cadaver allograft stimulated various attempts to employ allo- their TBSA.29 CEAs are grown in the laboratory from a biopsy of
graft for permanent dermal replacement. Jackson was the first to the patient’s own skin. A current example is Epicel (Genzyme
report the use of alternating strips of autograft and allograft for Biosurgery, Cambridge, Massachusetts), which is approved by the
Food and Drug Administration for use in the United States.
CEAs are most commonly applied to the granulation tissue of
chronic wound beds. As more clinical experience with CEAs was
amassed, the drawbacks of using epidermal components alone to
replace full-thickness skin loss became evident.50-54 The lack of a
dermal component made the CEAs extremely fragile and led to
high rates of sloughing and infection. Even when CEA engraft-
ment occurred, the BMZ structures critical to graft durability were
poorly reconstructed.54 Compton and coworkers compared the
outcome of wounds covered with CEAs alone with the outcome
of wounds covered first with allograft dermis and then with CEAs.
They found that in wounds containing the allograft dermal com-
ponent, there was greater initial take, better long-term durability,
and accelerated formation of important BMZ structures.55 It is
now well recognized that CEAs are capable of replacing the epi-
dermis but are not effective when used alone to resurface deep
partial-thickness and full-thickness wounds.
In vitro development of an epidermal replacement was made
Figure 11 Sponge deformity can occur if a skin graft is placed possible by the simpler biology of the epidermis. Development of
over a wound that heals beneath without sloughing of the overly- a dermal replacement has proved a more formidable challenge.
ing graft. Arrows depict the bridge of skin graft (a) that forms Dermis consists mainly of extracellular matrix, and its complex
over healed skin (b). structure is not amenable to growth in culture.
a b
Figure 12 A bilaminar skin substitute is placed on the excised burn wound (a) and secured with staples.
The skin substitute typically vascularizes in 2 weeks, at which point the Silastic outer layer is removed (b)
and the neodermis can be autografted.
Skin Substitutes
thicker the autograft, the lower the take rates.44,63 Alloderm has
The drawbacks of allograft and xenograft skin have further also been used for abdominal wall reconstruction and for soft tis-
underscored the need for an off-the-shelf dermal replacement. A sue augmentation in the face.64
pioneering approach to the development of a skin replacement A product known as TransCyte (Smith & Nephew)—formerly
containing both an epidermal and a dermal component was Dermagraft-TC—is approved by the FDA as a temporary (as
described by Yannis and Burke in the early 1980s.56-59 Recognizing opposed to permanent) cover for full-thickness wounds after exci-
the importance of the dermis in skin replacement, they developed sion.TransCyte is produced by seeding neonatal fibroblasts isolat-
a bilayer construct that is now commercially available under the ed from foreskin onto Biobrane, a synthetic dressing consisting of
name Integra (Integra LifeSciences Corporation, Plainsboro, New Silastic attached to a nylon mesh, which is coated with porcine
Jersey). The epidermal component of this construct consists of a peptides prepared from type I collagen. The Silastic layer of
layer of Silastic film, which acts as a protective barrier against infec- Biobrane serves as a temporary impermeable barrier, whereas the
tion and evaporation from the wound bed; the dermal layer consists fibroblast-impregnated nylon mesh serves as a dermal compo-
of a porous matrix of fibers composed of cross-linked bovine colla- nent.65 TransCyte is placed on an excised wound bed; when clini-
gen and a single type of GAG (chondroitin-6-sulfate). Integra can cally indicated, it is removed and replaced with split-thickness
be placed on a completely excised, noninfected wound bed. Initial autograft. TransCyte has been found to be statistically equivalent
studies indicated that a neodermis forms, created by the ingrowth to cryopreserved human allograft skin with respect to adherence
of fibroblasts and endothelial cells into the dermal matrix template to the wound bed, fluid accumulation, and ease of removal.66 It
provided by the Integra. Once this neodermis forms and the der- has also been used as a dressing for partial-thickness wounds,
mal scaffold is well incorporated into the wound (typically, after 14 including donor sites.67,68
days), the Silastic component is removed. A thin (0.006 in.) split- Dermagraft (Smith & Nephew), in contrast, is employed as a
thickness autograft is then placed on the neodermis [see Figure permanent dermal replacement. Dermagraft consists of human
12].56,60 Integra not only is a useful adjunct in the management of neonatal fibroblasts seeded onto an absorbable polyglactin mesh
large burn wounds but also can play an important role in the man- scaffold, which is intended to mimic the native dermal architec-
agement of hand and facial burns requiring excision and grafting.61 ture.35,69 It is approved by the FDA for treatment of venous stasis
It must be emphasized, however, that for Integra to vascularize ulcers, but it was developed for coverage of excised burn wounds
completely, it must be applied to a viable, noninfected wound bed. in conjunction with a split-thickness autograft.
In addition, meticulous surgical technique and appropriate postop- Although a permanent off-the-shelf skin replacement has yet to
erative care are critical for a successful outcome.62 be developed, the available products have already significantly
Another product marketed for dermal replacement is Alloderm influenced the management of burn wounds. In addition, the
(LifeCell, Branchburg, New Jersey), which is an acellular dermal shortcomings of each product and strategy have improved our
matrix produced from human cadaveric skin. The cadaveric skin understanding of skin biology and physiology and confirmed the
is first stored in normal saline for 15 hours to remove the epider- importance of both the epidermis and the dermis in the structure
mal component. The cadaveric dermis is then incubated in sodi- and function of skin. One group has combined keratinocytes genet-
um dodecyl sulfate to extract any remaining cellular components. ically modified to overproduce vascular endothelial growth factor
The decellularized substrate is freeze-dried and reconstituted by with a fibroblast-collagen-GAG biopolymer matrix to accelerate
soaking it in crystalloid solution before use.44 Alloderm can be the vascularization of these constructs and improve the overall heal-
used for immediate wound coverage in combination with a thin ing of wounds covered with them.70 This approach addresses the
split-thickness autograft. Data from multicenter trials indicate that shortcomings of using CEAs alone and the absence of an epider-
Alloderm works best with thin (0.006–0.008 in.) autografts: the mal component in the currently available dermal substitutes.
References
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excision with cadaver skin overlay in the treat-
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26:149, 1986 42. Burke, JF, Bondoc CC: A method of secondary grafting of the large burn wound. Problems in
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21. Thompson P, Herndon D, Abston S, et al: Effect
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43. Towpick E, Jupiec-Weglinski JW, Tyler DS, et al: of a permanent dermal allograft in full thickness
22. Tompkins RG, Burke JFF, Schenfield DA, et al:
Prompt eschar excision: a treatment contribut- Cyclosporine and experimental skin allografts: burns of the hand and foot: a report of three
ing to reduced burn mortality. Ann Surg long-term survival in rats treated with low main- cases. J Burn Care Rehabil 18:147, 1997
204:272, 1986 tenance doses. Plast Reconstr Surg 77:268, 1986 64. Terino EO: Alloderm acellular dermal graft:
23. Tompkins RG, Remensnyder JP, Burke JF, et al: 44. Wainwright D, Madden M, Luterman A, et al: applications in aesthetic soft-tissue augmenta-
Significant reduction in mortality for children Clinical evaluation of an acellular allograft der- tion. Clin Plast Surg 28:83, 2001
with burn injuries through the use of prompt mal matrix in full thickness burns. J Burn Care 65. Hansbrough JF, Morgan J, Greenleaf G, et al:
eschar excision. Ann Surg 208:577, 1988 Rehabil 17:124, 1996 Development of a temporary living skin replace-
ment composed of human fibroblast cultured in compared with cryopreserved human cadaver skin 70. Supp DM, Boyce ST: Overexpression of vascu-
Biobrane, a synthetic dressing material. Surgery for temporary coverage of excised burn wounds. J lar endothelial growth factor accelerates early
115:633, 1995 Burn Care Rehabil 18:43, 1997 vascularization and improves healing of geneti-
66. Purdue GF, Hunt JL, Still JM, et al: A multicen- 68. Hansbrough J: Dermagraft-TC for partial thick- cally modified cultured skin substitutes. J Burn
ter trial of a biosynthetic skin replacement, ness burns: a clinical evaluation. J Burn Care Care Rehabil 23:10, 2002
Dermagraft-TC, compared with cryopreserved Rehabil 18:24S, 1997
human cadaver skin for temporary coverage. J 69. Hansbrough JF, Dore C, Hansbrough W:
Burn Care Rehabil 18:52, 1997 Acknowledgments
Clinical trials of a living dermal tissue replace-
67. Hansbrough JF, Mozingo DW, Kealey P, et al: ment placed beneath meshed, split-thickness
Clinical trials of a bio-synthetic temporary skin skin grafts on excised burn wounds. J Burn Care Figure 1 Tom Moore.
replacement, Dermagraft-Transitional Covering, Rehabil 13:519, 1992 Figure 2 Seward Hung.
7 TRAUMA AND THERMAL INJURY 15 Miscellaneous Burns and Cold Injuries — 1
15 MISCELLANEOUS BURNS AND

COLD INJURIES
David M. Heimbach, M.D., F.A.C.S., and Nicole S. Gibran, M.D., F.A.C.S.
Electrical Injury
negligible. When the high current is terminated, the heart usually
Three main forms of electrical injury exist: low-voltage burns (i.e., reverts back to sinus rhythm, just as happens in cardiac defibrilla-
burns resulting from contact with circuits of less than 440 volts tion, when such high currents are deliberately applied to the chest
[V]), high-voltage burns (i.e., burns resulting from circuits of to depolarize the entire heart.
greater than 1,000 V), and super–high-voltage burns (caused In the event that the victim of electric shock is unconscious, the
by lightning). There is also a poorly defined “intermediate-volt- initial responder should remove the source of the current (taking
age” category, which includes burns caused by contact with indus- care not to become a victim of shock himself or herself) and then
trial circuits of 440 to 800 V; these burns have characteristics provide cardiopulmonary resuscitation (CPR); paramedics may
of both high-voltage and low-voltage burns, depending on the then begin defibrillation. If a sinus rhythm has not been established
circumstances. on arrival at the emergency department (ED), the physician
A common “electrical,” though noncontact, injury is an intense should treat the patient as he or she would any other dysrhythmia
flash burn resulting from the short-circuiting of an industrial cir- patient. If sinus rhythm has been established, the patient should be
cuit by an electrician with a metal tool. Such a short-circuiting treated as a sudden death victim, with evaluation for anoxic dam-
causes the metal part of the tool to vaporize, as if it were an uncon- age and cardiac monitoring.
trolled arc welder; this vaporization results in a very high tempera- Many patients come to the ED after receiving an electric shock
ture flash that causes deep burns to the hand holding the tool and from household current. If the electrocardiogram and rhythm strip
less deep burns to the upper body and face. Clothing can catch are normal, the patient should be reassured and discharged with-
fire, compounding the problem. These burns are not, however, out hospital admission. Muscle soreness will resolve spontaneous-
associated with the problems of contact electrical burns, and they ly in 24 to 48 hours and may be treated with analgesics, such as
should be treated in much the same way as other thermal burns. nonsteroidal anti-inflammatory drugs (NSAIDs).
An electrical burn is managed in essentially the same way as any Cutaneous burns with significant tissue necrosis rarely result
other burn except that a higher urinary output is necessary in the from contact with low-voltage current. Usually, the area of contact
presence of myoglobinuria. In addition to the potentially devastat- is large enough to dissipate the heat of the current, and underlying
ing tissue destruction seen with high-voltage injury, electrical tissue destruction is minimal.
injuries can lead to chronic and debilitating nonsurgical conditions
that must be addressed. Mouth Burns in Children
The exception to this rule is a child who may chew on the end
LOW-VOLTAGE INJURIES
of a live electric extension cord. The child’s saliva completes the
The human body is three to four times as sensitive to alternat- circuit between the positive and neutral leads; the resulting electri-
ing current as it is to direct current. Alternating current has gener- cal short may cause significant tissue destruction of the lips,
ally replaced direct current for all commercial power applications tongue, or both [see Figure 1].These burns should be evaluated and
because it is cheaper to transmit and can be more easily trans- treated by a plastic surgeon or a burn surgeon.The patient is often
formed to any required voltage. The amount of 60-cycle alternat- admitted to ensure he or she receives proper nourishment and that
ing current that can just be perceived in the hand is about 1.1 mil- the parent is comfortable with pain management and wound
liamperes (mA), which produces a tingling sensation. Skin resis- cleansing. The parent should be forewarned that the eschar might
tance, however, varies according to the thickness of the epidermal separate in a few days, resulting in bleeding from the labial branch
keratin layer, as well as the cleanliness and dryness of the skin.The of the facial artery. In an emergency setting, this bleeding can be
calloused hand may provide resistance of as much as 1,000,000 easily treated by pinching the lip between thumb and forefinger
ohms/in2 while dry; normal skin provides resistance of 5,000 while the child is brought to the ED for suture ligation.
ohms/in2; and wet skin provides resistance of only 1,000 ohms/in2. There are two plans for definitive care.1-3 Long-term results
With currents higher than 2 to 4 mA, the tingling gives way to appear to be about equal for nonoperative and operative acute
muscle contractions, which get stronger as the current increases. management. If nonoperative management is chosen, splinting is
The “let go” current is reached at approximately 15 mA, above usually recommended to keep the mouth stretched to prevent con-
which the victim cannot release his or her grasp of the conductor. tracture, but patients and parents do not always comply fully with
Above 20 mA, there is sustained spasm of the respiratory muscles. splint use. Immediate coverage with flaps hastens the healing but
If the passage of current lasts less than 4 minutes, respiration will leaves a permanent scar and may result in the sacrifice of some
resume; however, if it lasts longer than 4 minutes, asphyxiation normal tissue.
may occur, and mouth-to-mouth resuscitation may be required. At
HIGH-VOLTAGE INJURIES
levels above 30 to 40 mA, ventricular fibrillation (VF) may be
induced. As the current is increased, the heart’s susceptibility to Current in wires containing 1,000 V or more may cause massive
fibrillation first increases and then decreases. At 1 to 5 A, the heart tissue destruction. The tissue destruction results from electrical
goes into sustained contraction, and the likelihood of VF becomes energy being converted to heat as it meets resistance in the tissues.
in adults, especially in the presence of myoglobinuria.With signif-

icant myonecrosis, rhabdomyolysis results in increased levels of
circulating myoglobin and hemoglobin, as well as cell fragments,
which can plug the renal tubules and cause acute tubular necrosis.
Myoglobin precipitation is accentuated by acidic urine and
decreased by alkaline urine.There has never been a report of a cor-
relation between exact myoglobin levels in the urine or the blood
and development of renal failure.4,5 Because urinary myoglobin
levels can be significantly elevated even when the urine is clear, the
clinical relevance of quantifying such levels is unclear. However,
gross myoglobin in the urine should be treated with aggressive
fluid hydration. If the urine is red or reddish black, urinary flow of
at least 1 ml/kg/hr is indicated until the pigment clears, and acido-
sis should be corrected. An osmotic diuretic such as mannitol (25
g bolus, followed by 12.5 g every 2 to 4 hours) may be necessary
to maintain adequate urinary output. Use of sodium bicarbonate
to maintain urinary pH above 7 without raising blood pH above
7.5 theoretically may minimize protein precipitation in the urine.
SURGICAL CONSIDERATIONS
Figure 1 Shown is an electrical burn caused by a 110-volt house-
hold current. The injury resulted from the patient’s sucking on an There are two indications for early operation in a patient with a
extension plug. The burn was treated conservatively with a mouth high-voltage electrical burn. If the burn is making the patient sick
splint, which resulted in a nearly normal-appearing mouth with (e.g., myoglobin will not clear or acidosis will not resolve), the
good function. wound should be explored and all grossly necrotic tissue removed.
If the burn is making an extremity sick (e.g., there are signs of a
compartment syndrome), early escharotomy, fasciotomy, or both
The smaller the size of the body part through which the electrici- should be performed. Otherwise, delaying surgical exploration by
ty passes, the more intense the heat and the less the heat is dissi- a few days can often allow definitive debridement and wound clo-
pated. Fingers, hands, forearms, feet, and lower legs frequently are sure through a single operation.6,7
totally destroyed; areas of larger volume (e.g., the trunk) usually
dissipate enough current to prevent extensive damage to viscera Escharotomy and Fasciotomy
unless the contact wound is on the abdomen or the chest. As cur- In general, an escharotomy is indicated for a circumferential
rent passes through the body, arc burns, as well as the usual con- deep burn when there is evidence of impaired distal perfusion.
tact wounds, are common. These deep wounds, which may be as Fasciotomy is indicated for concomitant electrical injury to under-
destructive as contact wounds, occur when current takes a direct lying muscle when there is evidence of increased compartment
path, often between joints in close apposition to one another at the pressure, myoglobinuria, tense muscle compartments, or nerve or
time of injury. Burns of the volar aspect of the wrist, the antecu- vessel compression. Careful monitoring, including measurement
bital fossa when the elbow is flexed at the time of injury, and the of compartment pressures, is mandatory, and escharotomies and
axilla are most common. Such injuries should always be seen fasciotomies should be performed at the slightest suggestion of
immediately by a surgeon with a special interest in burns. The progression. Routine compartment pressure measurements may
immediate evaluation of the patient with a major electrical burn is be helpful, but any of the signs of impending compartment syn-
similar to that of any severely injured patient and includes evalua- drome (i.e., increased pain, pallor, absence of pulse, decreased
tion of the ABCs (Airway, Breathing, and Circulation). sensation, and tense swelling) mandate prompt compartment
In addition to burns, which may be obvious, the patient may release in the operating theater.
have other associated injuries resulting from falls or may have bro- One unique injury that must be considered in patients with
ken bones resulting from the tetanic spasms of major muscle electrical injuries to the hand is a carpal tunnel injury.7 With the
groups. Common potential fractures include those of the lumbar associated swelling, relatively small electrical injuries can lead to
spine and hip. swelling in the carpal tunnel that manifests as increasing paresthe-
sias and numbness in the distribution of the median nerve. If the
RESUSCITATION
injury is sufficiently devastating to create a mummified hand,
Flash and flame burns without electrical contact injuries are carpal tunnel release probably has no role in the treatment plan.
treated in the same manner as all thermal burns are. For patients
CONTACT SITES
with electrical contact injuries, fluid requirements are considerably
greater than are predicted by the various formulae used for ther- Because most electrical injuries result from alternating current,
mal burn victims; the reason is that the cutaneous injury is usual- entrance and exit sites are better referred to as contact points.
ly only the “tip of the iceberg,” and underlying deep tissue dam- These are thermal burns resulting from heat generation, but
age may be extensive. A good general starting point is to adminis- unlike flame burns, they are often associated with significant
ter lactated Ringer solution at two to three times the quantity spec- injury to the deep tissues.The amount of heat generated depends
ified by the Baxter (Parkland) burn formula. This would initially on the resistance to current flow. A dry hand or foot in contact
require providing 8 to 10 ml/kg/% of total body surface area with high voltage may generate heat in excess of 1,000° C, leading
(TBSA) that is burned. Fluid administration should be adjusted, to mummification at the contact site [see Figure 2].
with the aims of correcting metabolic acidosis, normalizing vital With the passage of a large current, multiple contact sites may
signs, and attaining a urinary output of approximately 100 ml/hr be seen along the route of the current, resulting in injuries that
suggest the effects of an explosion. Sites of current arcing (see

above) should be treated in the same manner as primary contact
sites because the underlying damage can be just as severe.
WOUND MANAGEMENT
Necrotic Fat,
In general, if there are large amounts of necrotic muscle as a Fascia, Muscle
result of high-voltage electrical contact, aggressive surgical
debridement to decrease myoglobinemia is indicated. This inter-
vention may minimize subsequent organ dysfunction. If gross
myoglobinuria does not resolve after several hours of aggressive
hydration, diuresis, and compartment release, the presence of a
large amount of dead muscle is a virtual certainty. Muscle of inde-
terminate viability should be spared, but if a limb is obviously
unsalvageable, guillotine amputation may be appropriate and life- Bone
saving. The goal of subsequent surgical procedures is to conserve
viable tissue while removing neighboring dead tissue. The uneven
nature of the injuries makes this approach difficult and time-con-
suming. If they are not exposed, small, scattered areas of injured
muscle will be replaced by fibrous tissue. A high fever and tachy-
cardia, however, may be physiologic evidence that remaining non- Figure 3 Shown is the same injury seen in Figure 2 just before a
viable muscle has become infected. Because bone resists current second debridement on day 7. Because this patient’s right leg was
amputated, every attempt was made to salvage as much of the
and becomes very hot, there may be a substantial amount of non-
left foot as possible. At initial debridement, it is difficult to tell
viable necrotic muscle tissue along the bone that must be debrid- precisely how much of the foot is possibly viable; note that there
ed. It is not uncommon for superficial forearm muscles to appear is still considerable nonviable soft tissue under the metatarsals
viable while necrotic muscle surrounds the radius and ulna. Use of and that the metatarsals are considerably exposed. After the sec-
vascular grafts to replace clotted arteries is sometimes an option. ond debridement, the foot was treated in a Wound Vac to stimu-
However, such grafts may actually increase morbidity and prolong late vascularization.
recovery; amputation followed by use of one of the newer prosthe-
ses may result in better function than would be available in a hand
or foot that has poor sensation and motor function.
In accordance with the principles used for thermal burns, devi-
talized tissue below the skin at the contact sites should be debrid-
ed within 7 days after injury [see Figure 3]. Sequential debridement
of residual necrotic tissue may be necessary over the ensuing 3 to
Figure 4 Shown is the same foot as in Figures 2 and 3 at the

time of discharge (day 21 after injury). Two toes and the fifth
metatarsal were removed, leaving a stable, sensate foot with sat-
isfactory cover.
5 days. Early aggressive debridement, followed immediately by

reconstructive surgery with tissue transfer by rotation or free flaps
to cover remaining viable tissue, nerves, vessels, and bone, may
facilitate early recovery [see Figure 4].
To help determine the optimal timing and results of operation,
Figure 2 Shown is a contact-point injury caused by a 15,000-volt
one group reviewed the charts of 62 patients who underwent treat-
current, seen on day 1. Although the injury looks relatively sim- ment for high-voltage electrical burns of the upper extremities.6 A
ple, a similar injury to this patient’s right foot led to a below-the- total of 100 upper extremities were treated. Of these, 22% under-
knee amputation. Careful monitoring for compartment syn- went decompression within 24 hours because of progressive nerve
drome in the leg is mandatory in such injuries. dysfunction, clinical compartment syndrome, or failure of resusci-
tation.This subset required a mean of 4.2 operations; the amputa- Peripheral neuropathies are relatively common in burned
tion rate was 45%, which was similar to that reported in other extremities, resulting either from direct nerve injury or from fibro-
series. For another 35% of the burned extremities, the first opera- sis occurring around the nerves. Reflex sympathetic dystrophy is
tive procedure was delayed until resuscitation was complete. This not uncommon. Many patients suffer aches, headaches, chronic
subset required a mean of 2.1 operations and no amputations. For pain, and various nonanatomic neurologic complaints for some
the remaining 43% of the extremities, no operations were required months after injury.18-20
to achieve healing. Overall results showed a 10% amputation rate
and a mean hospital stay of 27 days; these results were better than Cataracts
the results reported by others. The incidence of premature cataract development may be as
high as 5% to 10% after electrical injury.21-23 Surprisingly, cataracts
NONSURGICAL PROBLEMS RELATED TO ELECTRICAL INJURY
occur equally in patients who have obvious contact points on the
face or head and in those who do not.The latent period may range
Cardiac Injuries from weeks to years, with the average being 6 months.23 Therefore,
Immediate cardiac arrest is the most common cause of death complete ophthalmologic examination for cataracts at the time of
from electrical injury. Low-voltage exposure is likely to induce ven- hospitalization and, subsequently, with any subjective decrease in
tricular fibrillation, whereas high-voltage exposure is more likely to visual acuity is warranted. For workers’ compensation claims, an
produce cardiac standstill. Cardiac standstill and respiratory arrest eye examination shortly after the injury is indicated to document
may revert spontaneously if CPR prevents anoxia;VF is more like- normal lens transparency in case cataracts occur as an injury-relat-
ly to necessitate defibrillation. Conventional wisdom states that ed disease and not from preexisting problems.
patients who have sustained high-voltage injuries should be admit-
ted for 24-hour telemetry monitoring and that cardiac isoenzyme Psychological Effects
levels should be followed. Studies have shown that if the ECG is Posttraumatic stress syndrome is more common after electrical
normal on admission, subsequent cardiac dysrhythmias are rare burns than after thermal burns.24 However, general rehabilitation
and intensive monitoring is probably not necessary.8,9 The tran- and self-assessed quality of life are comparable after thermal burns
sient interest in isoenzyme and troponin levels has now waned, and and after electrical burns.25
assessment of these variables has not proved useful in predicting
LIGHTNING INJURY
cardiac damage.8,10-13
Myocardial infarction is uncommon, but it has been reported in A lightning strike is an extraordinarily high-voltage discharge of
a small percentage of cases in each series. In one patient at the brief duration. The current generated may reach 300,000 A and
University of Washington (UW) Burn Center, a papillary muscle 100 million V. Fortunately, the current often flows around the sur-
ruptured within 24 hours; this led to immediate, fatal congestive face of, rather than through, the body; this “flashover” permits an
heart failure. overall survival rate of 65% or higher.26-28 The most common
immediate potentially fatal complications are paralysis of the res-
Neurologic Complications piratory center and cardiac standstill. Cardiac activity will usually
Neurologic complications are common sequelae of high-voltage resume spontaneously, but apnea may be present for 15 minutes
electrical injuries and can affect the brain, spinal cord, and periph- or longer—long enough to cause anoxic brain injury in the absence
eral nerves. Immediate but frequently transient symptoms include of pulmonary resuscitation. A rare but fascinating complication is
varying levels of unconsciousness, respiratory paralysis, and motor keraunoparalysis, which is a transient paralysis associated with
paralysis. Permanent changes include cortical encephalopathy, extreme vasoconstriction and sensory disturbances of one or more
caused by the electrical injury itself or resulting from hypoxia at the extremities. It usually lasts only an hour (in rare instances, as long
time of the accident. Spinal cord injuries are rare but may present as 24 hours); a lifeless appearance should not result in the patient’s
as progressive muscular atrophy, amyotrophic lateral sclerosis, or being treated as a victim of sudden death.29 Cardiac and neuro-
transverse myelitis. These conditions may occur days to months logic complications are frequent and are generally similar to those
after the injury and progress slowly.14-16 resulting from man-made high-voltage injuries.30 Dendritic super-
A study of 90 patients (82 male and 8 female) with electrical ficial skin burns, known as Lichtenberg’s flowers or fractals,31 are
burns was conducted at the UW Burn Center to identify and eval- sometimes seen. These superficial burns heal rapidly without
uate neurologic consequences.17 There were four deaths. Of the 86 sequelae. Ruptured tympanic membranes and vertigo are com-
remaining patients, 22 sustained low-voltage injury. Of these 22, 11 mon accompaniments.32,33 Treatment of systemic effects is gener-
had immediate neurologic symptoms; these symptoms resolved in ally supportive; tissue injuries are treated in the same manner as
nine of the 11 patients. A total of 64 patients sustained high-volt- other high-voltage injuries.
age injury; of these, two thirds had immediate central or peripher-
al neurologic symptoms (or both). Loss of consciousness account-
ed for the largest percentage of central nervous system sequelae in Chemical Burns
the high-voltage group (45%). Of the 29 patients who lost con-
GENERAL EMERGENCY CARE
sciousness, 23 (79%) regained consciousness before arrival at the
hospital. Six patients remained comatose, three died, and three Immediate treatment of chemical burns involves the immediate
awoke but had neurologic sequelae. One third of the patients in the removal of affected clothing; the burns should then be thoroughly
high-voltage group had one or more acute peripheral neu- flushed with copious amounts of water at the scene of the accident.
ropathies; of these neuropathies, 64% resolved or improved. Five The only exception to this is for chemical burns involving dry pow-
patients had transient initial paralysis, but there were no delayed der; for such burns, the powder should be brushed from clothing
spinal cord symptoms. Eleven patients experienced one or more and skin. Chemicals will continue to burn until removed; washing
delayed peripheral neuropathies; half of these delayed neuropathies for at least 15 minutes under a stream of running water may limit
resolved or improved. the overall severity of the burn. No thought should be given to
searching for a specific neutralizing agent. Delay results in deepen- size the severity and long-term sequelae of the respiratory and ocu-
ing of the burn, and neutralizing agents may cause burns them- lar problems.40-44
selves; they frequently generate heat while neutralizing the offend-
ACIDS
ing agent, adding a thermal burn to the already potentially serious
chemical burn. As noted (see above), acid burns tend to denature (tan) the skin.
Chemical burns, usually caused by strong acids or alkalis, are Although they may be full-thickness burns, destruction of deeper
most often the result of industrial accidents, assaults, or the tissues is often limited as a result of the formation of an impervi-
improper use of harsh solvents and drain cleaners. In contrast to a ous carapace of the dermis.
thermal burn, chemical burns cause progressive damage until the
chemicals are inactivated by reaction with the tissue or are diluted Hydrochloric and Nitric Acids
by being flushed with water. Individual circumstances vary, but Hydrochloric and nitric acids are strong acids that denature pro-
acid burns may be more self-limiting than alkali burns. Acid tends teins but usually do not result in systemic poisoning unless inhaled
to tan the skin, creating an impermeable barrier that limits further or ingested.
penetration of the acid. Alkalis combine with cutaneous lipids to
create soap and thereby continue dissolving the skin until they are Chromic Acid
neutralized. A full-thickness chemical burn may appear deceptive- Some acids, such as chromic acid and dichromate, cause both
ly superficial, seeming to cause only a mild brownish discoloration systemic and cutaneous problems. Chromium poisoning is char-
of the skin. The skin may appear to remain intact during the first acterized by complete anuria, hepatic damage, and progressive
few days after the burn and only then begin to slough sponta- anemia. It can occur from the cutaneous absorption of chromi-
neously. Chemical burns should be considered deep dermal or um from chromic acid burns that are as small as 1% of TBSA.
full-thickness burns until proved otherwise. In general, definitive Aggressive surgical excision and prompt hemodialysis may be
treatment of these burns is the same as for thermal injuries—shal- lifesaving.45-48
low burns heal with infection prevention; deep burns are excised
and grafted as soon as their depth is determined. Formic Acid
Some chemicals, such as phenol, cause severe systemic effects; Similarly, formic acid causes metabolic acidosis, intravascular
others, such as hydrofluoric acid, may cause death from hypocal- hemolysis, and hemoglobinuria when ingested or when concen-
cemia even after moderate exposure. Unless the characteristics of trated solutions contact the skin.49,50
the chemical are well known, the treating physician is advised to
call the local poison control bureau for specifics on treatment. Carbolic Acid
Phenol (carbolic acid) is used as a hospital, industrial, and home
ALKALIS
disinfectant. Exposure may lead to rapid CNS depression, vomit-
Lime (calcium oxide/hydroxide) and sodium or potassium ing, coughing, stridor, and, in rare instances, seizures.51 The cuta-
hydroxide are examples of common alkalis used in industry and neous burns are usually first degree.
around the home.
Sodium or potassium hydroxide (drain cleaner) is ingested by Hydrofluoric Acid
children accidentally and by adults attempting suicide. Mouth Hydrofluoric acid burns are unique in terms of their presenta-
burns are the tip of the iceberg. Emergency treatment should be tion and current treatment. Hydrofluoric acid is used in industrial
directed to the oropharynx and the upper GI tract; description of cleaners and rust removers. It is used in concentrated form in the
such treatment is beyond the scope of this chapter. Sodium or etching of circuit boards and in dilute form as a cleaner for glass
potassium hydroxide is also used in assaults, especially in areas and milk cans. Hydrofluoric acid is a very strong acid that coagu-
where people cannot afford handguns.34 Teen hoodlums some- lates skin and allows entry of fluoride ions, which then chelate cal-
times fill water pistols with sodium hydroxide and squirt sleeping cium and magnesium in tissue and plasma. Local cell death
homeless people. Contact of concentrated sodium hydroxide with results; with severe exposure, severe systemic hypocalcemia and
the cornea results in prompt and permanent corneal destruction hypomagnesemia can result in fatal cardiac dysrhythmias.52-54
and blindness. Drain and oven cleaners are also favorite substances Fluoride, as the most electronegative element, tightly binds many
of patients who deliberately and repeatedly inflict injury on them- cations essential to hemostasis, inhibiting normal blood coagula-
selves (Munchausen syndrome).35-37 tion. As a metabolic poison, it stimulates some enzymes (e.g.,
The unwitting homeowner or novice construction worker who adenylate cyclase) and severely inhibits others (e.g., Na+,K+-
does not protect the skin when working with concrete cement (cal- ATPase and the enzymes of carbohydrate metabolism).55
cium hydroxide) is often surprised at day’s end with painful red Treatment of severe poisoning requires careful monitoring in an
contact areas on the hands, feet, knees, and forearms. By bedtime, ICU, replacement of magnesium and calcium, and consideration
these injuries have become excruciating and require emergency of dialysis.
treatment and, frequently, excision and grafting.38,39 More commonly, industrial exposure is limited to the hand.56
Strong alkali burns are invariably deep, though they may seem Exposure to concentrated solution will cause immediate symp-
deceptively shallow at their onset. toms, but the more common dilute solutions may not cause symp-
toms for hours. Often, the worker will go home and experience
ANHYDROUS AMMONIA
increasingly severe pain, which will prevent sleep and lead to a
Anhydrous ammonia is a colorless, pungent gas that is stored nighttime visit to the ED.The worker will likely be unaware of the
and transported under pressure in liquid form. Ammonia injury is cause of the pain; the emergency physician should question the
uncommon, but it is associated with high morbidity and mortality. patient about solvents used that day.
Particularly devastating is severe acute respiratory distress syn- Conventional treatment of burns to the hand and digits has
drome (ARDS) and long-term restrictive disease with bronchiec- consisted of local application of calcium liquids and gels. Direct
tasis. Most of the literature consists of case reports, but all empha- injection of calcium gluconate into the injury site is somewhat
effective but may cause pressure necrosis of fingers that are already gloves, and boots. The victim’s clothing is removed, and extensive
swollen. A much better treatment that can yield almost magical water lavage is provided, along with copious isotonic eye irrigation.
results is direct intra-arterial infusion of a dilute calcium gluconate Once decontamination has been completed, there is no danger to
solution through the radial or brachial artery.The sooner the infu- attendants; blister fluid does not contain chemicals.71 Burns are
sion is started after the onset of pain, the better the result. Pain is usually of partial thickness and can be treated in the same manner
immediately mitigated if not cured, and tissue destruction is often as other partial-thickness burns.
minimal.57,58 This measure has become the treatment of choice in
the UW Burn Center and has yielded good results with no com-
plications to date. However, therapy must be started within the Cold Injury
first 24 hours; after this point, tissue damage is permanent. An Cold injuries limited to digits, extremities, or exposed surfaces
alternative is intravenous infusion of calcium gluconate with the are the result of either direct tissue freezing (frostbite) or more
Bier block technique (i.e., a venous tourniquet applied proximal to chronic exposure to an environment just above freezing (chilblain
the infusion site),59-61 but this measure can increase swelling in the or pernio; trench foot). Cold injury has been a major cause of mor-
extremity. bidity during war, and it is described as being the single major
injury sustained by British soldiers in the Falklands expedition.
Cold injury resulted in over 7 million soldier fighting days lost by
War and Chemicals of Mass Destruction
Allied forces in World War II.72
NAPALM CHILBLAIN, PERNIO, AND TRENCH FOOT
Napalm is jellied gasoline that is generally ignited and sprayed Chilblain and pernio are descriptive terms for a form of local
on material and combatants in wartime. It causes devastating cold injury characterized by red-purple, pruritic skin lesions
burns because the gasoline sticks to clothing and skin while it is (papules, macules, plaques, or nodules) that are often associated
burning. Injuries are usually fourth-degree thermal burns, which with edema or blistering.These lesions are caused by a chronic vas-
are treated in the same manner as other very deep thermal burns. culitis of the dermis, and their development appears to be pro-
WHITE PHOSPHORUS
voked by repeated exposure to cold, though not freezing, temper-
atures. The injury typically occurs on the face, the anterior tibial
White phosphorus is used in many types of military munitions, surface, or the dorsum of the hands and feet—areas that are poor-
as well as in fireworks and in industrial and agricultural products. ly protected or are subject to long-term exposure to the environ-
In the presence of oxygen, it ignites spontaneously; when in con- ment.With continued exposure, ulcerative or hemorrhagic lesions
tact with skin, it causes deep thermal injuries. It may also give rise may appear and progress to scarring, fibrosis, and atrophy.
to multiple organ dysfunction syndrome (MODS) because of its Treatment consists of sheltering the patient, elevating the affected
toxic effects on erythrocytes, the liver, the kidneys, and the heart. part on sheepskin, and allowing gradual rewarming at room tem-
Treatment of the injured patient is difficult.The particles must be perature. Rubbing or massage is contraindicated, because further
debrided to prevent continued burning and systemic poisoning. damage and secondary infection may result.73-75
Conventional wisdom was to use a solution of copper sulfate to Trench foot or cold immersion foot (or hand) describes a non-
convert the elemental phosphorus into copper phosphate. freezing injury of the hands or feet, typically sustained by sailors,
However, this approach has fallen into disfavor because copper fishermen, or soldiers as a consequence of long-term exposure to
poisoning may result, the effects of which are often as bad as those wet conditions (e.g., water or mud) and temperatures just above
of phosphorus poisoning.62,63 During debridement in the operat- freezing.76-80 Alternating arterial vasospasm and vasodilatation
ing theater, exposure of the particles to air can reignite the phos- appear to occur, with the affected tissue first cold and anesthetic
phorus and thereby endanger the patient and the operating team. and then becoming hyperemic after 24 to 48 hours of exposure.
MUSTARD GAS, LEWISITE, AND PHOSGENE
With the hyperemia comes an intense, painful burning and dyses-
thesia, as well as tissue damage characterized by edema, blistering,
Sulfur mustard is a vesicant that alkylates DNA. In liquid or gas redness, ecchymosis, and ulceration. Complications consisting of
form, its main targets are the skin, the eyes, and the lungs.64-68 Its local infection and cellulitis, lymphangitis, and gangrene may occur.
clinical effects are similar to those of burns, with loss of immunity, After 2 to 6 weeks, a posthyperemic phase ensues, resulting in tis-
respiratory failure, and ophthalmic, gastrointestinal, and hemato- sue cyanosis with increased sensitivity to cold. Treatment is best
logic signs. In the Iraq-Iran war (1981–1989), extensive use of started during or before the reactive hyperemia state; it consists of
chemical weapons such as mustard gas caused injuries with high immediate removal of the extremity from the cold, wet environment
mortality and morbidity, as well as chronic side effects in vital and exposure of the extremity to warm, dry air.The limb is elevat-
organs, especially the respiratory tract. In a study that examined ed to minimize edema, pressure spots are protected, and local and
long-term effects of mustard gas exposure in 220 survivors, nearly systemic measures to combat infection are undertaken. Massage,
all the victims complained of cough, dyspnea, and suffocation. soaking of the feet, and rapid rewarming are not indicated.
Hemoptysis was found in six victims. Respiratory distress with use
of accessory muscles was observed in four. Two thirds of the sub- FROSTBITE
jects had wheezing and coarse rales. Most had obstructive patterns Frostbite is a common, severe form of cold injury that involves
on pulmonary function testing.69 Cutaneous exposure is manifest- local freezing of tissues. Frostbite is classified into four grades of
ed by a delayed erythema of skin occurring after about 4 hours, fol- severity81,82:
lowed by blistering in 12 to 48 hours.The blisters rupture, leaving
shallow, painful ulcers. Other vesicants are more corrosive: lewisite 1. First-degree injury involves the freezing of tissue with hyperemia
(arsine) and phosgene are both more potent than mustard gas, and and edema but without blistering.
symptoms appear sooner with these agents.70 2. Second-degree frostbite involves the freezing of tissue with hy-
Rescuers should be protected with suitable clothing, respirators, peremia, edema, and characteristic large, clear blisters.
TREATMENT
3. Third-degree frostbite involves the freezing of tissue with the
death of subcutaneous tissues and skin, resulting in hemorrhag- Prehospital or field care of a victim of cold injury should focus
ic vesicles that are generally smaller than those seen in second- on removing the patient from the hostile environment and pro-
degree frostbite. tecting the injured body part from further damage. Rubbing or
4. Fourth-degree frostbite is notable for tissue necrosis, gangrene, exercising the affected tissue does not augment blood flow and
and, eventually, full-thickness tissue loss. risks further cold injury or mechanical trauma. Because repeated
bouts of freezing and thawing worsen the injury, it is preferable for
The degree of severity of frostbite is often not apparent for sev-
the patient with frostbite of the hands or feet to seek definitive shel-
eral days. For all forms of frostbite, the initial presentation is pain
ter and care immediately rather than to rewarm the tissue in the
or discomfort, as well as pruritus if the injury is mild. With more
field and risk refreezing. Once rewarming has begun, weight bear-
severe injury, there is a progressive decrease in range of motion,
ing should be avoided.
and edema becomes prominent. The injury progresses to numb- The ED treatment of a frostbite victim should first focus on the
ness and eventual loss of all sensation in the affected tissue. The basic ABCs of trauma resuscitation [see 7:1 Initial Management of
involved area appears white or blue-white and is firm or even hard Life-Threatening Trauma] and on identifying and correcting sys-
(frozen) to the touch. The tissue is cold and insensate. Although temic hypothermia. Frostbitten tissue should be immersed in a
the initial symptoms may be mild and may be overlooked by the large water bath of 40° to 42° C (104° to 108° F).The bath should
patient, severe pain, burning, edema, and even necrosis and gan- be large enough to prevent rapid loss of heat, and the water tem-
grene may appear with rewarming. perature should be maintained. This method of rapid rewarming
Weather conditions, altitude, degree of protective clothing, may significantly decrease tissue necrosis caused by full-thickness
duration of exposure, and degree of tissue wetness are all con- frostbite.88,90,91 Dry heat is not advocated, because it is difficult to
tributing external factors to the development of frostbite. regulate and places the patient at risk for a burn injury. The
Acclimation to cold may be protective, whereas a previous history rewarming process should take about 30 to 45 minutes for digits.
of frostbite probably does predispose an individual to another cold The affected area appears flushed when rewarming is complete
tissue injury. Smoking and a history of arterial disease also are con- and good circulation has been reestablished. Narcotics are
tributing factors. In urban environments, more than 50% of frost- required, because the rewarming process may be quite painful.
bite injuries are alcohol related, and a significant percentage (16%) The skin should be gently but meticulously cleansed and air-
of patients have an underlying psychiatric illness.83,84 dried, and the affected area should be elevated to minimize edema.
Current evidence suggests that frostbite injury may in fact have A tetanus toxoid booster should be administered as indicated by the
two components: (1) the initial freeze injury and (2) a reperfusion immunization history. Sterile cotton should be placed between toes
injury that occurs during rewarming.85-87 The initial response to or fingers to prevent skin maceration, and extreme care should be
tissue cooling is vasoconstriction and arteriovenous shunting, taken to prevent infection and to avoid even the slightest abrasion.
relieved intermittently (every 5 to 7 minutes) by vasodilatation. Prophylactic antibiotics and dermal blister debridement are both
With prolonged exposure, this response fails, and the temperature controversial; most clinicians debride blisters and reserve antibiotics
of the freezing tissue will approximate ambient temperature until a for identified infections. A 2005 study reported a lower than expect-
temperature of –2° C is reached. At this point, extracellular ice ed digit amputation rate when rapid rewarming was followed by
crystals form; as these crystals enlarge, the osmotic pressure of the treatment with hepatin and tissue plasminogen activator (tPA), but
interstitium increases, resulting in the movement of intracellular to date, this finding has not been confirmed by other studies.94
water into the interstitium. Cells begin to shrink and become After rewarming, the treatment goals are to prevent further
hyperosmolar, disrupting cellular enzyme function. If freezing is injury while awaiting the demarcation of irreversible tissue destruc-
rapid (i.e., if the temperature falls by more than 10° C/min), intra- tion. All patients with second- and third-degree frostbite should be
cellular ice crystal formation will occur, resulting in immediate cell hospitalized. The affected tissue should be gently cleansed in a
death. Intravascularly, endothelial cell disruption and red cell warm (38° C) whirlpool bath once or twice a day; some clinicians
sludging result in cessation of circulation.88-91 add an antiseptic such as chlorhexidine or an iodophor to the bath.
During rewarming, red cell, platelet, and leukocyte aggregation On the basis of findings of arachidonic acid metabolites in the blis-
is known to occur; this results in patchy thrombosis of the micro- ters of frostbite victims, some authors advocate the use of topical
circulation.92 These accumulated blood elements are thought to aloe vera (a thromboxane inhibitor) and systemic ibuprofen or
release, among other products, the toxic oxygen free radicals and aspirin. After resolution of edema, digits should be exercised dur-
the arachidonic acid metabolites prostaglandin F2 and thrombox- ing the whirlpool bath, and physical therapy should begin.Tobacco,
ane A2, which further aggravate vasoconstriction and platelet and nicotine, and other vasoconstrictive agents must be withheld.
leukocyte aggregation. However, the exact mechanism of tissue Numerous adjuvants have been suggested and tried in an effort
destruction and death after freeze injury remains poorly defined. to restore blood supply to frostbitten areas. Because of the intense
Animal studies suggest that vascular injury, in the form of endothe- vasoconstrictive effect of cold injury, attention has been focused for
lial cell damage and subsequent interstitial edema (but not vessel many years on increased sympathetic tone. Sympathetic blockade
thrombosis) is the primary initial event in rewarming injury. It has and even surgical sympathectomy have been advocated as early
been demonstrated that a marked amelioration of the frostbite therapy, the theoretical rationale being that sympathetic blockade
injury can be achieved in a rabbit ear model by treating the animals should release the vasospasm that may precipitate thrombosis in
(after cold injury and before rewarming) with a monoclonal anti- the affected tissue. Unfortunately, this method of treatment has
body to the neutrophil CD18 glycoprotein complex.93 The impli- produced inconsistent results in experimental studies and is diffi-
cation of this observation is that neutrophil adherence to the cult to evaluate clinically.89,95 Experience with intra-arterial vasodi-
endothelium of frostbitten tissue during rewarming (reperfusion) lating drugs such as reserpine and tolazoline has also failed to ver-
is at least partially responsible for the subsequent tissue injury. ify this hypothesis. In a controlled clinical study, immediate (mean,
Clinical application of these experimental observations remains 3 hours) ipsilateral intra-arterial reserpine infusion coupled with
untested. early (mean, 3 days) ipsilateral operative sympathectomy failed to
alter the natural history of acute frostbite injury.89 Sympathectomy one theory, certain offending drugs that should be metabolized are
may, however, mollify the chronic pain, hyperhidrosis, and instead deposited in the epidermis, leading to an immune
vasospasm of cold injuries; some clinicians also suggest that it response, which causes the body to reject the skin. In 1998, Viard
reduces the risk of subsequent cold injury. Heparin, low-molecu- pointed out that keratinocytes normally express the death receptor
lar-weight dextran, thrombolytic agents, and hyperbaric oxygen Fas (CD95); keratinocytes from TEN patients were found to
have failed to demonstrate any substantial treatment benefit express lytically active Fas ligand (FasL). Antibodies present in
(despite the suggestive results of the 2005 study by Twomey and pooled human intravenous immunoglobulins (IVIg) blocked Fas-
associates94). mediated keratinocyte death in vitro. In a pilot study, 10 consecu-
The difficulty in determining the depth of tissue destruction in tive individuals with clinically and histologically confirmed TEN
cold injury has led to a conservative approach to the care of frost- were treated with IVIg; disease progression was rapidly reversed,
bite injuries. As a general rule, amputation and surgical debride- and the outcome was favorable in all cases. The implication was
ment are delayed for at least 1 month unless severe infection with that Fas-FasL interactions were directly involved in the epidermal
sepsis occurs.The natural history of a full-thickness frostbite injury necrolysis of TEN and that IVIg might be an effective treatment.99
leads to the gradual demarcation of the injured area; dry gangrene This report sparked numerous small clinical series, the results of
or mummification clearly delineate nonviable tissue. Often, the which have been, at best, inconclusive.100-104 A 2005 study of the
permanent tissue loss is much less than originally suspected. In effect of IVIg on ocular complications was unable to demonstrate
one review, only 39% of urban frostbite victims required debride- any benefit.105 There may be a role for γ-globulin, but current data
ment and skin grating or amputation.84 Emergency surgery is indicate that it is no miracle cure. Because of the high cost of
unusual, but during the rewarming phase, vigilance should be γ-globulin and its potential for inducing renal damage, we no
maintained to detect the development of a compartment syn- longer use it to treat TEN at the UW Burn Center.
drome necessitating fasciotomy. Open amputations are indicated TEN should be distinguished from a somewhat similar disease,
in patients with persistent infection and sepsis that is refractory to staphylococcal scalded skin syndrome (SSSS).This entity is caused
debridement and antibiotics. by a bacterial exotoxin, which splits the epidermis above the der-
Frostbitten tissues seldom recover completely. Some degree of mal-epidermal junction. Although patients with SSSS experience
cold insensitivity invariably remains. Hyperhidrosis (occurring in severe erythema, the skin exfoliates rather than blisters. SSSS does
as many as 72% of patients), neuropathy, decreased nail and hair not involve mucosa, and the patients are in a septic state from
growth, and persistent Raynaud phenomenon in the affected part the underlying staphylococcal infection. SSSS usually affects
are frequent sequelae of cold injury.96 The affected tissue remains newborns, becoming much less common as people get older.
at risk for reinjury and should be carefully protected during any This unusual disease is treated with antibiotics directed against
cold exposure. Treatment with antiadrenergics (e.g., prazosin staphylococci.106
hydrochloride, 1 to 2 mg/day) or calcium channel blockers (e.g., The TEN-induced areas of denudation are comparable to those
nifedipine, 30 to 60 mg/day) and careful protection from further affected by a very shallow second-degree burn. Oropharyngeal,
exposure are often helpful. However, there is little that appears to esophageal, anal, urethral, and vaginal107,108 mucosal sloughing are
afford significant relief to the chronic symptoms that follow tissue also characteristic of TEN.The disease attacks squamous epitheli-
freeze injury; sympathectomy, beta- and alpha-adrenergic blocking um, so the remainder of the GI tract is usually spared.There is only
agents, calcium channel blockers, topical and systemic steroids, one case report of intestinal epithelial sloughing.109 Complications
and a host of home remedies have all been tried, with only occa- such as infection, malnutrition, negative nitrogen balance, severe
sional individual success.78 wound pain, and MODS are identical to those seen in patients
with major burns. The most common causes of death in TEN
patients are systemic infection and pneumonia.The potential mor-
Toxic Epidermal Necrolysis tality from TEN is high, but it is reduced by treatments and proto-
Toxic epidermal necrolysis (TEN) is a devastating, though (for- cols common in burn centers (e.g., wound coverage with biologic
tunately) rare, exfoliative disease of the skin and mucous mem- dressings).There is good evidence that patients affected with TEN
branes that results in full-thickness epidermal necrosis. The first should be referred early for management in a burn center.110-112
published report of adult TEN appeared in 1956, when Lyell, in The role of the dermatologist is to define the diagnosis and deter-
Lyon, France, compared four cases to scald burns.97 Some authors mine the potential cause.
describe a similar skin sloughing but with lesser involvement,
CLINICAL MANIFESTATIONS
termed the Stevens-Johnson syndrome. In reality, the two diseases
are exactly the same: Stevens and Johnson anticipated Lyell by 34 A prodrome of TEN usually consists of fever, sore throat, and
years when they described the same pathology in two children in malaise; 1 to 2 days after these symptoms appear, the skin of the
South Africa.98 Dermatologists have long known the disease as ery- face and extremities usually becomes tender and erythematous.
thema multiforme majus exudativum.Thus, even though only one Lesions appear either as large areas of red skin or as target lesions
disease process is involved, various names continue to be used: that are about 2 cm in diameter and consist of concentric rings of
Europeans refer to this condition as Lyell disease, pediatricians call erythema. At the same time, ulcerations in the lips and mouth
it the Stevens-Johnson syndrome, dermatologists refer to it as ery- appear, making oral intake painful.
thema multiforme majus, and American surgeons and internists In 24 to 96 hours, the involved skin begins to form both small
call it TEN. blisters and bullae. Moderate traction of the erythematous skin
TEN can be precipitated by the administration of medications, results in separation of the epidermis from the dermis—a positive
most commonly sulfonamides, antibiotics, and anticonvulsants. It Nikolsky sign.113 When the bullae rupture, large denuded areas of
can also be caused by events such as immunizations, systemic dis- skin become apparent. Fingernails, toenails, and the skin of the
eases, and viral illnesses. Some cases have no known precipitating palms and soles may also slough.
cause. One hallmark of this disease is severe inflammation of the
The molecular etiology of TEN remains unclear. According to mouth. Blisters develop on the oral mucosa, leaving a very raw, red
surface. The lips quickly become swollen and crusted with clotted Cardiovascular function is initially impaired as a result of hypo-
blood. The oral lesions may be confined to the oral cavity or may volemia caused by plasma leaking from the blisters, increased skin
extend to the larynx or even to the trachea and the esophagus.The evaporative losses, and decreased oral intake. Controlling the
patient is usually unable to eat. The eyelids swell as conjunctival febrile response will also help decrease fluid losses, vasodilatation,
inflammation develops. Conjunctival infection, usually caused by and the resulting hyperadrenergic response. Careful use of
Staphylococcus aureus, may lead to scarring and permanent blind- NSAIDs is often necessary to keep the patient’s temperature below
ness.114 The nasal and urethral mucosa may also become inflamed, 102° F (38.9° C). Adequate pain control is essential. Methadone
and erosions can develop on the genital and perianal skin. is effective for long-acting pain control, and morphine is a good
Renal failure can occur as a result of hypovolemia, the septic choice for procedural pain.
response, or membranous glomerulonephritis. In as many as 50% Aggressive oral care is critical because of the high risk of local
of cases, there are abnormalities in liver enzymes, including mod- mouth infection and consequent wound and lung infection. Early
est increases in aspartate aminotransferase (AST) and alanine and continued assessment and aggressive management of corneal
aminotransferase (ALT). Bilirubin levels often show modest to involvement are required. Administration of ophthalmic antibiotic
severe increases.115 The mechanism of these increases, which ointments and gentle breaking of adhesions between conjunctiva
appear to be a part of the toxic component of TEN, is unknown. and eyelids with a small glass rod are the standard treatment.125
TREATMENT OPTIMIZING NUTRITION
The initial focus of treatment is on restoration and maintenance Nutrition is a major component of care, and it often cannot be
of cardiopulmonary stability. Because TEN does not induce the delivered orally because of oral lesions. A small gastric feeding
intense cytokine reaction that is associated with similar-sized tube is preferred, as the GI tract between stomach and anus is usu-
burns, massive anasarca is unusual; resuscitation need not proc- ally intact and is normally functional.126 In general, standard tube-
ceed in the manner recommended for burns. Maintenance of nor- feeding formulas for an individual under moderate stress are suf-
mal vital signs and adequate urinary output (0.5 ml/kg) is satisfac- ficient because the full ravages of postburn hypermetabolism are
tory. Because of the high incidence of catheter infection in the probably not present. When sepsis is avoided, it is very unusual
absence of epidermis, use of Swan-Ganz catheters is usually avoid- for the gut to fail and for intravenous parenteral nutrition to be
ed when possible.116 needed.
Treatment involves aggressive wound management, similar to The role of corticosteroids in the treatment of TEN remains
that of a massive second-degree burn, in which the emphasis is on unclear. Although some patients who were receiving steroids
optimizing healing and controlling infection. A crucial feature of before the development of TEN still get severe disease,127 a num-
TEN is an intact and uninjured dermis, which, if protected, rapid- ber of dermatologists feel that the administration of steroids when
ly reepithelializes from sweat glands and hair follicles, which appear the disease process is just beginning, before skin sloughing occurs,
to remain intact. Treatment must, therefore, protect the dermis can attenuate the process and thereby reduce subsequent slough-
from desiccation and infection. Routine use of ointments and ing. However, once vesicles have formed and the separation has
salves not only creates intense pain but also increases the risk of the occurred, corticosteroids no longer effectively attenuate skin
formation of a “pseudo eschar” of crusts and devitalized dermis sloughing; in fact, the use of corticosteroids retards the rate of heal-
that impairs wound healing. ing. In one study, the complication rate was found to be higher in
Biologic or manufactured covers have formed an important role patients who received steroids.128 This study, however, did not take
in wound treatment.111,117,118 Emergency operative wound cleans- into account the patients whose disease might have been suffi-
ing and application of commercially available pigskin (porcine ciently limited by steroid use to make burn center treatment
xenograft) has been the standard of care at the University of unnecessary.
Washington Burn Center in more than 130 cases. The pigskin is
FOLLOW-UP CARE
stapled in place, the patient is treated for several days in a fluidized
bed, and the pigskin is removed as the denuded areas heal. The Fortunately, when treatment is successful, the disease usually
pigskin is relatively inexpensive, adheres well, is nontoxic, and resolves without hypertrophic scarring, though some mismatching
probably provides some growth factors to hasten healing.With this of epidermal pigmentation may be evident. Nails may remain
management plan and meticulous systemic care, mortality at the deformed, and eyes are usually dry, requiring periodic lubrication.
UW Burn Center has been below 20% for the past 15 years.119 Obviously, patients must not again contact the medication that
Alternative covers include Acticoat120 (Smith & Nephew, London, caused the disease; for common medications, a Medic Alert
United Kingdom) and Biobrane121-124 (Mylan Laboratories, bracelet is useful.
Canonsburg, Pennsylvania), which follow the same principle of
dermal protection to permit uninfected healing.
In addition, associated physiologic and psychological care must Ionizing Radiation Burns
be meticulous. Lung function is often impaired as a result of the The burn surgeon may encounter ionizing radiation injuries in
aspiration of secretions from involved oral mucosa and a reduction three settings. Of these, by far the most common involves deliber-
in the clearance of secretions as a result of oral pain and overall ate exposure to radiation (i.e., radiation used in treatment) or acci-
weakness. Pain control and aggressive pulmonary toilet to assist dental radiation in a hospital, a laboratory, or an industrial com-
the patient’s cough are the first line of defense. Suctioning can lead plex. In such settings, a single individual is likely to be injured.The
to significant bleeding and should be used either sparingly or only second scenario involves failure of a nuclear energy plant, such as
after an endotracheal tube is in place. The patient should be intu- occurred at Chernobyl; in this scenario, dozens to hundreds of
bated if lung function is progressively impaired. If the patient is exposures may occur. The third setting is that resulting from a
intubated, partial ventilatory assistance is often required because nuclear explosion through military or terrorist action. In such a
chest wall pain, systemic toxicity, and weakness can severely impair scenario, thousands of casualties will immediately overwhelm all
spontaneous ventilatory efforts. resources.
LOCALIZED INJURY WHOLE-BODY IRRADIATION AND RADIATION SICKNESS
A gray (Gy) is the current unit of radiation, defined as 1 joule (J) A detailed description of whole-body radiation exposure and
of energy deposited in 1 kg of tissue; 1 Gy is the equivalent of 100 its treatment is beyond the scope of this chapter. Radiation sick-
rads. ness, also known as the acute radiation syndrome, may begin
Localized injury is produced by local irradiation of a small area; within hours of exposure. It is initially characterized by nausea,
no systemic effects are produced. As with thermal burns, the vomiting, diarrhea, and lethargy; this is followed by the
degree of injury is dependent on the type of radiation encountered, hematopoietic syndrome (neutropenia and thrombocytopenia)
the radiation dose delivered, and the susceptibility of the tissue. An and the gastrointestinal syndrome (severe diarrhea, bowel
initial erythema appears within minutes or hours of exposure and ischemia, bacterial translocation, and sepsis).130 Treatment is
subsides over 2 to 3 days. Secondary erythema occurs 1 to 3 weeks mainly supportive.
after exposure and is associated with hair loss and desquamation of A nuclear explosion is characterized by a supersonic blast, a
the epidermis. At about 3 weeks, blisters (after doses of about 20 fireball extending miles from the epicenter, and immense
Gy) or ulcerations (after doses in excess of 25 Gy) may occur. amounts of ionizing radiation. These three components interact,
Ulceration may recur months to years after injury. Blood vessels causing severe mechanical injury, flash and flame burns from the
become telangiectatic, and deeper vessels become occluded, lead- ignition of clothing, and, of course, severe radiation exposure.131
ing to fibrosis, atrophy, and necrosis.129 The flash has been described as being so intense that the side of
Wounds are generally treated in a manner similar to the treat- a victim facing the flash will be charred to bone while the oppo-
ment of thermal burns, with the additional caveat that radiation site side is unburned. Doctors in Hiroshima after the atomic
sickness is accompanied by immunosuppression, and that endar- bombing there observed that for a time, thermal burns appeared
teritis obliterans will markedly diminish the blood supply. Infection to be healing, but in the second and third weeks, the wounds
is common, and the optimal timing of excision and grafting of deep broke down and infection set in as the acute radiation syndrome
ulcers is not known. became manifest.
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7 TRAUMA AND THERMAL INJURY 16 Rehabilitation of the Burn Patient — 1
16 REHABILITATION OF THE BURN

PATIENT
Lee D. Faucher, M.D.
Of all the different processes that a burn patient undergoes, reha- It is not surprising that patients with larger injuries have longer
bilitation lasts the longest: it begins on the day of the injury and hospital stays, incur more expenses, and usually require years of
never truly ends. With current methods of burn care, patients are rehabilitation. This being the case, it is reasonable to consider
increasingly able to survive larger, more debilitating burns; accord- whether a person who sustains a massive burn injury and who
ingly, the main objective (and primary measure of success) of may suffer irreparable loss of function as a result can be said to
quality burn care has shifted from survival per se to restoration of have a good quality of life after recovery. Unfortunately, data com-
burn patients to their preinjury level of function, with the best pos- paring the perceived quality of life of severely burned individuals
sible cosmesis. Achieving this objective requires a team of highly to that of unburned healthy individuals are scarce.3
trained and knowledgeable physical and occupational therapists, A massive burn injury has both physical and psychological con-
under the direction of rehabilitation physiatrists. sequences. The physical consequences include pain, itching, and
The specific objectives of a rehabilitation program change over loss of function; the psychological consequences include (but are
time. In the early stages, rehabilitation focuses on restoring base- not limited to) depression, anxiety, loss of self-esteem, and inabil-
line cardiopulmonary status and preventing musculoskeletal dys- ity to socialize. An accurate assessment of quality of life would take
function. In the later stages, rehabilitation focuses on regaining account of both types of consequences. In 1982, the Burn Specific
baseline function, returning to work or school, and adjusting to Health Scale (BSHS) was developed in an attempt to quantitate
possible aesthetic and psychological changes.This changing focus and evaluate quality of life for all burn survivors.4 In 1987, this
underscores the need for an integrated team approach. 114-item inquiry was shortened to an 80-item questionnaire,5 and
The qualifications and capabilities of rehabilitation programs for in 1992, it was again revised and renamed the Revised Burn
burn patients, as well as similar programs for other injuries and neuro- Specific Health Scale (BSHS-R).6 The BSHS-R measures seven
logic disorders, are determined by the Commission on Accredi- domains—simple functional abilities, work, body image, interper-
tation of Rehabilitation Facilities (CARF). This independent, not- sonal relationships, affect, heat sensitivity, and treatment regimens
for-profit organization is responsible for reviewing and granting ac- [see Table 1]—and has proved to be a valid and reliable outcome
creditation requests from facilities. CARF-accredited programs and scale for burn patients. It has also been translated into Finnish and
services have demonstrated that they meet internationally recognized Spanish and has proved reliable and valid in those languages as
standards and have made a commitment to continual enhancement well.The results of the BSHS-R give a clinician an idea of how an
of the quality of their services and programs. More information and a individual patient is affected by the injury and where to focus ther-
complete list of accredited providers can be found at the CARF web apy and treatment. Follow-up evaluations can be used to quantify
site (http://www.carf.org). improvements in quality of life, as was shown in a 2002 study that
A national agenda for addressing rehabilitation and recovery has analyzed 110 burn-injured patients with the BSHS.7 In this study,
been developed, spearheaded by the National Institute on Disability patients had an improved quality of life when overall stress was
and Rehabilitation Research (NIDRR). NIDRR is one of the three reduced and the level of pain lowered. Physical quality of life was
components of the Office of Special Education and Rehabilitative better at 6 months from the time of injury than at 2 months.
Services at the U.S. Department of Education; it operates in concert Fewer than 50% of patients who experience a major burn injury
with the Rehabilitation Services Administration and the Office of return to the same job with the same employer without accom-
Special Education Programs.The mission of NIDDR is to generate,
disseminate, and promote new knowledge so as to improve the op- Table 1—Selected Items from the BSHS-R6
tions available to disabled persons, with the ultimate goal of return-
ing individuals to their preinjury status as integrated members of
Sample Items Response Format
their community. NIDRR is a national leader in sponsoring re-
search: in 2001, it supported 344 projects and had a total annual Heat sensitivity 0—Extreme(ly)
budget of $141 million.1 More information can be found at the Being out in the sun bothers me 1—Quite a bit
NIDDR web site (http://www.ed.gov/offices/osers/nidrr). Hot weather bothers me 2—Moderate(ly)
I can’t get out and do things in hot weather 3—A little bit
It bothers me that I can’t get out in the sun 4—None (not at all)
Quality of Life after Burn Injury My skin is more sensitive than before
Better acute management of patients with massive burns has Work
been one of the major advances in trauma care over the past two My burn interferes with my work
Being burned has affected my ability to work
decades. Before 1970, persons who sustained a burn covering
My burn has caused problems with my working
more than 30% of their total body surface area (TBSA) nearly al-
I’m working in my old job performing old duties
ways died; today, only about 12% of those who sustain burns of
this magnitude die.2
modations having to be made.8 Because most health insurance is lized for substantial periods, ranging from a few days to several
connected with employment, prolonged time off work can cause weeks, as a consequence of their critical illness. Accordingly, early
significant hardship to patients and their families. Little informa- ambulation, its well-established benefits notwithstanding, is not
tion is available on the factors that influence return to work after feasible in this population. Even when a critically ill burn patient’s
burn injury. This is unfortunate, because such information could condition improves to the point where such mobilization is possi-
have a positive impact on quality of life after injury. ble, he or she still usually requires maximal assistance to perform
Quality of life remains difficult to measure. Several studies have this task [see Figure 2]. Factors such as severe weakness, impaired
demonstrated that many burn survivors are able to return to their motor control, and decreased cognitive status are responsible.
preinjury functional status.3,7,9,10 The chances of achieving a posi- Several bed rest studies have determined that the antigravity mus-
tive outcome are enhanced if the patient is free of emotional and cles of the lower extremities are the first muscles to weaken dur-
physical distress and resumes involvement in some of the same ing periods of inactivity.16 A tilt table can be a bridge to ambula-
activities enjoyed before the injury.7,11 Outcome can also be position by allowing a patient to perform a weight-bearing exercise in
tively affected by comprehensive multidisciplinary aftercare10 and a gravity-reduced environment.17
supportive and healthy family dynamics.9 It is important that all wounds be properly dressed and lower-
extremity wounds supported with elastic wraps. Wrapping the
gravity-dependent areas can decrease edema and thus minimize
Components of Rehabilitation pain during periods of ambulation.
The patient should be kept well informed of the progress made
EXERCISE AND AMBULATION during exercise and ambulation sessions. Before any intervention
As noted, rehabilitation is a long and typically painful process.To is started, the goals of each session should be outlined and the
get patients through this process, it is essential to inculcate in them a patient told that the goals will be advanced at each session. Many
solid understanding of the importance of exercise.The underlying patients do well when there is a visual goal (e.g., a specific loca-
principle of the recovery of the burn patient is return to normal tion to which they walk). The use of a toy or a game can some-
function.Through exercise, the patient can attempt to maintain nor- times help younger patients reach the desired goal.
mal activity from admission through hospital care and beyond.The Many clinicians discontinue range-of-motion exercises and am-
specific goals of exercise are to reduce the effects of edema, maintain bulation for 3 to 14 days after autografting to minimize graft trauma.
range of motion, stretch the eschar and scar, and achieve an optimal It is my practice to begin range-of-motion exercises 5 days after
level of function.12 An aggressive exercise program has been shown grafting for hands and faces and 7 days after grafting for other areas.
to improve pulmonary function in severely burned children,13 re- One must remember to weigh the risk of graft loss against the possi-
ble loss of function when ordering a period of inactivity.
duce the need for scar release after burn,14 and also improve muscle
strength, power, and lean body mass.13 PRESSURE AND OCCLUSION
Scar is the limiting factor for proper range of motion. Some
scar is always made as burns or grafted areas heal. Burns and burn Pressure Garments
scars lead to contractures, and the skin that overlies joints is at the
The use of pressure garments on grafted burns or burns that
highest risk for loss of function.15 A patient with full range of
take longer than 14 days to heal is considered standard care in
motion can lose a great deal of range overnight after a burn.
most burn care centers, despite reports in the literature that ques-
Monitoring of range of motion in all joints should be done on a
tion its efficacy.18,19 The proponents of the use of pressure assert
daily basis so that attention can be directed to specific joints at that it helps reduce hypertrophic scarring by decreasing blood
risk. Trained therapists should be brought in to provide instruc- flow and oxygen delivery, thereby lowering the rate of collagen
tion about exercise methods tailored to individual patients and
varying levels of understanding.
Range-of-motion exercises should begin on the day of admission.
Ideally, they should be done twice daily on all joints of the upper and
lower extremities [see Figure 1]. Care must be taken with especially
painful and newly grafted areas. Patients with large burns may be in-
capacitated and unable to participate in these exercises. Passive
stretching of all extremities should be done during times when pa-
tients cannot perform the range-of-motion exercises.
It is often helpful to coordinate exercise with administration of
pain control medications. Patients frequently undergo general
anesthesia for excision and grafting several times during the early
postburn period. Such occasions provide a good opportunity to
evaluate a patient for range-of-motion limitations, in that the
activity will not be hindered by pain. As the patient begins to par-
ticipate in range-of-motion exercises, the therapist can begin pas-
sive resistance exercises. This step is the beginning of strength
training, in which the amount of resistance is increased until the
patient (ideally) returns to his or her preinjury state.
Early ambulation is known to help maintain range of motion,
maintain strength in the lower extremities, and prevent throm-
boemboli; it is also known to maintain bone density and promote Figure 1 Shown are range-of-motion exercises being done on the
functional independence.12 Patients with large burns are immobi- hand.
trials have conclusively demonstrated that such therapy minimizes

hypertrophic scarring.
SPLINTING
Splinting can be used as an adjunct to range-of-motion therapy

throughout all phases of burn care. It is also used postoperatively
to protect newly placed autografts. Many ready-made splints are
available, but most therapists prefer to customize splints for the
needs of each patient; in this way, changes can easily be made as
these needs evolve. In every case, the overall medical status of the
patient and any associated injuries must be taken into account in
the decision process.
Certain positions are generally used for splinting various areas
of the body. The neck is splinted in extension; the arms are exter-
nally rotated, abducted, and supinated; the trunk is straight; the
hip and knee are in neutral rotation and straight; and the feet are
in dorsiflexion. Particular patients may have slightly different
needs, but this overall plan should be followed.
There are several principles that should be followed in design-
Figure 2 Patients who have sustained major burn injuries typi- ing a splint [see Table 2]. In particular, the splint should not cause
cally cannot be mobilized for days to weeks after their injury.
pain and should be easy both to apply and to remove. In addition,
Even when they have improved sufficiently to permit mobiliza-
it should be lightweight and should allow adequate ventilation so
tion, they usually require considerable assistance.
as to minimize the risk of skin breakdown.
The use of continuous passive-motion devices in conjunction
deposition in the healing wound. As a result, a balance is reached with passive splints can provide an additional therapeutic option
between production and breakdown of collagen, leading to a flat- for increasing the range of motion of certain joints.
ter scar.20 Clinical studies, however, have not found this to be the
PAIN CONTROL
case and have shown that pressure garments do not alter wound
maturation time.19 Moreover, patient compliance with the use of Quantifying pain is notoriously difficult, but it is widely believed
pressure garments is generally very poor,21,22 and medical insur- that a burn injury may be the most painful trauma a person can
ance often does not cover their cost.23 sustain. Proper treatment of a burn involves daily wound care,
Those who elect to use pressure garments in the treatment of exercise, and ambulation, all of which are painful. Initial care is fol-
burn scars and tissue edema adhere to the following simple plan. lowed by months of rehabilitation, which often makes patients feel
If a burn heals in less than 14 days, pressure is not used. If a burn that their pain is unending. All patients have different thresholds
takes 14 to 21 days to heal, pressure is applied only if the wound for pain and different abilities to cope with pain and long-term
begins to show signs of hypertrophy. Finally, pressure therapy is rehabilitation. Satisfactory pain control is not always achievable,
always used in grafted burns and those that take longer than 21 but it should always be striven for. Poor pain control can render a
days to heal. patient unable to complete required tasks during therapy.
Pressure garments deliver pressures ranging from 10 to 40 mm A generalized treatment plan for pain control follows a struc-
Hg; the usual recommended pressure is about 25 mm Hg, so as tured approach that is unique to each burn patient. The plan
to oppose the capillary pressure.24 The garments come in many should cover the three types of pain involved: background pain,
colors and are custom-made for each patient for use on any part breakthrough pain, and procedural pain. Narcotics and anxiolyt-
of the body. They conform to body movements and can be worn ics should be employed as needed, and nonpharmacologic thera-
during therapy or other activities. The garments should be worn pies should be included as appropriate. The plan should also be
23 hours a day. They are quite durable, lasting about 3 months. flexible and capable of conforming to the changing needs of the
When the garments no longer feel tight to the patient, they should
be replaced.
Silicone Table 2—Purpose of General
Topical application of silicone has also been employed to treat Splinting Design12
burn-related scarring. Of the various forms of silicone available—flu-
ids, gels, and elastomers—elastomer sheets are most commonly used Allows for edema reduction
for this purpose today.25 Silicone elastomer sheets easily conform to Maintains joint alignment
Supports, protects, and immobilizes joints
the contours of the burn wound and can be used either in conjunc-
Maintains and/or increases joint range of motion
tion with pressure garments or alone. Silicones are not believed to Maintains tissue elongation
apply any significant pressure to the wound; rather, they are believed Remodels joint and tendon adhesions
to increase the wound temperature and thereby change the oxygen Promotes wound healing
tension, thus reducing scarring.26 An alternative theory is that sili- Relieves pressure points
cone provides a water barrier that allows the scar to remain hydrated Protects newly placed grafts
and thus decreases blood flow, thereby reducing collagen deposition Allows normal function of nonsplinted joints
and scar hypertrophy.27 Counteracts gravity to assist in functional activity
Much is known about the effect of topical silicone application, Strengthens weak muscles
but to date, as with pressure garments, no randomized, controlled
patient. Each institution should develop its own guideline-based

approach to pain control [see Table 3].28 Table 3—Guideline-Based Approach to
Opioid agonists are the cornerstones of therapy for burn-related Pain Control in Burn Patients28
pain.These agents provide good flexibility in that they can be admin-
istered via different routes and in varying dosages and possess differ- Promise attentive patient care
ent durations of action. Nonsteroidal anti-inflammatory drugs Chart and display assessment of pain and pain relief
(NSAIDs) and acetaminophen, though rarely indicated in the acute Define pain and relief levels to trigger review
setting, can be very useful throughout the rehabilitation period. Survey patient satisfaction
Monitor treatment efficacy
A number of nonpharmacologic adjuncts to pain control have
been studied for use during the acute phase of burn care, includ-
ing hypnosis, virtual reality, and cognitive interventions. Each of
these has proved to offer some benefit in this setting, but there are occurred around postburn day 30, and that 90% of patients were
few data on their use in the rehabilitation and recovery phase. able to tolerate a regular diet at discharge.40
Nevertheless, it would seem logical that learned pain management
techniques, such as distraction and relaxation, might assist pa- SKIN CARE
tients throughout their entire course of therapy, not just in the Grafted and healed burn skin is not as durable as uninjured
acute phase of care. skin. The injury itself depletes the skin of its native ability to
remain moisturized, and this depletion increases the likelihood of
WEIGHT GAIN AND RECOVERY
chapped skin. Liberal use of skin products that contain lanolin can
In no other disease or trauma is the postinsult hypermetabolic re- help keep the skin moisturized. These products may also lessen
sponse as severe as it is in a major burn injury. A person with a 40% itching and thus reduce the likelihood of trauma from scratching.
TBSA area burn may have metabolic requirements that are twice Healed and grafted burns are also at risk for hyperpigmentation
normal.29 The hypermetabolic response begins on postburn day 5 if exposed to direct sunlight during the postinjury inflammatory
and continues for nearly 1 year afterward.30 phase, which may last as long as 2 years after a burn.41 A sun block
Severe catabolism and loss of lean body mass are well-recog- should be used at all times during exposure to sunlight, in combi-
nized complications of major burn injury. Approximately 30% of nation with clothing that provides appropriate coverage. Clothing
the calories burned during the hypermetabolic state are from mus- by itself does not offer sufficient protection: ultraviolet light can
cle, and weight loss rates as high as 1 lb/day have been described.31 penetrate clothing and cause skin damage.42
Continued loss of lean body mass can lead to further complica-
tions from depressed immune function, pneumonia, and impaired Itching
wound healing.32 Patients recovering from burn injuries can suffer severe dis-
The mainstay of treatment is prevention of weight loss by giv- comfort from itching. Itching does not stop when the wound is
ing a diet high in calories and proteins. A typical daily intake closed but continues throughout the healing process. Histamine
ranges from 30 to 35 cal/kg/day, with 1.8 to 2 g/kg/day of protein. released during the inflammatory phase of wound healing and
Close monitoring of daily intake of nutrition and daily measure- during the prolonged phase of collagen deposition is thought to be
ment of weight are necessary. A dietitian with special training in the main cause of itching, but stress and opioid medications have
the nutritional needs of burn patients can take on the task of daily been implicated as well.
monitoring and can be a great asset to the burn care team. A number of studies have attempted to identify the optimal treat-
Severe catabolism in a burn patient is the result of increased lev- ment of itching.Therapies evaluated in these trials include antihista-
els of catabolic hormones, decreased levels of anabolic hormones, mines, skin moisturizers, distraction therapy, special bath oils, and
and direct cell injury caused by inflammatory mediators.33-35 low-dose antibiotics.To date, none of these treatments, either alone
Oxandrolone, an anabolic steroid and testosterone analogue, can or in combination with others, has been shown to be effective.
increase the rate of weight gain when used in conjunction with an Currently, however, the therapeutic picture is beginning to look
aggressive exercise program and appropriate nutrition,32 and its brighter. There are now two topical creams for which there is
use is not age-dependent in adults.36 These positive effects have promising preliminary data supporting their efficacy against post-
not yet been replicated in children. burn itching. In a 2002 report, topical 5% doxepin cream, applied
to healed burn wounds three times daily, significantly decreased
SPEECH THERAPY
burn itching in comparison with oral antihistamines.43 In a pilot
Speech pathologists also fill an important role in the multidisci- study from the same year, topical dapsone gel, applied one to four
plinary burn care team.They possess special skills in the early clin- times daily, significantly reduced itching in 84% of patients.44 As
ical evaluation and management of dysphagia and can provide an of October 2003, dapsone was being evaluated in phase II trials; it
accurate assessment of the efficacy of the pharyngeal phase of is hoped that further promising results will follow.
swallowing so as to determine the adequacy of airway protection.37
MASSAGE THERAPY
They can also offer useful assistance in stretching and strengthen-
ing the facial and oral muscles.38 Although massage has been a part of burn care for some 400
Dysphagia, defined as the inability of a patient to accept and years,45 there is little in the way of high-level evidence to indicate that
safely transport food and liquid from the mouth to the stomach, is it is effective in reducing burn scarring. One thorough study found
a consistent and prominent impairment associated with all types no difference between a group of patients that received massage and
of burn injuries.39 Patients with larger burns may also require pro- a control group that did not,46 but the authors admitted that the 10-
longed mechanical ventilation, in which case the initial dysphagia minute treatments administered may not have been long enough.
assessment is delayed until extubation. A retrospective review from Massage has, however, been shown to decrease itching,47 pain,47-49
2001 found that the initial dysphagia assessment typically oc- anxiety,47-49 anger,49 and depression47,49 and thus is a useful adjunct
curred around postburn day 20, that the first safe oral intake in burn treatment and rehabilitation.
BODY TEMPERATURE REGULATION One way of possibly reducing hypertrophic scarring and contrac-
Core body temperature is regulated through alteration of cuta- ture is to minimize the period over which wound contraction takes
neous blood flow and dissipation of heat via sweating. A full-thick- place. Early excision and grafting have been shown to lessen the
ness burn destroys the dermis and the elements that are the basis amount and intensity of inflammation59 and reduce the develop-
of temperature regulation. The body can compensate for this loss ment of hypertrophic scarring by shortening the duration of the in-
through excessive sweating in the unburned areas of the body, but flammatory phase.60 In grafting a wound, it is important to use
this compensatory response is believed to be limited to patients enough tissue to cover all of the wound edges and to use sheet grafts
whose burns cover less than 40% of their TBSA.50 There are, how- whenever possible.59 A full-thickness skin graft results in less skin
ever, current data suggesting that improved cardiovascular fitness contraction during healing than a split-thickness graft does.The thin-
may allow patients with larger burns to mount such a response.51 ner the split-thickness graft, the greater the degree of contraction.
Because healed and grafted burns have less cutaneous blood The main treatment options for hypertrophic scar are aggressive
flow, effective conductive heat loss cannot be achieved through range-of-motion therapy and surgical excision.When therapy fails to
vasodilation.50,52 Sweating in these areas does not aid in evapora- stretch the scar and a life-style–limiting contracture develops, surgi-
tive heat loss either, because of an isolation effect in the hypovas- cal excision may become necessary. Often, the scar is excised and the
cularized area.53 As a consequence of the impairment of both con- defect covered with another skin graft. Alternatively, the scar may be
excised and the wound closed primarily, provided that there is
ductive and evaporative heat loss mechanisms, patients exercising
enough tissue to allow coverage of the wound with a tension-free clo-
in climates that are both hot and humid have the greatest difficul-
sure. Corticosteroid injection into the wound after scar excision has
ty in maintaining their thermoequilibrium.
been studied and found to yield a 30% to 100% reduction in scar-
Control of ambient temperature is most critical during the
ring.61 To date, no prospective, randomized trials have evaluated the
acute phase of burn care and in the operating room. In my expe-
use of corticosteroid injections in this setting, but the initial results
rience, burn patients who are in the rehabilitation phase are not
are undoubtedly promising.
uniform in their tolerance to heat and cold: some require more
clothing to tolerate the cold, and others have the same exercise tol- HETEROTOPIC OSSIFICATION
erance after their burn as they had before it. I know of one burn
Heterotopic ossification (HO) is a condition in which mature
patient whose temperature tolerance changed so drastically that he
lamellar bone is laid down in tissues that do not usually ossify. HO
had to move to a snow-belt state to get away from the heat, and I was first described in the early 20th century and usually occurs in
know of another who had to move out of a snow-belt state to get patients who have medical conditions with poor prognoses. As sur-
away from the cold. vival rates have increased in patients with major burns, so too has
Whenever patient temperature tolerance negatively affects burn the incidence of HO: it is currently about 3% overall.62 HO tends
rehabilitation efforts, the ambient environment must be changed to affect joints underlying areas of full-thickness burns in patients
to meet the individual patient’s needs. with burns covering more than 20% of their TBSA,62 but it can
occur anywhere. The most common site is probably the upper
Special Problems extremity, with the elbow the most frequently involved joint.63
At present, how best to treat HO is as uncertain as what causes it.
HYPERTROPHIC SCARRING All treatment modalities remain controversial. Surgical treatment
yields less than optimal results. Medical treatment incorporates the
When skin is injured, scar is formed in an attempt to rapidly use of steroids and NSAIDs for prophylaxis and treatment.64
restore protective covering to the injured area; the reason why scar Etidronate, an inhibitor of osteoclast bone resorption, has proved ef-
is formed instead of the original tissues being regenerated is not fective at reducing HO developing after spinal column65 and hip in-
known. During this attempt to form a new protective covering, juries.66 This agent has yet to be prospectively studied in burn pa-
new connective tissue is created, which gives the scar strength. tients but is widely used to treat HO in this population nonetheless.
When scar formation becomes extensive, it leads to a hypertrophic
scar. A hypertrophic scar is a raised, erythematous, pruritic, and PSYCHOLOGICAL PROBLEMS
inelastic mass of tissue that is the result of a large amount of extra- A burn injury can be the most aesthetically devastating traumatic
cellular matrix whose composition and organization are altered event a person can experience. Given society’s emphasis on youth
from those of normal dermis. Microscopically, there is a whorllike and beauty, a severely impaired appearance can be socially incapaci-
pattern of collagen, an abundance of immature connective tissue, tating. Furthermore, the very process of being treated for a major
and a prolonged chronic inflammatory reaction.54 The extracellu- burn can cause psychological difficulties. Patients with burn injuries
lar matrix is composed of a multitude of cell types that are main- essentially lose control of their lives upon arrival at the burn center.
tained in a hyperactive state by inflammatory mediators. Every moment of every day is planned for them: they undergo thera-
Formation of hypertrophic scars is generally considered common py, wound care, nutritional supplementation, and operations accord-
after a burn injury; surprisingly, however, published data on the ing to a strict schedule for an indeterminate period.
prevalence of hypertrophic scarring after burn injury are scant.55 Es- Accordingly, it is not surprising that psychological problems are
timates range from 4% in burns that heal spontaneously56 to 75% in identified in a significant number of burn patients. Effective treat-
grafted burns.57 Eventually, all hypertrophic scars undergo some ment may include psychological debriefing, use of appropriate
spontaneous resolution, but such resolution is unpredictable. pharmacologic interventions, exposure therapy, or desensitiza-
Tissue contraction is a normal and necessary part of wound tion.67 It is important to provide psychiatric services as soon as the
healing. Contracture, however, is an abnormal process resulting need arises, so that early and effective interventions can support
from long-term shrinkage of a scar. This process can continue the patient through this traumatic event.
indefinitely until it either achieves a comfortable position or meets Previous psychiatric diagnoses have been shown both to
an equal opposing force.58 If allowed to progress uncontrolled, increase mortality and to prolong length of stay.68 Preexisting psy-
contracture can lead to a loss of function in the affected area. chological disorders can be exacerbated during rehabilitation, and
new ones can arise even in the absence of risk factors. Any previ- The first priority in burn reconstruction is to obviate further
ous psychiatric diagnosis warrants early and effective intervention reconstruction by providing proper postoperative care.The second
in the acute phase of burn care.The clinician, the pharmacist, and priority is to restore active function, and the third is to restore pas-
the psychiatrist must have a firm understanding of burn physiolo- sive function. To address these priorities requires a systematic
gy and burn pharmacokinetics to ensure that an effective medical approach that includes all members of the multidisciplinary burn
treatment plan is established. team, as well as the patient. By following a rational and orderly
Depression, anxiety, and guilt often arise during the early plan of possible reconstruction and considering the patient as a
course of rehabilitation. Posttraumatic stress disorder (PTSD) whole, the question of what is to be reconstructed and in what
may develop in as many as 43% of patients during the hospital order can be clarified.
phase of burn care. Alteration of the patient’s self-image is thought Primary closure is preferred with any wound, whether the
to be the most common predisposing factor for PTSD; other fac- wound is being repaired directly or is undergoing reconstruction.
tors include poor pain control and associated physical impair- In many burn patients, however, the wound is too large to allow
ments. Often, PTSD develops only after hospital discharge, and it primary closure. Occasionally, large hypertrophic scars that are
is difficult to identify patients at risk.69 Therefore, it is imperative surrounded by uninjured tissue can be excised through multiple
for clinicians to provide education and psychological intervention excisions and primary closure. This is a time-consuming process
to all patients during the hospital course and maintain aggressive but will lead to a good result.
follow-up after discharge. Z-plasty may be employed to gain length along a scar or skin fold
The most effective way of treating PTSD is to attempt to min- at the expense of surrounding tissues [see 3:7 Surface Reconstruction
imize its occurrence. To this end, control of pain and anxiety is Procedures].The angles of the limbs of the Z dictate how much length
essential. As stated (see above), opioids are the cornerstone of pain can be gained over the original scar: approximately 25% for 30° an-
management. The addition of benzodiazepines can facilitate pain gles, 50% for 45° angles, and 75% for 60° angles.
control considerably.Withdrawal from these medications can pro- If these approaches are not feasible, the alternative is excision of
duce symptoms similar to those of PTSD, but this concern should the scar or contracture with placement of a skin graft [see 3:7 Surface
not dissuade clinicians from using them when appropriate. Nearly Reconstruction Procedures]. After excision of the scar, the wound usu-
every psychotropic medication has been tried as therapy for ally retracts quite widely, leaving a much larger skin deficit. The
PTSD; none has yet proved more effective than any of the others. thickness of the graft depends on the need for the reconstruction.
Thinner grafts are more likely to survive but are at higher risk for
NEUROLOGIC COMPLICATIONS
wound contracture during the maturation phase. Full-thickness
Peripheral neuropathy is a well-known complication after major grafts have the best color matching and hair pattern, but they require
burn injury, but its incidence is unknown. In 1971, when this com- near-perfect conditions to survive, and the donor sites do not heal
plication was first described, the incidence was reported to be 15% spontaneously. If a full-thickness graft is needed for reconstruction
in the 249 burn patients studied.70 Since then, multiple studies and the donor site cannot be closed primarily, the donor site can be
have been done, reporting incidences ranging from 2% to 84%.71-75 closed with a split-thickness skin graft.
In all of these studies, peripheral neuropathy was correlated with A flap may be used for reconstruction when primary closure
increased length of stay, increased percentage of TBSA burned, and skin grafting either are not possible or are undesirable.
and electrical injury. Exposed bones or tendons must be covered with a vascularized
In a 2001 retrospective review of cross-sectional data from 572 section of tissue because they lack the vascular supply required
patients with major burn injuries, the incidence of peripheral neu- to support a skin graft. Contour defects are also managed with
ropathy was 11%.76 The patients who were more likely to exhibit flaps.
peripheral neuropathy were those whose burns covered more than Several types of flap are used in burn wound reconstruction [see
15% of their TBSA, those who spent more than 20 days in the 3:7 Surface Reconstruction Procedures]. A random flap receives its
intensive care unit, and those who sustained electrical injuries.76 blood supply from the musculocutaneous arteries penetrating its
Precisely what causes peripheral neuropathy is not known. It is base; the Z-plasty (see above) is an example of this type of flap. An
important that all burn patients, especially those with known risk fac- axial flap receives its blood supply from a direct cutaneous artery;
tors, receive comprehensive neurologic examinations aimed at de- the pivot point of the flap is the artery itself. A radial forearm flap
tecting this devastating complication. It is often possible to limit the is the classic example of this type of flap. Axial flaps are very use-
progression of peripheral neuropathy—and sometimes to prevent ful in burn reconstruction, but an exact knowledge of cutaneous
it—by paying particular attention to (1) prevention of compartment arterial anatomy is necessary to design one. A free flap can be
syndrome, (2) proper patient positioning (to prevent nerve compres- divided from its vascular pedicle and used to cover a distant defect.
sion), (3) use of the shortest feasible tourniquet times, and (4) avoid- Free flaps are highly useful in burn patients because very often, the
ance of prolonged use of compressive dressings. tissue surrounding a defect is also damaged and cannot be used
for reconstruction.
Tissue expanders may also be used to achieve wound coverage.
Burn Wound Reconstruction An expandable device is surgically placed beneath the skin and
Reconstruction of a burn wound is postponed until the wound gradually increased in size, thus stretching the uninjured skin so
is fully matured, which can take as long as 2 years.59 If, however, that it may be used to cover the defect.This technique is best suit-
contracture is causing a severe functional deficit, early reconstruc- ed to parts of the body with a bony background (e.g., the skull or
tion is indicated to correct the problem. the chest wall).
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7 TRAUMA AND THERMAL INJURY 17 INJURIES TO THE PERIPHERAL BLOOD VESSELS — 1
17 INJURIES TO THE PERIPHERAL

BLOOD VESSELS
Todd R.Vogel, M.D., M.P.H., and Gregory J. Jurkovich, M.D., F.A.C.S.
Before and during World War II, management of extremity vascu- may give rise to an intimal flap, a pseudoaneurysm (secondary to
lar trauma consisted of vessel ligation, which resulted in amputa- partial arterial injury), or an arteriovenous (AV) fistula.
tion rates as high as 70%. As surgical techniques improved and Penetrating trauma may transect the vessel completely and may
primary arterial repair became standard, amputation rates be manifested as thrombosis resulting from vessel spasm or frank
declined to approximately 30%. By the time of the Vietnam War, bleeding. If the vessel is only partially transected, it may contract
the use of routine angiography and repair had reduced amputation and continue to bleed; even if it is initially controlled, it may
rates to 15%.1 On the modern battlefield, the incidence of extrem- rebleed as the patient is resuscitated and arterial pressure rises
ity injury remains high, with 88% of vascular injuries occurring in toward normal. In many cases of penetrating trauma, the location
the extremities.2 Current management of extremity arterial trau- of a presumed vascular injury may be determined simply by fol-
ma yields amputation rates ranging from 5% to 20%.2-4 lowing the path of the penetrating object. If there is evidence of
In this chapter, we outline the current standard of care for vas- ongoing bleeding from a penetrating vascular injury, prompt oper-
cular injuries in the extremities. Management of such injuries ative intervention, without further evaluation, is indicated.The risk
requires knowledge of mechanisms of injury, awareness of high- of amputation varies: stab wounds are unlikely to lead to amputa-
risk injury patterns, familiarity with modern diagnostic techniques tion, whereas high-velocity firearm injuries with concomitant blast
and their indications, and comprehensive understanding of the effect and tissue loss are considerably more likely to do so.5 In
assessment, triage, and management decisions that influence out- modern military contexts, blast injuries account for 50% to 70%
come in this setting. of cases of vascular trauma.2 Vascular trauma from blast wounds
may present as thrombosis (related to intimal injury resulting from
the application of kinetic force to the tissue) or as deep cavitary
Mechanisms and Sites of Extremity Vascular Injury injuries with vessel disruption and even segmental arterial loss.
BLUNT VERSUS PENETRATING TRAUMA LOCATION OF INJURY AND RISK OF AMPUTATION
Arterial trauma is typically classified according to the general Extremity vascular trauma is commonly encountered by sur-
mechanism of injury—that is, blunt or penetrating—because differ- geons in both urban and rural practices. In urban settings, upper-
ent mechanisms tend to produce different types of injuries. After and lower-extremity injuries account for 40% and 20% of all vas-
blunt trauma, the vascular injury most commonly seen is avulsion, cular injuries, respectively.6 In rural settings, extremity injuries
in which the artery is stretched.This stretching results in disruption account for approximately 50% of all vascular injuries.3
either of the tunica intima alone or of both the tunica intima and Current military data indicate that the most frequently injured
the tunica media, leaving the highly thrombogenic tunica externa lower-extremity vessel in the setting of penetrating trauma is the
to maintain temporary vessel continuity [see Figure 1]. Complete superficial femoral artery (SFA), followed by the popliteal artery,
occlusion typically occurs when significant intimal damage leads to the profunda femoris, the tibial arteries, and the common femoral
thrombosis of the artery. Injuries that do not produce occlusion artery (CFA); the most frequently injured upper-extremity vessel
a b c
d e Figure 1 Shown is an avulsion

injury, in which the artery is
stretched, resulting either in par-
tial (a) or complete (b) intimal
disruption or in complete intimal
or medial disruption (c), with or
without pseudoaneurysm forma-
tion (d) and complete separation
of all layers of the vessel wall (e).
is the brachial artery, followed by the radial artery and the ulnar injury, whereas the onset of ischemic neuropathy may be delayed
artery.2 In civilian settings, injuries leading to limb loss often for minutes to hours); and a wound that is in proximity to vascu-
include damage to bones and nerves. lar structures.7 Management of patients with soft signs of injury
Stepwise logistic regression analysis demonstrates that the follow- presents a more difficult diagnostic dilemma and is discussed in
ing are independent risk factors for amputation: occluded grafts, com- more detail elsewhere (see below).
bined above-the-knee and below-the-knee injury, tense compart- It is important to keep in mind that palpation of a pulse is a
ments, arterial transections, and associated compound fractures.5 subjective measure and is thus prone to wide interobserver varia-
tion. Furthermore, pulses may be palpable distal to major arteri-
al lesions, including complete arterial disruptions.7,8 These limita-
Initial Assessment tions notwithstanding, a precise and well-documented physical
examination is an appropriate screening tool for vascular injuries.
HISTORY
NONINVASIVE EVALUATION IN CONJUNCTION WITH
Assessment of an injured extremity starts with a history, which
can be obtained in parallel with the physical examination.The infor-
mation that should be collected includes the patient’s bleeding his- In patients with soft signs of arterial injury, the ankle-brachial
tory at the scene, the time of injury, and the mechanism of injury. index (ABI)—also known as the arterial pressure index (API),
the Doppler pressure index (DPI), or the ankle-arm index
(AAI)—is a highly useful adjunct to the physical examination.
The physical examination is the most important part of the The ABI is obtained by placing a blood pressure cuff on the
assessment. A careful evaluation of the extremities can provide supine patient proximal to the ankle or wrist of the injured limb.
information on the location and severity of vascular injuries; iden- The systolic pressure is determined with a Doppler probe at the
tify the trajectory and the entrance and exit points of wounds; and respective posterior tibial and dorsalis pedis arteries or at the
suggest appropriate triage and management of vascular injuries. ulnar and radial arteries. The ratio of the highest systolic pres-
The initial part of the examination should follow advanced sure obtained in the affected extremity to the systolic pressure in
trauma life support (ATLS) guidelines, with attention paid to the an unaffected extremity (most often a brachial artery) is the ABI
ABCs (Airway, Breathing, and Circulation). Areas of obvious [see Figure 2].
hemorrhage should be addressed in the primary survey; more A 1991 study assessed the sensitivity and specificity of Doppler-
specific evaluation of the extremities for vascular injury can be derived arterial pressure measurements in trauma patients under-
carried out during the secondary survey. Blood pressure, temper- going evaluation for possible extremity vascular injury.9 An ABI
ature, and distal pulses are evaluated. Side-to-side symmetry is was obtained in 100 consecutive injured limbs, and all patients then
important; thus, injured extremities should be compared with underwent contrast arteriography. An ABI lower than 0.90 was
their uninjured counterparts. 87% sensitive and 97% specific for arterial injury. The authors
If pulses are absent and a joint dislocation or fracture-disloca- concluded that in the absence of hard signs of arterial injury, ABI
tion is present, then reduction should be done. Frequently, a is a reasonable substitute for screening arteriography, particularly
pulseless extremity regains pulses once the fracture or dislocation if continued observation can be ensured.
is reduced. If pulses return after reduction, the assessment may The use of the ABI has been extended to the management of blunt
move on to the next priority. If pulses do not return, vascular extremity trauma associated with high-risk fractures and disloca-
injury is assumed, and treatment of such injury becomes the tions. In a controlled trial that included 75 consecutive patients with
immediate priority. blunt high-risk orthopedic injuries, the negative predictive value of
Once the initial part of the examination has been carried out, a a Doppler-derived ABI higher than 0.9 was 100%. In the 70% of
neurologic examination should be done. Motor and sensory func- patients who had an ABI higher than 0.9, clinical follow-up revealed
tion should be assessed in a distal-to-proximal direction on each no major or minor arterial injuries. Of the 30% who had an ABI
extremity. Any gross limb deformities should be reduced and lower than 0.9, 70% had an injury that was diagnosed by arteriog-
splinted to yield a more anatomic alignment of the extremity and raphy, and 50% of these injuries necessitated operative repair.10,11
relieve any compromise of neural or vascular structures. It is important to remember that there are several situations in
which a vascular injury may not lead to an abnormal ABI. For
CLINICAL CATEGORIZATION OF VASCULAR INJURY
example, an injury that is considered nonaxial (e.g., an injury to
Traditionally, clinical evidence of vascular injury has been the profunda femoris in the thigh or the profunda brachii in the
divided into hard and soft signs. Hard signs of extremity vascular arm) may not lower the ABI and thus may be missed. In addition,
injury include arterial bleeding, ongoing hemorrhage with shock, a lesion that does not disrupt arterial flow (e.g., an intimal flap or
an expanding or pulsatile hematoma, a palpable thrill or audible a transected artery that is maintained in continuity by connective
bruit over the injured area, absent distal pulses, and limb ische- tissue) may yield a normal ABI. Finally, an AV fistula may be asso-
mia. When a patient presents with hard signs of vascular injury, ciated with a normal ABI.
immediate surgical exploration and vascular repair are warranted. Certain patient characteristics may affect the ABI as well. For
The exception to this rule is the case where the patient presents example, noninvasive measurement of the ABI may fail to detect
with multilevel trauma to an extremity and the level of arterial an injury if the patient is severely hypotensive or in shock and the
injury is in question. In this situation, arteriography is indicated— clinical circumstances do not permit placement of a cuff around
preferably intraoperative angiography to minimize delay in repair- an injured site or extremity. Moreover, elderly patients may have
ing the injury and to facilitate intraoperative decision making. abnormal preinjury ABIs as a consequence of atherosclerosis. In
Soft signs of vascular injury include a history of severe hemor- these situations, the concept of symmetry is crucial. It is also
rhage at the scene; hypotension; a stable, small hematoma that is important to consider the possibility that the patient may have
not expanding or pulsatile; diminished or unequal pulses; a neu- previously undergone peripheral vascular surgery, though this is
rologic deficit (primary nerve injury occurs immediately after rarely the case in the typical trauma population.
Patient presents with injured extremity
Look for signs of extremity vascular injury.
Hard signs of vascular injury (e.g., pulseless Hard signs of vascular injury are absent; only
limb, audible bruit or palpable thrill, pulsatile soft signs (e.g., hypotension, diminished
hemorrhage, expanding hematoma, or limb or unequal pulses, neurologic deficit, proximity
ischemia) are present of wound to vessels, or stable, small hematoma)
are noted
Measure ABI.
Patient does not have Patient has multilevel trauma

multilevel trauma (e.g., floating joint or shotgun wound)
Perform immediate ABI < 0.90 ABI > 0.90

surgical exploration
and vascular repair. Perform duplex US.
Sonogram is positive Sonogram is negative
Figure 2 Shown is an
algorithm for the workup
of a patient with potential
extremity vascular injury. Perform arteriography. Follow patient with serial clinical exams,
(US—ultrasonography) Perform surgical exploration and vascular repair. without further workup.
IMAGING ed for arteriography in the evaluation of similar vascular trauma

patients. Duplex ultrasonography has no inherent risks, and it may
Diagnostic Angiography be more cost-effective for screening certain injuries than either
Arteriography has a sensitivity of 95% to 100% and a specificity arteriography or exploration. Duplex ultrasonography has been
of 90% and 98% and is therefore considered the gold standard for shown to be a reliable method of diagnosis in patients with poten-
evaluation or confirmation of arterial injury.12,13 In the setting of tial peripheral vascular injuries.18,19
extremity injury, however, nonselective angiography has not been The advantages of duplex ultrasonography notwithstanding, it
found to be cost effective, and it is often overly sensitive, detecting is important to remember that this imaging modality may not be
minimal injuries that do not call for further management.14-16 Fur- equally appropriate in all scenarios. As an example, given that
duplex ultrasonography is highly operator dependent, the results
thermore, arteriography can be time consuming, can delay defini-
of duplex examination may not be reliable in situations where the
tive treatment, and can give rise to complications of its own, includ-
examiner has not had sufficient access to the technology or expe-
ing renal contrast toxicity and pseudoaneurysm formation.16
rience with the technique. As another example, injuries in certain
Angiography should be reserved for patients with soft signs of
anatomic locations (e.g., injuries in regions where bone structures
vascular injury and an abnormal ABI; there is little reason to per-
interpose themselves, injuries in areas with concomitant soft tissue
form angiography in a patient with hard signs of injury, unless an injuries, injuries that dive into the pelvis or chest, and injuries in
intraoperative angiogram is needed to delineate the anatomy. In no patients with a large body habitus) may not be well visualized by
case should transport to the OR for definitive treatment be delayed duplex ultrasonography. Such considerations are important in
so that arteriography can be performed. Several reviews have sup- assessing patients with potential extremity vascular injuries; if
ported reserved use of arteriography in this setting. A 2002 report either applies in a given case, angiography may be required.
concluded that physical examination in conjunction with measure-
ment of the DPI (i.e., the ABI) was an appropriate method of iden- Computed Tomographic Angiography
tifying significant vascular injuries caused by penetrating extremity Ongoing radiologic advances have led some centers to consider
trauma.17 Patients with normal physical examinations and normal using computed tomographic angiography (CTA) to evaluate
DPIs could safely be discharged; angiography was indicated only arterial injury. To date, this approach has been formally evaluated
for asymptomatic patients with abnormal DPIs.17 in only a modest number of studies, though there is reason to
believe that it will be more widely used in the future. A few small
Duplex Ultrasonography
series found CTA to have a sensitivity and specificity of approxi-
Several studies have evaluated the efficacy and accuracy of mately 90% in the evaluation of large arteries; other studies sug-
duplex ultrasonography in the setting of extremity vascular trau- gested that this modality might be a reasonable alternative to con-
ma.The sensitivity of duplex ultrasonography is between 90% and ventional arteriography for diagnosis of traumatic arterial injuries.
95%, the specificity is in the range of 99%, and the overall accura- Before CTA can be considered equivalent to the gold standard,
cy is between 96% and 98%.These figures approach those report- large randomized trials will have to be performed.20,21
MANAGEMENT ALGORITHMS should be performed, the results of which will dictate the final plan
On the basis of the data available on noninvasive assessment of action. It is impossible to define every single clinical scenario
and diagnostic imaging, an effective management algorithm can that could possibly give rise to arterial trauma.The ABI fulfills the
be created [see Figure 2].22,23 If the ABI is higher than 0.9, the requirements of a useful screening tool, in that it is sensitive, spe-
patient may be followed clinically without further workup. If the cific, reproducible, noninvasive, and inexpensive.
ABI is lower than 0.9, arteriography or duplex ultrasonography Management of complex extremity trauma involving soft tissue,
nerve, and arterial injury must include consideration of primary
amputation to increase patient survival. This issue is well
addressed by an algorithm for complex extremity trauma created
Patient has complex extremity trauma by the Committee on Trauma of the American College of Sur-
Resuscitation and management of all life-threatening injuries
geons (ACS) [see Figure 3].24 The algorithm incorporates the envi-
must take priority over any extremity problems. Only active ronment, the type of injury sustained, and the stability of the
extremity hemorrhage must be addressed at this point. patient into the process of deciding whether to attempt limb sal-
vage or perform amputation.
HIGH-RISK LOWER-EXTREMITY INJURIES
No factors posing increased One or more factors posing Certain lower-extremity injuries—such as knee dislocations,
risk of limb loss are present increased risk of limb loss displaced medial tibial plateau fractures and other displaced
are present bicondylar fractures around the knee, open or segmental distal
Assess patient for signs of femoral shaft fractures, floating joints, gunshot wounds in proxim-
vascular injury. Perform primary amputation.
ity to neurovascular structures, and mangled extremities—are
associated with a particularly high incidence of vascular trauma.25
The most commonly injured lower-extremity artery in the setting
of blunt trauma is the popliteal artery, which starts below the ad-
Hard signs of vascular injury Hard signs of vascular
are present injury are absent ductor hiatus and ends at the soleus arch. Because the vessel’s start
and end points areas are relatively fixed, there is a potential for sig-
Perform arteriography (preferably nificant stretch injury at the knee joint. A purely ligamentous knee
in ER). If imaging is not feasible, dislocation is associated with a high risk of arterial injury, despite
consider immediate surgical
exploration of vessel at risk. the lack of sharp fracture fragments. The risk of popliteal injury
may be as high as 40% in patients with knee dislocations.
Although the arterial disruption may be only a minor intimal tear
and examination may reveal no evidence of injury, such internal
Arteriogram is positive Arteriogram is negative tears are thrombogenic and may result in delayed thrombosis.
Because lower extremities are often splinted and covered during
Consider four-compartment stabilization, delayed thrombosis may not be recognized in a time-
fasciotomy of distal extremity. ly fashion.
Workup of a patient with a posterior knee dislocation may or
may not require angiography. Some authors maintain that angiog-
Patient or wound is unstable Patient and wound raphy is unnecessary in routine evaluation of patients with blunt
are stable lower-extremity trauma who present with a normal neurovascular
Place arterial shunt. examination and that angiography or duplex ultrasonography
Achieve skeletal stabilization Perform definitive
should be used selectively for patients with diminished pulses who
by splinting or external fixation. vascular repair.
lack associated indications for mandatory operative exploration.26
Perform definitive vascular repair. In addition, the use of the ABI has been validated in the setting of
blunt lower extremity trauma. The ABI has proved to be a rapid,
reliable, noninvasive tool for diagnosing vascular injury associated
Perform definitive skeletal repair. with knee dislocation. At present, the evidence suggests that routine
Inspect wounds frequently. Debride arteriography for all patients with knee dislocation is not indicated
any dead or necrotic tissue and but that a secondary study should be ordered when the ABI is low
change dressings accordingly. or the neurovascular examination yields abnormal results.10,12,27
Reevaluate after 24–48 hr. When managing a posterior knee dislocation, one should have a
high index of suspicion for vascular injury and a low threshold for
obtaining secondary studies.
No factors posing increased One or more factors posing
risk of limb loss are present increased risk of limb loss
are present Management
Continue efforts at limb salvage.
Perform secondary amputation. INITIAL TREATMENT CONSIDERATIONS
Figure 3 Shown is an algorithm for the management of complex Time to Repair

extremity trauma, adapted from an algorithm developed by the
ACS Committee on Trauma. The full annotated version of the ACS A warm ischemia time of less than 6 hours is generally accept-
algorithm is available at the ACS Web site (http://www.facs.org/trau- ed as the standard interval within which arterial continuity must
ma/publications/mancompexttrauma.pdf). be restored to prevent permanent damage to the soft tissues.28,29
Cephalic Vein Graft
Axillary Artery
Median Nerve Coracobrachial and

Biceps Muscles
Coracoid
Process
Figure 4 Depicted is
exposure of the axillary
artery.
Suture Graft to
Pectoralis Minor
Axillary Artery
and Major Divided
Axillary Vein
This interval may vary depending on several factors, including the Tourniquets are often placed on hypotensive patients before re-
level of injury, previous vascular disease, the presence of collateral suscitation, and these patients sometimes start bleeding through their
vessels, and previous extremity surgery. tourniquets when resuscitation is initiated. Accordingly, tourni-
quets should be continuously monitored and tightened for maxi-
Vascular Control mal effectiveness during resuscitation. In the hospital setting, pneu-
As has long been a dictum in vascular surgery, it is important to matic tourniquets may be used as temporizing proximal clamps in
gain proximal control of the injured vessel—meaning control at a patients with multiple injuries, as well as patients with blast
point one level higher than the injured area—before assessing the injuries, massive soft-tissue destruction, or mangled extremities.30
site of the injury.This maneuver reduces blood loss from the injury
EXPOSURE OF INJURY
during repair and minimizes hematoma formation and subsequent
loss of tissue planes. Entering an injured area without first obtain- Once the decision has been made to transport the patient to the
ing proximal control can be dangerous, can cause additional injury operating room, the next step is to determine the operative
to other neurovascular structures, and can result in belated approach that will optimize exposure of the injury. Often, expo-
attempts to gain proximal control in a hurried fashion, which may sures of upper-extremity arteries prove more challenging than
cause secondary injury to the vessel. In situations where proximal exposures of lower-extremity vessels, primarily because they are
control has not yet been obtained or cannot be obtained, an intra- performed less frequently. A thorough discussion of all extremity
luminal or intra-arterial balloon (e.g., a Fogarty catheter or even a vascular exposures is beyond the scope of this chapter. Accordingly,
Foley catheter, in larger arteries) may be used to achieve temporary in what follows, we discuss those exposures of the upper and lower
control.This simple technique sometimes proves to be lifesaving. extremities that are particularly useful in the trauma setting.
Use of Tourniquets Upper Extremity
Surgeons have long debated the use of tourniquets in the man- Operative exposure of potential vascular injuries in the upper
agement of vascular trauma. Undoubtedly, the tourniquet can be a extremity requires detailed knowledge of the anatomy of the axil-
lifesaving addition to the surgeon’s armamentarium if used correct- lary and brachial arteries. The axillary artery is surrounded by
ly and appropriately. Proximal application of a tourniquet may muscle on all sides, including the chest wall, the pectoral girdle,
facilitate examination, permit definitive control of a bleeding point, and the brachium. The vessel itself is divided into three segments
and help determine whether significant nerve, muscle, or tendon by the pectoralis minor: the medial segment, the posterior seg-
injury has occurred. Even if a tourniquet is kept in place for only a ment, and the lateral segment. The specific operative approach
short period, it may be invaluable for the control of hemorrhage. depends on which of these three segments has been injured.
When a tourniquet is used, it must be applied correctly. To gain access to the first (medial) segment of the axillary artery,
Incorrectly applied tourniquets actually increase bleeding from an the infraclavicular region must be exposed [see Figure 4]. This
extremity wound and increase the risk of early exsanguination. approach may also be useful for proximal control of more distal
This paradoxical effect results from occlusion of the lower-pres- injuries, depending on the location and type of injury being treat-
sure venous outflow and inadequate occlusion of the higher-pres- ed. A horizontal incision is made 2 cm below the middle third of
sure arterial inflow. A properly applied tourniquet causes substan- the clavicle, and dissection continues through the subcutaneous
tial pain, which should be managed with intravenous or intramus- fascia, the pectoral fascia, the pectoralis fibers, and the clavipectoral
cular analgesics.30 fascia. At this level, the neurovascular bundle can be identified,
Brachial Artery
Figure 5 (a) Depicted is

exposure of the brachial b
artery, with removal of an
occluded segment to restore
blood flow to the hand and
forearm. (b) The incision is
extended onto the forearm in
an S shape to afford complete
exposure.
with the artery lying superior and deep to the axillary vein. To gain access to the femoral artery, a vertical skin incision is made
Exposure and control of the artery are obtained by means of sharp midway between the superior iliac spine and the pubic tubercle
dissection. To gain access to the second (posterior) and third (lat- [see Figure 6].This incision is opened to expose the superficial epi-
eral) portions of the axillary artery, an incision is made along the gastric and superficial circumflex branches. The fascia lata is
lateral border of the pectoralis major from the chest wall to the incised along the medial portion of the sartorius up to the inguinal
biceps. The coracobrachialis can then be identified; the neurovas- ligament, and the femoral sheath is exposed and opened. (In an
cular sheath is located at the posterior border of this muscle.31 emergency situation where retroperitoneal or abdominal exposure
As an alternative, the deltopectoral approach may be employed is not warranted, the inguinal ligament can also be divided if nec-
to gain access to any of the segments of the axillary artery. An inci- essary for more proximal control).The CFA can then be identified
sion is made from the midpoint of the clavicle along the anterior lateral to the femoral vein and can be tracked downward to the
border of the deltoid muscle. The incision is deepened through point where it bifurcates into the profunda femoris and the SFA.
subcutaneous tissue to reach the intramuscular groove. The Typically, the profunda femoris branches laterally off of the CFA
cephalic vein is retracted, and the axillary artery may then be 3 to 5 cm distal to the inguinal ligament; the SFA lies superior to
traced proximally and distally. the profunda femoris. The incision may be extended inferiorly as
To expose the brachial artery, a longitudinal incision is made in necessary to locate more distal vascular injuries.31
the medial arm between the biceps and the triceps [see Figure 5], In the setting of trauma, exposure of the popliteal artery is
and dissection is carried out through the subcutaneous tissue.The best accomplished via a medial approach. To expose the proxi-
basilic vein can then be identified.This vein is retracted inferiorly, mal (supragenicular) popliteal artery, an incision is made in the
and the neurovascular bundle is exposed by opening the deep fas- distal portion of the thigh along the anterior border of the sarto-
cia at the medial border of the biceps.To expose the brachial artery rius [see Figure 7]. The fascia can be incised, the muscle retract-
along with the arteries in the forearm, an S-shaped incision is ed posteriorly, and the popliteal vessels may be identified. It may
made over the antecubital fossa. The superior portion of the inci- be necessary to divide the adductor tendon or the semimembra-
sion follows the medial border of the biceps muscle and extends nous muscle for exposure. If necessary, this incision can be
horizontally in the antecubital fossa; the inferior portion is made extended down the leg for exposure of the tibial vessels. To
laterally on the volar forearm. Such an incision affords complete expose the distal (infragenicular) popliteal artery, an incision is
exposure of all of the target vessels. On subcutaneous dissection, made just behind the posteromedial surface of the tibia [see
multiple veins can be seen, including the median cubital vein, the Figure 8]. The gastrocnemius is retracted posteriorly, and the
cephalic vein, and the basilic vein. Exposure of the deep fascia and semitendinous, gracilis, and sartorius muscles are retracted
entrance into the bicipital aponeurosis allows exposure of the superiorly. (These muscles may also be divided if more exposure
median nerve, the brachial artery, and two deep veins.The incision is needed.) The popliteal vein is the first and most superficial
can be extended to track the radial and ulnar arteries.31 portion of the neurovascular bundle. The tibial nerve is posteri-
or and medial to the popliteal artery and should always be iden-
Lower Extremity tified and protected during the dissection. If necessary, this
In addressing potential vascular injuries in the lower extremity, exposure can be extended inferiorly to the tibial peroneal trunk
it is essential to be able to expose the CFA and the popliteal artery. for control of the distal arteries.31
DEFINITIVE REPAIR OF INJURY made to form a larger conduit by using a spiral technique or a
panel graft technique.32 The superficial femoral vein (SFV)
Primary Repair versus Grafting may also be used as a conduit,33 but the dissection required is
Once the need for operation has been established and the expo- tedious and time-consuming and may be associated with sig-
sure chosen, the next step to determine which type of repair will nificant morbidity.
be performed. Primary repair is preferred when possible; substan- Autogenous conduits should be used in contaminated wounds
tial proximal and distal mobilization of the artery may be required when direct vascular repair is not feasible. Nonautogenous con-
to allow a tension-free anastomosis. duits (e.g., polytatrafuoroethylene [PTFE] or Dacron grafts) may
also be employed, but as a rule, they should be reserved for
Choice of Conduit extreme situations in which native vein is not available. For
Often, the extent of the injury is such that primary repair is patients with severe peripheral vascular injuries but without ade-
impossible and a conduit (autogenous or prosthetic) must be quate available vein, PTFE appears to be an acceptable choice for
placed. It is crucial that the contralateral leg be prepared, so primary reconstruction; graft infection is rare if the graft is covered
that a venous segment can be harvested if needed. In view of with healthy tissue.34,35
the possibility that the extremity arterial injury may be accom- Management of Arteries in Distal Extremity
panied by significant venous injury, harvesting vein from the
ipsilateral leg is discouraged. The most commonly used con- On occasion, arteries in the distal extremities (e.g., the radial,
duit is the great saphenous vein (GSV), which can be cut and ulnar, or tibial arteries) may have to be repaired or ligated after
Lymphoadipose Mass
a b c
Deep Fascia
Sartorius
Muscle
Femoral Arterial
Sheath
d e
Figure 6 Depicted is exposure of the femoral artery. (a) A curved 10 to 12 cm. skin incision
is made slightly lateral to the pulsation of the femoral artery. (b) Lymphoadipose tissue is
retracted to expose the deep fascia overlying the course of the femoral artery. (c) The deep
fascia is incised, exposing the femoral arterial sheath, which is then opened along its axis (d).
(e) The common and superficial femoral arteries are mobilized and encircled with Silastic
vessel loops.
a b
d
c
Adductor
Magnus
Muscle
e
f
Adductor
Magnus Highest
Tendon Genicular
Artery
Figure 7 Depicted is medial exposure of the proximal popliteal artery. (a) An incision is made in
the lower third of the thigh, anterior to the sartorius muscle. (b) The deep fascia is incised, and the
sartorius muscle is retracted posteriorly, allowing the popliteal artery to be readily palpated. (c) The
popliteal arterial sheath is opened, exposing the vessel and its surrounding venules. The adductor
magnus tendon may be seen covering the proximal end of the artery (d), and it may have to be
divided (e) to provide better exposure of the artery. (f) The popliteal artery, freed of the venous
plexus, is mobilized between two vessel loops.
trauma. In most patients, there is little need for repair of these structures. If primary repair is not possible, a patch is recommend-
arteries, which can typically be ligated without deleterious effects. ed.To augment venous flow and help maintain patency, an AV fis-
The safety of ligation is predicated on the presence of adequate tula may be created, then ligated at a later point. The administra-
arterial flow from the nonaffected arteries, as well as retrograde tion of heparin and the use of a foot pump may also help maintain
blood flow from an intact palmar or plantar arch.36,37 Repair of the patency of a venous repair, as well as reduce the hypercoagu-
injuries to these arteries is associated with the possibility of lability associated with Virchow’s triad and venous occlusion.
embolization or other surgical problems. In addition, the patency If the vein cannot be repaired, it may have to be ligated. For
rate for grafts in the distal extremities tends to be low.38 injuries to the tibial vein and some injuries to the brachial vein or
a more distal arm vein, ligation may be chosen over repair, with
Repair of Venous Injuries few deleterious consequences. For injuries to the popliteal vein or
In most regions of the extremities, repair of any concomitant the SFV, repair is recommended when possible to optimize con-
venous injuries is recommended, on the grounds that it may help tinued venous drainage of the extremity. As noted [see Choice of
keep an arterial repair open and prevent postoperative edema. Conduit, above], if vein is harvested, it should come from the con-
Primary repair involves closing the venotomy transversely; this tralateral leg so as to permit continued outflow from the injured
may be facilitated by mobilizing the proximal and distal venous lower extremity.39,40
If proximal ligation of a lower-extremity vein is required, it MANAGEMENT OF COMPARTMENT SYNDROME

should be performed on the common iliac vein rather than the Compartment syndrome is a condition characterized by abnor-
external iliac vein. Higher ligation allows cross-pelvis collateral cir- mally high pressure within a closed space. The elevated tissue
culation via the internal iliac veins. In addition, ligation of the exter- pressure leads to venous obstruction within the space. When the
nal iliac vein is fraught with difficulty. Every attempt should be pressure continues to increase, the intramuscular arteriolar pres-
made to repair the vein to prevent major morbidity, including poor sure is eventually exceeded. At that point, blood can no longer
venous return and resultant severe edema. Ligation of the common enter the capillary space, and the result is shunting within the
femoral vein (CFV) is also not ideal, because of the risk of leg compartment. If the pressure is not released, muscle and nerve
edema; however, if ligation at the level of the CFV proves neces- ischemia occurs, leading to irreversible damage to the contents of
sary, it does allow some venous return flow via the cruciate collat- the compartment.41
eral vessels, the obturator vein (from the medial circumflex femoral Underlying pathologic processes that reduce the size or
vein), and the gluteal vein (from the lateral circumflex femoral increase the contents of a compartment include hemorrhage,
vein). reperfusion edema, a tight cast, constrictive dressings, and pneu-
matic antishock garments. Crush injury may be associated with
Postoperative Care
rapid development of swelling and rigid compartments. The key
After repair of a vascular injury, patients require 24 hours of to the diagnosis of compartment syndrome is continuous assess-
monitoring in the intensive care unit for serial pulse and Doppler ment of any extremity injury in which elevated pressures may
assessments, monitoring of hemodynamic status, and evaluation develop. It must always be remembered that the diagnosis is a clin-
of the site of the repair. In addition, patients must be watched for ical one; although compartment pressures may be measured, clin-
the development of metabolic derangements (e.g., metabolic aci- ical suspicion and findings suggestive of compartment syndrome
dosis, hyperkalemia, myoglobinuria, and renal failure) after hem- on physical examination should suffice to mandate therapy.
orrhagic shock and reperfusion of ischemic limbs. Changes in the Current management of compartment syndrome is derived
findings from physical examination, the neurologic status of the from a 1970 review by Patman and Thompson, in which fascioto-
extremity, or the ABI warrant immediate investigation, usually my was performed after arterial reconstruction in 164 patients with
beginning with duplex ultrasonography.Typically, a duplex exam- peripheral vascular disease.42 The investigators concluded that fas-
ination is also performed in the early postoperative period to ciotomy could result in limb salvage and implied that it should be
establish a baseline for subsequent surveillance of the graft or considered after restoration of arterial inflow to an extremity.
repair. Indications for fasciotomy included pain on palpation of the
a b c
Gracilis
Semitendinous Tendon
Tendon
Crural
Fascia
d e
Popliteus Muscle
Soleus
Muscle
Medial Head of
Gastrocnemius
Muscle
Figure 8 Depicted is medial exposure of the distal popliteal artery. (a) An incision is made just behind
the posteromedial surface of the tibia. (b) The crural fascia is exposed. (c) The fascia is incised, exposing
the vascular bundle. (d) The medial head of the gastrocnemius muscle is retracted posteriorly, exposing
the distal popliteal vessels and the arcade of the soleus muscle. (e) The distal popliteal artery is freed
and mobilized between vessel loops.
posterior compartment, and the deep posterior compartment.The

thigh contains three osseofascial compartments: the quadriceps,
the hamstrings, and the adductors. For fasciotomies of the lower
leg, there are two techniques: perifibular fasciotomy and the dou-
ble-incision technique. Perifibular fasciotomy affords access to all
four compartments of the leg via a single lateral incision that
extends from the head of the fibula to the ankle, following the gen-
Anterior
Compartment
eral line of the fibula.The double-incision technique employs two
vertical skin incisions that are separated by a bridge of skin at least
8 cm wide [see Figure 9]. The first incision extends from knee to
Posteromedial ankle and is centered over the interval between the anterior and
Incision lateral compartments; the second also extends from knee to ankle
Anterolateral and is centered 1 to 2 cm behind the posteromedial border of the
Incision tibia.41 Although decompression in the lower extremity may be
achieved via either of the two techniques, the double-incision tech-
nique is preferred in the setting of trauma because it readily
ensures that all four compartments have been decompressed.
The forearm consists of three osseofascial compartments: the
superficial flexor compartment, the deep flexor compartment, and
the extensor compartment. To decompress the upper extremity, a
volar fasciotomy, a dorsal fasciotomy, or both may be performed.
A volar fasciotomy decompresses the superficial and deep flexor
compartments of the forearm via a single skin incision.41 This inci-
sion begins medial to the biceps tendon, crosses the elbow crease,
proceeds toward the radial side of the forearm, and extends distal-
ly along the medial border of the brachioradialis, finally continu-
ing across the palm along the thenar crease [see Figure 10]. After
Deep Posterior the superficial and deep flexor compartments of the forearm are
Compartment
Lateral decompressed, intraoperative pressure measurements may be
Compartment Superficial obtained to help determine whether fasciotomy is necessary to
Posterior decompress the extensor compartment. If the pressure continues
Compartment to be elevated in the extensor compartment, a dorsal fasciotomy
Figure 9 (a) Illustrated is the two-incision technique for should be performed.With the arm pronated, a straight incision is
lower leg decompression in compartment syndrome. Two ver- made from the lateral epicondyle to the midline of the wrist.41
tical skin incisions are made from knee to ankle, separated by After fasciotomy, both the fascia and the skin are left widely
a skin bridge at least 8 cm wide. (b) Fasciotomies are then open.The skin defects may be closed with skin grafts at the time of
performed in all four compartments along the dashed lines.
original operation, provided that this can be done without excessive
tension or pressure. Alternatively, the patient may be returned to
swollen compartment, reproduction of symptoms with passive the OR after the swelling resolves for delayed skin closure (with the
muscle stretch, a sensory deficit in the territory of a nerve travers- fascia left open) or split-thickness skin grafting, as indicated.
ing the compartment, muscle weakness, diminished pulses (a very It is important to consider fasciotomy in patients with arterial
late sign), and compartment pressure exceeding 30 to 35 mm Hg. injuries associated with crush injury and venous injury or occlu-
It has been noted that the difference between the diastolic pression.These secondary injuries may be associated with a higher risk
sure and the measured compartment pressure may be a more reli- of compartment syndrome than either isolated arterial injuries or
able clinical indicator of compartment syndrome than the com- ischemia-reperfusion alone.43 In any setting, the most important
partment pressure by itself. A difference of less than 30 mm Hg concerns in performing a fasciotomy are that the procedure must
between the two pressures is significant and may be the most reli- be done in a timely manner and that all of the compartments must
able indicator of when fasciotomy is warranted. be completely decompressed.
There are a number of clinical situations in which fasciotomy
should be considered: when there is a 4- to 6-hour delay before
Special Considerations
revascularization, when arterial injuries are present in conjunction
with venous injuries, when crush injuries or high–kinetic energy
MANAGEMENT OF INTIMAL INJURIES
injuries have been sustained, when vascular repair has already
been performed (reperfusion), when an artery or vein has been lig- How best to manage small traumatic intimal injuries identified
ated, when a patient is comatose or has a head injury and physical by means of angiography has been the subject of considerable
examination is impossible, and when a patient has tense compart- debate. In general, patients who have injuries shorter than 2 mm
ments or elevated compartment pressures. In these scenarios, fas- and involving less than 50% of the vessel circumference, with no
ciotomy should be considered as a prophylactic maneuver. noted pulse deficits, may be placed on an antiplatelet regimen and
followed clinically; evidence from animal studies supports this
Fasciotomy approach.44 There is some clinical evidence to suggest that
The lower leg contains four osseofascial compartments: the antiplatelet medication (e.g., acetylsalicylic acid) and observation
anterior compartment, the lateral compartment, the superficial alone may be adequate treatment in such patients; however, addi-
Figure 10 Shown are inci-

sions for forearm decom-
pression in compartment
syndrome.
Flexor Carpi Radialis
Radial Artery
Flexor Digitorum Radial Nerve

Superficialis
Brachioradialis
Extensor Carpi
Radialis Brevis
Flexor Carpi Ulnaris
tional follow-up studies are required before this recommendation ENDOVASCULAR INTERVENTION
can be confirmed.45 At present, although there are several potential uses for
Even though some cases can be treated conservatively, it is endovascular techniques in the trauma setting, there are no
important not to underestimate the potential importance of clear indications for such interventions in the management of
angiographically identified intimal injuries. Patients with such extremity vascular injuries.The reality is that there are few long-
injuries are at risk for the development of a pseudoaneurysm, AV term data on the use of stents in the peripheral arteries even in
fistula, dissection, or even thrombosis.44,46,47 nontrauma settings. For example, the patency rate for endolu-
minal stents in the SFA is between 60% and 80% at 2 years, a
ANTICOAGULATION
range lower than that of primary repairs or interposition
Whether anticoagulation is indicated in patients with vascular grafts.49 In addition, many patients who sustain extremity trau-
trauma is also debatable. It has been suggested that early admin- ma are younger than the average vascular stent patient and have
istration of systemic anticoagulant therapy (heparin, 100 U/kg) poorer access to health care; consequently, close long-term fol-
may reduce amputation rates by preventing microvascular throm- low-up after an endovascular intervention may be harder to
bosis. There is some evidence that anticoagulation may improve carry out in this population.
limb salvage rates while posing only a minimal risk of bleeding Endovascular therapy may be considered in certain instances of
complications.48 Systemic anticoagulation may be contraindicated extremity vascular trauma, such as when systemic conditions rule
in certain situations, such as active hemorrhage, coagulopathy, out operative repair and a temporizing measure is warranted. It
and craniocerebral injury. If heparin cannot be given systemically, should be kept in mind, however, that endovascular repair of
it may be administered locally during the operation, at the site of peripheral vascular injuries is still a developing form of treatment
the arterial repair. and not the standard of care.50,51
TIMING OF ORTHOPEDIC REPAIR VIS-À-VIS VASCULAR REPAIR SALVAGE OF SEVERELY INJURED OR MANGLED EXTREMITIES
Another issue that continues to evoke controversy is the timing When an extremity is severely injured or mangled, a decision
of repair of concomitant vascular and orthopedic injuries—in par- must be made whether to attempt salvage or perform amputa-
ticular, the order in which these injuries should be repaired. In tion. Because of the need to take the patient’s emotional and
general, vascular repair should take precedence over orthopedic medical concerns into account, evaluation of an extremity for
reconstruction when possible. Vascular surgeons have long been potential salvage is a difficult undertaking. Several scoring sys-
tems have been developed to help make this decision-making
concerned about the instability of knee dislocations and distal
process somewhat easier.The most commonly used system is the
femoral or proximal tibial fractures, fearing that a fragile vascular
Mangled Extremity Scoring System (MESS), which uses four
reconstruction might be undone by subsequent orthopedic objective criteria to predict the likelihood of amputation after
maneuvers; however, the data do not support this fear. There is lower-extremity trauma: skeletal/soft tissue injury, limb
some evidence that in patients with combined injuries, giving pri- ischemia, shock, and patient age. A MESS score of 7 or higher
ority to revascularization over orthopedic fixation leads to shorter predicts amputation with an accuracy approaching 100%.
hospital stays and a trend toward lower fasciotomy rates. In a 2002 However, it is essential to remember that each patient must be
study, revascularization before fracture fixation was not found to carefully evaluated and that attempts at limb salvage must not be
result in iatrogenic disruption of the vascular repair.43 base solely on a high MESS score.54,55
When an extremity has been substantially destabilized as a con- The need for amputation may be best predicted by the occur-
sequence of bony injury, short-term external fixation may be rence of severe injuries to the sciatic or tibial nerves, the presence
employed to facilitate vascular repair. A temporary intraluminal of associated fractures, and the failure of arterial repair.5 Often, the
shunt is often used to maintain perfusion during initial orthopedic decision to amputate is not made at the time of presentation or
stabilization. One study demonstrated that routine use of intralu- during the initial operation. If, after revascularization and skeletal
stabilization, the extremity is clearly nonviable or remains insen-
minal shunts in patients with complex extremity vascular injuries
sate, then delayed amputation may be performed under more con-
had the potential to reduce excessive morbidity (e.g., the need for
trolled circumstances.56
fasciotomy and the resultant prolonged hospital stay) from pro- The optimal approach to evaluating a severely injured extremi-
longed arterial insufficiency.52 In selected patients with combined ty involves a multispecialty group, including the trauma surgeon,
skeletal and vascular injuries to the upper or lower limb, tempo- the vascular surgeon, and the orthopedic surgeon.With full knowl-
rary vascular shunting may reduce complications resulting from edge of the patient’s condition, an attempt at limb salvage may be
prolonged ischemia and permit an unhurried and reasonable appropriate. In some cases, though, amputation may be preferable
sequence of treatment.53 to preservation of an insensate, nonfunctional limb.
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risk factors associated with limb loss. J Vasc Surg 15. Reid JD, Redman HC,Weigelt JA, et al:Wounds of 24. Pasquale MD Frykberg ER, Tinkoff GH, et al:
33:1212, 2001 the extremities in proximity to major arteries: value Management of complex extremity trauma. Bull
6. Bongard F, Dubrow T, Klein S:Vascular injuries in of angiography in the detection of arterial injury. Am Coll Surg 91(6):36, 2006
the urban battleground: experience at a metropol- AJR Am J Roentgenol 151:1035, 1988 25. Subasi M, Cakir O, Kesemenli C, et al: Popliteal
itan trauma center. Ann Vasc Surg 4:415, 1990 16. Reid JD, Weigelt JA, Thal ER, et al: Assessment of artery injuries associated with fractures and dislo-
7. Snyder WH 3rd, Thal ER, Bridges RA, et al: The proximity of a wound to major vascular structures cations about the knee. Acta Orthop Belg 67:259,
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trauma. Arch Surg 113:424, 1978 123:942, 1988 26. Abou-Sayed H, Berger DL: Blunt lower-extremity
8. Weaver FA, Yellin AE, Bauer M, et al: Is arterial 17. Conrad MF, Patton JH Jr, Parikshak M, et al: trauma and popliteal artery injuries: revisiting the
proximity a valid indication for arteriography in Evaluation of vascular injury in penetrating case for selective arteriography. Arch Surg
penetrating extremity trauma? A prospective analy- extremity trauma: angiographers stay home. Am 137:585, 2002
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9. Lynch K, Johansen K: Can Doppler pressure mea- 18. Bynoe RP, Miles WS, Bell RM, et al: Noninvasive Blunt vascular trauma in the extremity: diagnosis,
surement replace “exclusion” arteriography in the diagnosis of vascular trauma by duplex ultrasonog- management, and outcome. J Trauma 55:814,
diagnosis of occult extremity arterial trauma? Ann raphy. J Vasc Surg 14:346, 1991 2003
Surg 214:737, 1991 19. Kuzniec S, Kauffman P, Molnar LJ, et al: 28. Menzoian JO, Doyle JE, LoGerfo FW, et al:
10. Mills WJ, Barei DP, McNair P: The value of the Diagnosis of limbs and neck arterial trauma using Evaluation and management of vascular injuries of
ankle-brachial index for diagnosing arterial injury duplex ultrasonography. Cardiovasc Surg 6:358, the extremities. Arch Surg 118:93, 1983
after knee dislocation: a prospective study. J 1998 29. Green NE, Allen BL: Vascular injuries associated
with dislocation of the knee. J Bone Joint Surg Am Management and short-term patency of lower popliteal arteries. J Vasc Surg 38:1178, 2003
59:236, 1977 extremity venous injuries with various repairs. Am 50. Risberg B, Lonn L: Management of vascular
30. Starnes BW, Beekley AC, Sebesta JA, et al: J Surg 186:631, 2003 injuries using endovascular techniques. Eur J Surg
Extremity vascular injuries on the battlefield: tips 40. Pasch AR, Bishara RA, Schuler JJ, et al: Results of 166:196, 2000
for surgeons deploying to war. J Trauma 60:432, venous reconstruction after civilian vascular trau-
51. Lonn L, Delle M, Karlstrom L, et al: Should blunt
2006 ma. Arch Surg 121:607, 1986
arterial trauma to the extremities be treated with
31. Valentine RJ, Wind GG, Wind GG: Anatomic 41. Browner BD: Skeletal Trauma: Basic Science, endovascular techniques? J Trauma 59:1224, 2005
Exposures in Vascular Surgery, 2nd ed. Lippincott Management, and Reconstruction, 3rd ed. WB
52. Johansen K, Bandyk D, Thiele B, et al: Temporary
Williams & Wilkins, Philadelphia, 2003 Saunders Co, Philadelphia, 2003
intraluminal shunts: resolution of a management
32. Keen RR, Meyer JP, Durham JR, et al: 42. Patman RD,Thompson JE: Fasciotomy in periph- dilemma in complex vascular injuries. J Trauma
Autogenous vein graft repair of injured extremity eral vascular surgery: report of 164 patients. Arch 22:395, 1982
arteries: early and late results with 134 consecutive Surg 101:663, 1970
patients. J Vasc Surg 13:664, 1991 53. Reber PU, Patel AG, Sapio NL, et al: Selective use
43. McHenry TP, Holcomb JB, Aoki N, et al: of temporary intravascular shunts in coincident
33. MacDonald S, Meneghetti AT, Lokanathan R, et Fractures with major vascular injuries from gun- vascular and orthopedic upper and lower limb
al: Superficial femoral vein for arterial reconstruc- shot wounds: implications of surgical sequence. J trauma. J Trauma 47:72, 1999
tion in trauma. J Trauma 59:747, 2005 Trauma 53:717, 2002
54. Johansen K, Daines M, Howey T, et al: Objective
34. Shah DM, Leather RP, Corson JD, et al: Polytetra- 44. Sawchuk AP, Eldrup-Jorgensen J, Tober C, et al: criteria accurately predict amputation following
fluoroethylene grafts in the rapid reconstruction of The natural history of intimal flaps in a canine
lower extremity trauma. J Trauma 30:568, 1990
acute contaminated peripheral vascular injuries. model. Arch Surg 125:1614, 1990
Am J Surg 148:229, 1984 55. Helfet DL, Howey T, Sanders R, et al: Limb sal-
45. Hernandez-Maldonado JJ, Padberg FT Jr, Teehan
vage versus amputation: preliminary results of the
35. Feliciano DV, Mattox KL, Graham JM, et al: Five- E, et al: Arterial intimal flaps: a comparison of pri-
Mangled Extremity Severity Score. Clin Orthop
year experience with PTFE grafts in vascular mary repair, aspirin, and endovascular excision in
Relat Res (256):80, 1990
wounds. J Trauma 25:71, 1985 an experimental model. J Trauma 34:565, 1993
36. Aftabuddin M, Islam N, Jafar MA, et al: Manage- 46. Tufaro A, Arnold T, Rummel M, et al: Adverse 56. Poole GV, Agnew SG, Griswold JA, et al: The
ment of isolated radial or ulnar arteries at the fore- outcome of nonoperative management of intimal mangled lower extremity: can salvage be predict-
arm. J Trauma 38:149, 1995 injuries caused by penetrating trauma. J Vasc Surg ed? Am Surg 60:50, 1994
37. Sultanov DD, Usmanov NU, Baratov AK, et al: 20:656, 1994
Traumatic injuries of the popliteal and tibial arter- 47. Perry MO: Complications of missed arterial
ies: limb ischemia and problems of surgical man- injuries. J Vasc Surg 17:399, 1993
agement. Angiol Sosud Khir 10:104, 2004 48. Guerrero A, Gibson K, Kralovich KA, et al: Limb
Acknowledgment
38. Johnson M, Ford M, Johansen K: Radial or ulnar loss following lower extremity arterial trauma: Figures 1, 4 through 10 Alice Y. Chen.
artery laceration: repair or ligate? Arch Surg what can be done proactively? Injury 33:765, 2002 The authors thank Kimberly Riehle, M.D., University
128:971, 1993 49. Vogel TR, Shindelman LE, Nackman GB, et al: of Washington School of Medicine, for her help in the
39. Parry NG, Feliciano DV, Burke RM, et al: Efficacious use of nitinol stents in the femoral and editing of the manuscript.
8 CRITICAL CARE 1 Cardiac Resuscitation — 1
1 CARDIAC RESUSCITATION
Terry J. Mengert, M.D.
Approach to Cardiovascular Resuscitation
Out-of-hospital sudden cardiac arrest claims the lives of more than INITIATION OF CPR
300,000 persons in the United States each year, making it the leading While awaiting the arrival of a defibrillator and advanced help,
cause of death.1-4 In fact, approximately 50% of all cardiac deaths are the rescuer assesses the patient’s airway, breathing, and circulation
sudden deaths.5 In hospitals, a minimum of 370,000 patients also suf- [see The Primary Survey, below] and initiates CPR [see Table 1].
fer a cardiac arrest, followed by an attempted, but only sometimes When CPR is started within 4 minutes of collapse, the likelihood of
successful, resuscitation.6 Although most victims of sudden death patient survival at least doubles.17,18
have underlying coronary artery disease (70% to 80%), sudden death
is the first manifestation of the disease in half of these persons.2 Other INITIATION OF DEFIBRILLATION
causes and contributing factors include abnormalities of the my- When the AED or monitor-defibrillator arrives, attach it appro-
ocardium (i.e., chronic heart failure or hypertrophy from any cause), priately to the patient and analyze the patient’s rhythm; if the patient
electrophysiologic abnormalities, valvular heart disease, congenital is in VF or pulseless VT, a defibrillatory shock should be rapidly ap-
heart disease, and miscellaneous inflammatory and infiltrative disease plied [see Tables 2 and 3]. If required, two additional shocks may be
processes (e.g., myocarditis, sarcoidosis, and hemochromatosis).7-9 administered sequentially.The importance of rapid access to defib-
The pathophysiology that culminates in a sudden cardiac death rillation cannot be overemphasized. In a patient who is dying from a
is complex and poorly understood. It likely represents a mix of elec- shockable rhythm, the chance of survival declines by 7% to 10% for
trical abnormalities combined with acute functional triggers, such every minute that defibrillation is delayed.19
as myocardial ischemia, central and autonomic nervous system ef-
fects, electrolyte abnormalities, and even pharmacologic influ- INITIATION OF ADVANCED CARE
ences.1 Classically, most sudden deaths that occur in adults in the
If the patient remains pulseless despite the steps described above,
community are thought to be secondary to ventricular tachycardia
resume CPR; establish a definitive airway, confirm its correct place-
(VT) that quickly degenerates into ventricular fibrillation (VF). In a
ment, and then secure it; establish intravenous access; then adminis-
10-year study in the Seattle area, the different arrhythmias found in
ter appropriate medications as determined by the rhythm and the ar-
prehospital cardiac arrest patients presumed to have underlying car-
rest circumstances. If the patient is in VF or pulseless VT, repeated
diovascular disease were VF (45%), asystole (31%), pulseless elec-
attempts at defibrillation are interspersed with delivery of vasoactive
trical activity (PEA; 10%),VT (1%), and other arrhythmias (14%).3
and antiarrhythmic drugs [see Table 4].
Studies indicate that the out-of-hospital incidence of VF has de-
creased in recent years, probably because of the decrease in mortal- RESUSCITATION OUTCOME
ity from coronary artery disease.10
When every link in the chain of survival is quickly and sequen-
tially available, the patient is provided an optimal opportunity for
return of spontaneous circulation.19-22 In the United States, indi-
The Chain of Survival
vidual communities report survival rates of 4% to 40% or more in
The resuscitation of an adult victim of cases of sudden cardiac death.23-27 Prehospital victims of VF have
sudden cardiac arrest should follow an had survival rates to hospital discharge of greater than 50% when
orderly sequence, no matter where the an AED was expeditiously used.28 Many other factors also influ-
patient’s collapse occurs. This sequence ence patient survival, however; these include whether the patient’s
is called the chain of survival.11 It com- collapse was witnessed, the rapidity and effectiveness of bystander
prises four elements, all of which must be CPR, the rhythm associated with the cardiac arrest, and underly-
instituted as rapidly as possible: activa- ing comorbidities.29,30 With inpatient cardiac arrest, for example,
tion of the emergency medical service overall survival rates vary from 9% to 32%,31-37 but in one study,
network, cardiopulmonary resuscitation survival to hospital discharge was 30% for patients with primary
(CPR), early defibrillation, and provision heart disease, 15% for patients with infectious diseases, and only
of advanced care. 8% for patients with other end-stage diseases (e.g., cancer, lung
ACTIVATION OF EMERGENCY MEDICAL SERVICES disease, liver failure, or renal failure).38
Such statistics underline the importance of using cardiac resusci-
A person in cardiac arrest is unresponsive and pulseless, although tation appropriately and with discrimination. Cardiac resuscitation
agonal respirations may last for minutes. Confirm unresponsiveness provides rescuers with powerful tools that save the lives of thou-
by speaking loudly and gently shaking the patient. If the patient is sands of people every year.These techniques are capable of return-
truly unresponsive, immediately call for help by activating the emer- ing patients who would otherwise die to productive and meaningful
gency medical service in the community (in most locales, this
lives. However, cardiac resuscitation should not be employed to re-
means calling 911); or if the patient is already in the hospital, call a
verse timely and natural death. Under those circumstances, it has
code (e.g., code blue, code 199). If an automated external defibril-
the potential to lengthen the dying process and to increase human
lator (AED) is available, have it brought to the resuscitation scene.
suffering. All practitioners are well advised to remember that “death
AEDs are both easily used and lifesaving.12-16
is not the opposite of life, death is the opposite of birth. Both are as-
Patient is in cardiac arrest
Confirm unresponsiveness.
If out of hospital, call EMS.
If in hospital, activate appropriate code.
Approach to Call for a defibrillator.
Cardiovascular
Resuscitation Primary survey
Assess ABCs.
Begin CPR; when defibrillator arrives,
attach to patient and briefly withhold CPR.
Assess rhythm.
Pulseless VT or VF Pulseless electrical activity Asystole
Immediately administer shock, first at 200 J, Resume CPR. Resume CPR and confirm asystole.
then 200–300 J, then 360 J; if patient is already Ensure that patient is appropriately attached to
attached to a monitor-defibrillator, begin monitor-defibrillator, that ECG gain control on
resuscitation with immediate defibrillation. the defibrillator is at maximum, and that the
Resume CPR. rhythm is assessed in several leads.
Secondary survey
Endotracheally intubate, confirm tube placement, secure tube, establish I.V. access.
Concomitantly with preceding steps, identify and correct technical difficulties
hampering resuscitation [see Table 6]; initiate emergency therapy for conditions
contributing to cardiac arrest [see Table 7].
Pulseless VT or VF Pulseless electrical activity Asystole
Subsequent steps assume continuing VT or VF Subsequent steps assume continuing Subsequent steps assume continuing
despite interventions; do not interrupt CPR PEA despite interventions; do not asystole despite interventions; do not
except as required for rapid performance of interrupt CPR except as required for interrupt CPR except as required for rapid
lifesaving procedures. rapid performance of lifesaving performance of lifesaving procedures.
Administer vasoactive drugs with ongoing CPR: procedures. Attempt transcutaneous pacing, if
Epinephrine, 1 mg I.V. push, repeated every Administer epinephrine, 1 mg I.V. push, available (may be initiated simultaneously
3–5 min throughout CPR with ongoing CPR; repeat every 3–5 with above steps).
or min as long as CPR is required. Administer medications with ongoing CPR:
Vasopressin, 40 U I.V. push in a single dose; If heart rate as shown on monitor is Epinephrine, 1 mg I.V. push; repeat
if no response after 10 min, administer slow, administer atropine, 1 mg I.V. every 3–5 min for as long as patient
epinephrine as described above. push, with ongoing CPR; may repeat requires CPR (vasopressin, 40 U I.V.
every 3–5 min to a total dose of 3 mg. one time, is a reasonable alternative)
Follow medication delivery with a 20 ml and
saline bolus and elevation of the Atropine, 1 mg I.V. push; repeat every
Administer antiarrhythmic drugs with ongoing CPR: extremity containing the I.V. line. 3–5 min to a total dose of 3 mg
Amiodarone, 300 mg I.V. push; if a second dose is Follow medication delivery with a 20 ml
needed, 150 mg after 5 min saline bolus and elevation of the
or extremity containing the I.V. line.
Lidocaine, 1.0–1.5 mg/kg I.V. push; if a second
dose is needed, repeat initial dose in 3–5 min. End resuscitation attempt if patient remains
in confirmed asystole for > 10 min and
Hypomagnesemia or torsade de pointes is suspected: there is no technical problem preventing
Magnesium sulfate, 1–2 g I.V. push resuscitation, no imminently treatable
Intermittent or recurrent VT/VF after an initial cause, and no extenuating circumstance.
response to shocks:
Procainamide, 20–50 mg/min I.V. infusion to a
total dose of 17 mg/kg.
Follow medication delivery with a 20 ml saline
bolus; elevate extremity with I.V. line, and continue
CPR for 30–60 sec to circulate medication; then
administer shock (360 J for up to three shocks).
in the laboratory, an arterial pressure wave occurred.42 Further

Table 1 Initial Resuscitation Steps in the study and refinements led to the technique of closed-chest CPR,
the careful description of which was published in 1960.43 The first
Unresponsive Patient
report of the use of this technique in patients was in 1961.44 Since
Confirm unresponsiveness those early days, the fundamentals of closed-chest CPR have re-
Activate the emergency medical system mained relatively unchanged. Mouth-to-mouth, mouth-to-mask,
In most community locales, call 911 or bag-valve-mask ventilation oxygenates the blood. Chest com-
In the hospital, activate the appropriate code response pressions produce forward blood flow.This flow appears to result
Call for an automatic external defibrillator (AED) from a combination of direct compression of the heart and in-
Begin basic life support (CPR) trathoracic pressure changes.45,46
Open airway CPR in isolation does not defibrillate the heart. Its main benefit
Check breathing; if not breathing, deliver two initial breaths
is to extend patient viability until a defibrillator and advanced inter-
Check for a carotid pulse; if pulseless, do the following:
ventions become available and, one hopes, succeed in restoring
Begin chest compressions at the rate of 100 compressions/min, de-
pressing the sternum 4–5 cm per compression in patients older than spontaneous circulation in the patient. CPR is not nearly as effec-
8 yr tive as a contracting heart; systolic arterial pressure peaks of 60 to
Intersperse ventilations with chest compressions: in nonintubated pa- 80 mm Hg may be generated, but diastolic blood pressure remains
tients, deliver 15 compressions, pause for two breaths, then repeat;
in intubated patients, deliver one breath every 5 sec, with no pause low, and a cardiac output of only 25% to 30% of normal can be
in compressions achieved even under optimal conditions.47 Still, effective CPR is
Reassess for return of spontaneous circulation every 1–3 min critical to keeping the patient alive. It is worth remembering that
When defibrillator arrives, immediately analyze and treat arrhythmia the most important rescuers at a cardiac resuscitation are those
Attach patient to AED [see Table 2] or the monitor-defibrillator who are performing expert CPR, because it is only through their ef-
[see Table 3]
Analyze arrhythmia and treat as appropriate
forts that the patient’s heart and brain are kept viable until defibril-
lation and other advanced interventions can restore spontaneous
circulation.
After unresponsiveness is confirmed, the emergency medical
pects of life.”39 It is untimely death that requires immediate inter- system is activated and an AED is called for; the primary survey
vention with cardiac resuscitation. (A, B, C, and D) proceeds as described (see below) until the
AED arrives.
The Primary and Secondary Surveys of Cardiac Airway Optimization
Resuscitation
Open the patient’s mouth and optimize the airway in the non-
A cardiac resuscitation is a stressful event for everyone involved. trauma patient by use of the head-tilt and chin-lift maneuver. A
Too often, clinic and inpatient cardiac arrests and their manage- jaw-thrust maneuver should be used instead of the head-tilt tech-
ment are episodes of chaos in the busy lives of resident and attend- nique if cervical spine injury is suspected. In patients with suspect-
ing physicians.Yet, it has been eloquently stated that a good resusci- ed spine injury, proper spine alignment must be maintained
tation team should function like a fine symphony orchestra.40 Such throughout all phases of the resuscitation. In such circumstances, as
skill levels require dedicated individual and team practice and care-
ful code-team organization. Mastery in cardiac resuscitation is in
fact a lifelong pursuit that requires training and retraining in ad-
vanced cardiac life support (ACLS); regular practice and review;
and leadership and team skill development. Its key elements in- Table 2 Using an Automatic External
clude not only the resuscitation itself but the response to the an- Defibrillator in Patients Older than 8 Years
nouncement of a code, postresuscitation stabilization of the patient,
notification of the family and primary care provider, and code cri- Automatic external defibrillator (AED) arrives (CPR is in progress)
Place AED beside patient.
tique and debriefing.To help practitioners learn and apply some of
Turn on the AED.
the most essential techniques used in cardiac resuscitation more
Attach the electrodes to the AED (they may be preattached).
easily and effectively, the American Heart Association (AHA) has Attach the electrode pads to the patient (as diagrammed on the pads).
developed the concepts of primary and secondary surveys of a pa- AED analyzes patient’s rhythm
tient in atraumatic cardiac arrest.41 Stop CPR (and ensure no one is touching the patient).
Press the Analyze button on the AED (some devices analyze the rhythm
THE PRIMARY SURVEY automatically as soon as the pads are placed on the patient).
The primary survey for the victim of AED instructs rescuers (via an audible voice prompt and/or on-screen
instructions)
sudden cardiac arrest consists of the ap- Shock is indicated: clear the patient (ensure no one is touching the
propriate assessment of the patient’s air- patient) and push the Shock button.
way (A), breathing (B), and circulation After delivering shock, press the Analyze button again; the sequence of
(C) and the simultaneous application of analysis followed by shock (if so indicated) may be performed a total
of three times.
expert CPR until defibrillation (D) be- or
comes possible (assuming the patient is Shock not indicated: reassess the patient for signs of circulation; if pres-
in VF or pulseless VT).Thus, the primary ent, assess the adequacy of breathing; if there are no signs of circula-
survey includes the second and third tion, resume CPR for 1–2 min. After 1 min of CPR, assess the patient
again for signs of circulation; if present, assess the adequacy of
links in the chain of survival (see above). breathing. If the patient is still pulseless, repeat analysis, followed
In 1958, Kouwenhoven noted that when his research fellow (if indicated) by shock steps.
forcefully applied external defibrillating electrodes on a dog’s chest
nal thrusts are then applied, followed by a finger sweep of the

52,89 oropharynx to relieve suspected obstruction, and then ventilation
Table 3 Using a Manual Defibrillator attempts are repeated. Definitive intervention for an obstructed air-
Defibrillator arrives (CPR is in progress)
way in the hospital setting may involve laryngoscopic visualization
Place defibrillator beside patient. of the cause of obstruction and foreign-body removal. If an ade-
Turn defibrillator on (initial energy level setting is typically 200 J).* quate airway cannot be established by less invasive means, cricothy-
Set Lead Select switch to Paddles. Alternatively, if patient is already at- rotomy may be required.
tached to monitor leads, set Lead Select switch to lead I, II, or III; en-
sure all three leads are correctly attached to the patient and the defib- CPR Initiation
rillator: white to right shoulder, black to left shoulder, red to ribs on left
side. The health care rescuer next checks for a carotid pulse in the un-
Apply gel to paddles or place conductor pads on patient’s chest. Some responsive patient but should allow no more than 10 seconds to do
devices use disposable electrode patches that are prepasted with a
conducting gel. In either case, the appropriate positions of the pad-
so. (The AHA no longer recommends pulse checks for rescuers who
dles with applied gel, conductor pads, or disposable paddles are as are not health care providers.49 Instead, lay rescuers should initiate
follows: sternal paddle is placed to the right of the sternum, just below chest compressions if the patient is not breathing, coughing, or mov-
the right clavicle; apex paddle is placed to the left of the left breast,
centered in the left midaxillary line at the fifth intercostal space. ing after the initial two breaths.) If the patient has no carotid pulse,
Analyze rhythm begin chest compressions.The patient should be on a firm surface,
Briefly withhold CPR and the heel of the rescuer’s hand should be in the center of the infe-
If using paddles to assess rhythm, apply paddles as described with firm rior half of the patient’s sternum (but cephalad to the xiphoid
pressure (25 lb of pressure to each paddle) and visually assess rhythm
on monitor (if using leads, briefly withhold CPR and assess rhythm in
process). The rescuer’s other hand is placed on top of the lower
leads I, II, or III). If rhythm is either pulseless VT or VF, proceed as fol- hand, with the fingers interlocked.
lows: The rescuer’s arms are held straight, with the force of each com-
Defibrillate, then reassess pression coming from the rescuer’s trunk. In patients older than 8
Announce to resuscitation team, “Charging defibrillator, stand clear!”
and press Charge button on either paddles or defibrillator (initial
years, the sternum is smoothly compressed by 1.5 to 2.0 inches,
energy, 200 J, not synchronized).* then released.The duration of the compression-release cycle is di-
Warn resuscitation team that a defibrillatory shock is coming: vided equally between compression and release. The rate of chest
“I am going to shock on three! ONE, I’m clear; TWO, you’re clear, compression is 100 compressions/min in patients older than 8
THREE, everybody’s CLEAR!” Simultaneously with these statements,
visually ensure that no resuscitation team member is in contact with years.The chest should be allowed to rebound to its precompres-
patient. sion dimensions between compressions, but the resuscitator’s palm
Press the Discharge buttons on both paddles simultaneously to deliver a closest to the patient should remain in contact with the sternum.
defibrillatory shock.
Reassess rhythm on monitor; if patient is still in VT or VF, recharge defib-
In nonintubated patients, chest compressions are regularly inter-
rillator (now 300 J)* and repeat process of loudly informing team mem- rupted for the delivery of ventilations.The sequence is the same, re-
bers by giving the warning statements as above, and then apply defib- gardless of whether one-rescuer or two-rescuer CPR is being per-
rillatory shock.
formed: the rescuer delivers 15 compressions, pauses for two
Reassess rhythm on monitor; if patient is still in VT or VF, recharge defib-
rillator (now 360 J)* and repeat process of loudly informing team mem- breaths (each given over 2 seconds), then resumes compressions. In
bers by giving the warning statements as above, and then apply defib- endotracheally intubated patients, no pause for ventilation is neces-
rillatory shock.
sary; every 5 seconds, one ventilation is delivered over a period of 1
Reassess rhythm on monitor; if patient is still in VT or VF, resume CPR
and continue with resuscitation sequence. to 2 seconds, while compressions continue.18
The optimal timing and ratio of ventilations to compressions in
*Note: if using a biphasic defibrillator, a lower initial defibrillatory energy level (< 200 J) CPR is an ongoing area of research, which may lead to changes in
without energy escalation on subsequent shocks is acceptable.
VF—ventricular fibrillation VT—ventricular tachycardia
the current recommendations. In the porcine model, for example,
optimal neurologic outcome was achieved with the use of only com-
pressions for the first 4 minutes, followed by a compression-ventila-
tion ratio of 100:2.50 In the prehospital setting, when rapid advanced
equipment becomes available, the patient’s spine requires immobi- care is available within minutes, bystander-initiated mouth-to-
lization with a padded backboard, hard cervical collar, appropriate mouth ventilation combined with chest compressions offers no ad-
bolstering around the patient’s head to prevent movement, and vantage over chest compressions alone.51
strapping of the patient to the backboard.48 Good technique is critical throughout CPR delivery.The patient
should have carotid pulses with chest compressions and should
Breathing Assessment have appropriate breath sounds and chest movement with ventila-
To assess breathing, the rescuer places his or her cheek close to tions. Interestingly, femoral pulsations with CPR do not necessarily
the patient’s mouth and looks, listens, and feels for patient respira- indicate effective CPR; these pulsations often are venous rather
tions. If the respirations are agonal or the patient is apneic, the res- than arterial. Quantitative end-tidal carbon dioxide levels can be
cuer then delivers two initial breaths. Each breath is delivered over monitored, if practical. Higher levels correlate with more effective
1.5 to 2.0 seconds.The patient’s chest should rise with each deliv- CPR and increased survival.52 The patient should be reassessed for
ered breath, and exhalation is allowed for between breaths. Breaths return of spontaneous circulation every 1 to 3 minutes [see Table 1].
may be delivered using the mouth-to-mouth technique with appro-
priate barrier precautions (the patient’s nose should be pinched if Defibrillation
the mouth-to-mouth technique is used) or mouth-to-mask tech- When the monitor-defibrillator or AED arrives, it is attached to
nique.The ideal device, if available, is a bag-valve-mask device at- the patient; the rhythm is analyzed, and if the patient is in VF or
tached to high-flow oxygen; this allows the delivery of a substantial- pulseless VT, defibrillation is provided [see Tables 2 and 3].
ly higher oxygen concentration to the patient. If the patient cannot Defibrillation is thought to work by simultaneously depolarizing a
be ventilated, the rescuer repositions the airway and attempts the sufficient mass of cardiac myocytes to make the cardiac tissue ahead
technique again. If the airway is still obstructed, up to five abdomi- of the VT or VF wavefronts refractory to electrical conduction. Subse-
Table 4 Drugs Useful in Cardiac Arrest3,90

Drug and Doses Indications in
Category Adult Dosage Comments
Supplied Cardiac Arrest
I.V. boluses of epinephrine (1 mg) are appropriate only in

1 mg I.V. push; may repeat every 3–5 min pulseless cardiac arrest patients; if continued epinephrine
Epinephrine, 1 mg in 10 ml Pulseless VT or VF unre-
for as long as patient is pulseless; can is required after resuscitation, a continuous infusion should
emergency syringe; sponsive to initial de-
Vasopressors also be given via the endotracheal route: be started (1–10 µg/min).
1 mg/ml (1 ml and 30 ml fibrillatory shocks; PEA;
2–2.5 mg diluted with normal saline (NS) High-dose epinephrine (up to 0.2 mg/kg I.V. per dose) does
vials) asystole
to 10 ml total volume not improve survival to hospital discharge in cardiac arrest
patients and is no longer recommended in adults.
Vasopressin, Pulseless VT or VF unre- 40 IU I.V. push, single dose only; can also be
If no response after 10 min of continued resuscitation, ad-
20 IU/ml (1 ml vial) sponsive to initial de- given via endotracheal tube: same dose,
minister epinephrine, as above.
fibrillatory shocks diluted with NS to 10 ml total volume
Pulseless VT or VF unre- VT/VF: 300 mg diluted in 20–30 ml; NS or

sponsive to initial de- D5W rapid I.V. push; a repeat dose of
Amiodarone, Side effects may include hypotension and bradycardia in the
fibrillatory shocks and 150 mg may be given if required in 5
50 mg/ml (3 ml vial) postresuscitation phase.
epinephrine plus min; maximum dose in 24 hr should not
shock(s) exceed 2,200 mg
Initial dose: 1–1.5 mg/kg I.V.; for refractory If lidocaine is effective, initiate continuous I.V. infusion at 2–4
Lidocaine, 50 mg or Pulseless VT or VF unre- VF or unstable VT, may repeat 1–1.5 mg/min when patient has return of a perfusing rhythm (but
100 mg in 5 ml emer- sponsive to initial de- mg/kg I.V. in 3–5 min; maximum dose, do not use if this rhythm is an idioventricular rhythm or
gency syringes; pre- fibrillatory shocks and 3 mg/kg third-degree heart block with an idioventricular escape
mixed bag, 1 g/250 ml epinephrine plus May also be given endotracheally: rhythm).
or 2 g/250 ml shock(s) 2–4 mg/kg diluted with NS to 10 ml total Continuous infusion should begin at 1 mg/min in congestive
volume heart failure or chronic liver disease or in elderly patients.
Antiarrhythmics Pulseless VT or VF un- Administer 1–2 g diluted in 100 ml D5W Measured magnesium levels correlate only approximately
responsive to initial de- I.V. over 1–2 min
Magnesium sulfate, with the actual level of deficiency.
fibrillatory shocks and Total body magnesium deficits should be
500 mg/ml (2 ml and Patients with renal insufficiency are at risk for dangerous
epinephrine plus replaced gradually after initial therapy
10 ml vials), or 10 ml hypermagnesemia; use appropriate caution.
shock(s) if suspected has stabilized the emergency: adminis-
emergency syringe
hypomagnesemic ter 0.5–1 g/hr for 3–6 hr, then reassess Side effects may include bradycardia, hypotension, generalized
state continued need weakness, and temporary loss of reflexes.
20–30 mg/min I.V. (up to 50 mg/min if sit-

uation is critical); maximum dose is 17 Administer procainamide during a perfusing rhythm.
Procainamide, 100 mg/ml
Recurrent or intermittent mg/kg over time (but maximum dose is Stop procainamide administration when arrhythmia is ade-
(10 ml injection);
pulseless VT or VF reduced to 12 mg/kg in setting of car- quately suppressed, hypotension occurs, QRS widens to
500 mg/ml (2 ml vial)
diac or renal dysfunction) > 50% of original duration, or maximum dose is administered.
Maintenance infusion is 1–4 mg/min
For asystole or PEA: 1 mg I.V. every 3–5

Atropine, 1 mg in 10 ml Asystole or PEA (if rate of min up to 3 mg Minimal adult dose is 0.5 mg.
Anticholinergic Avoid use in type II second-degree heart block or third-
emergency syringe rhythm is slow) May be given via ET tube: 2–3 mg diluted
with NS to 10 ml degree heart block.
Significant hyperkalemia
In non–dialysis-dependent hyperkalemic patients, bicarbon-
Significant metabolic aci- Hyperkalemia therapy: 50 mEq I.V.
ate is most useful if metabolic acidosis is also present; bi-
dosis unresponsive to Metabolic acidosis: 1 mEq/kg slow I.V. carbonate is less effective in dialysis-dependent renal fail-
Bicarbonate, 50 mEq optimal CPR, oxygena- push; may repeat half initial dose in 10
in 50 ml emergency ure patients. The use of bicarbonate in metabolic acidosis
tion, and ventilation min; ideally, ABGs should help guide fur- management in cardiac arrest patients is controversial.
syringe ther therapy
Certain drug overdoses, in- Side effects may include sodium overload, hypokalemia, and
Miscellaneous cluding tricyclic anti- Use in overdose: discuss with toxicologist metabolic alkalosis.
depressants and aspirin
Significant hyperkalemia Do not use if suspected cause of hyperkalemia is acute

In hyperkalemia: 5–10 ml slow I.V. push;
Calcium chloride, Calcium channel blocker digoxin poisoning.
may repeat if required
100 mg/ml in 10 ml drug overdose Do not combine in same I.V. with sodium bicarbonate.
prefilled syringe In calcium channel blocker overdose: dis-
Profound hypocalcemia of cuss with toxicologist Calcium chloride is not a routine medication in cardiac
other causes arrest.
Note: All medications used during cardiac arrest, when given via a peripheral venous site in an extremity, should be followed by a 20 ml I.V. saline bolus and elevation of the extremity for
10 to 20 sec.
ABG—arterial blood gases D5W—5% dextrose in water ET—endotracheal PEA—pulseless electrical activity VF—ventricular fibrillation VT—ventricular tachycardia
quently, the sinus node or another appropriate pacemaker region of charge was 74% for patients who received their first defibrillation no
the heart with inherent automaticity can resume orderly depolariza- later than 3 minutes after a witnessed collapse.28 In this study, defib-
tion-repolarization, with return of a perfusing rhythm.15,53 The sooner rillation was delivered via an AED operated by casino security officers.
defibrillation occurs, the higher the likelihood of resuscitation.When Early defibrillation is so critical that if a defibrillator is immediately
defibrillation is provided immediately after the onset of VF, its suc- available, its use traditionally takes precedence over CPR for patients
cess rate is extremely high.54 In a study of sudden cardiac arrest pain VF or pulseless VT of recent onset. If CPR is already in progress, it
tients in Nevada gambling casinos, the survival rate to hospital dis- should of course be halted while defibrillation takes place. Newer de-
fibrillators can compensate for thoracic impedance, ensuring that the

selected energy level is in fact the energy that is delivered to the my- Table 5 Confirmation of Endotracheal
ocardial tissue. In addition, defibrillators that deliver biphasic defibril-
Tube Placement
lation waveforms instead of the standard monophasic damped sinu-
soidal waveforms allow effective defibrillation at lower energy levels Intubation process
(< 200 joules) and without the need for energy-level escalation during Vocal cords are visualized by intubator
subsequent shocks.15,55-58 In the Optimized Response to Cardiac Ar- Tip of ET tube is seen passing between the cords
rest (ORCA) study, which involved 115 patients with prehospital VF, Cuff of ET tube also passes cords by 1 cm
the 150-joule biphasic-shock AED was more effective than the tradi- Postintubation checks
tional high-energy monophasic-shock AED in four respects: it was Esophageal detector device or end-tidal CO2 detector confirms ET tube
placement in trachea
more successful in producing defibrillation with the first shock (96%
Breath sounds are symmetrical (auscultate over lateral anterior chest
versus 59%); it led to a higher rate of ultimate success with defibrilla- and in midaxillary line bilaterally)
tion (100% versus 84%); it had a better rate of return of spontaneous No gurgling with auscultation over epigastrium
circulation (76% versus 54%); and its use was associated with a high- Patient’s chest rises and falls appropriately with ventilation
er rate of good cerebral performance in the survivors (87% versus ET tube depth is appropriate: 21 cm at the corner of the mouth in
women, 23 cm in men
53%).59 There were no differences, however, in terms of survival to
Secure the ET tube to prevent dislodgment
hospital admission or discharge, and replication of the ORCA find-
Reassess the adequacy of oxygenation and ventilation throughout the re-
ings is lacking at this time. Current AHA guidelines state that lower- suscitation (bedside patient assessment; also obtain ABGs when feasible)
energy biphasic waveform defibrillators are safe and have equivalent After resuscitation, obtain a portable chest radiograph
or higher efficacy for termination of VF, as compared with the stan-
dard monophasic waveform defibrillator.15,49 ABG—arterial blood gas ET—endotracheal
Ongoing research suggests that the duration of VF is a consider-
ation in deciding whether to defibrillate immediately and as soon as
a defibrillator is available or to perform CPR for a brief period first
to “prime the pump” before proceeding to defibrillation. In the theless, oral endotracheal intubation is generally the preferred ad-
porcine model in the setting of prolonged VF (> 10 minutes), CPR vanced airway technique for cardiac resuscitation, especially in the
before countershock provides several physiologic benefits.60 Studies hospital setting, where experienced intubators are generally present;
have found that patients with VF of longer than 5 minutes’ duration in the prehospital setting, the evidence supporting endotracheal in-
had better return of spontaneous circulation, survival to hospital tubation remains inconsistent. Endotracheal intubation isolates the
discharge, and 1-year survival if ambulance personnel provided 3 airway, maintains airway patency, helps protect the trachea from the
minutes of CPR before performing defibrillation than if ambulance ever-present risk of aspiration, helps permit optimal oxygenation
personnel performed defibrillation immediately after arriving at the and ventilation of the patient, allows for tracheal suctioning, and
scene; however, some experts question the validity of these results, even provides a route for delivery of some medications to the sys-
on the basis of study design.61,62 temic circulation (via the pulmonary circulation) if intravenous ac-
cess is unobtainable or lost.63
THE SECONDARY SURVEY
The secondary survey for a victim of Optimization of Breathing and Ventilation

persistent cardiac arrest takes place after When a cardiac arrest patient undergoes endotracheal intuba-
completion of the primary survey. Like tion, correct positioning of the ET tube must be immediately con-
the primary survey, the secondary survey firmed and regularly reconfirmed during and after the resuscitation
follows an ABCD format, which in this [see Table 5]. Routine use of an esophageal detector device or end-
case consists of advanced airway inter- tidal CO2 detector is recommended, along with careful patient ex-
ventions (A); optimized oxygenation and amination. Caution is necessary with qualitative colorimetric end-
ventilation by confirmation of endotra- tidal CO2 detectors because both false positive and false negative
cheal (ET) tube placement and repeated results have been documented during cardiac arrests.65 Breath
reassessment of the adequacy of deliv- sounds should be present during auscultation over the anterior and
ered breaths (B); intravenous access and appropriate medication lateral chest walls, and the patient’s chest should rise and fall with
delivery to the patient’s circulation (C); and definitive therapy (D), delivered ventilations. No gurgling should be heard when the epi-
based on a differential diagnosis that considers the specific disease gastrium is auscultated.The ET tube should be inserted to the ap-
processes thought to be responsible for, or contributing to, the car- propriate depth marking: for average-sized adults, this is 21 cm at
diac arrest. The secondary survey includes the fourth link in the the corner of the mouth in a woman and 23 cm in a man.The pa-
chain of survival, rapid advanced care (see above). tient’s skin color should be reasonable (i.e., not dusky or cyanotic),
provided that the patient’s pigmentation allows such assessment.
Placement of an Advanced Airway Once correct positioning is confirmed, the ET tube is then appro-
Patients who remain in cardiac arrest after completion of the pri- priately secured to prevent its dislodgment.When feasible, an arteri-
mary survey require placement of an advanced airway. Depending al blood gas (ABG) measurement will help further confirm the ade-
on the setting and the experience of the rescuers, this advanced air- quacy of oxygenation and ventilation as the resuscitation proceeds.
way may be a laryngeal mask airway, an esophageal-tracheal Com-
bitube (a tracheal tube bonded side by side with an esophageal ob- Establishment of Circulation Access
turator), or an ET tube.36,63,64 The laryngeal mask airway and the Access to the patient’s venous circulation is mandatory; such ac-
Combitube can be placed by personnel with less training than that cess may be achieved by a code-team member or members simulta-
required for endotracheal intubation, and they do not require addi- neously while other resuscitators pursue steps A and B of the sec-
tional special equipment or visualization of the vocal cords. Never- ondary survey. Ideally, a large intravenous cannula is placed in a
Table 6 Technical Problems That May Prevent a Successful Resuscitation

Problem Patients at Risk Recommendations
Ensure technically perfect CPR.

Confirm carotid pulses with CPR.
Ineffective CPR All cardiac arrest
If arterial line was in place before cardiac arrest, confirm adequate arterial waveform with CPR on arterial line monitor.
patients
Monitor end-tidal CO2 if available (higher levels correlate with better CPR and improved patient survival).
Confirm adequate oxygenation with an ABG when feasible.
Ensure optimal airway positioning and control.

Have suction immediately available to manage pharyngeal and airway secretions.
Ensure use of properly fitting, tightly sealed face mask for bag-valve mask (BVM) ventilation until a definitive airway is
established.
Inadequate Apply cricoid pressure to prevent gastric distention during BVM ventilation until a definitive airway is established.
oxygenation All cardiac arrest Ensure that supplemental oxygen is flowing to BVM at 15 L/min.
and ventilation patients
Deliver an appropriate tidal volume per breath (6–7 ml/kg if oxygen is available) at the rate of 12–15 breaths/min.
Confirm bilateral and equal breath sounds with ventilation.
Confirm that patient’s chest rises with each ventilation.
Allow adequate time for exhalation between breaths.
Confirm optimal oxygenation and ventilation with an ABG when feasible.
Allow ≤ 20–30 sec/intubation attempt.

Intubator should see tip of ET tube and cuff pass between vocal cords at time of intubation.
All patients intubated After intubation, immediately confirm correct ET tube placement; regularly reconfirm ET tube placement throughout
ET tube difficulties resuscitation.
with ET tube
Confirm adequacy of oxygenation and ventilation with an ABG.
After intubation, consider nasogastric tube placement to decompress stomach and optimize diaphragmatic excur-
sions with ventilation.
Place one or more 18-gauge or larger I.V. cannulas in an antecubital or external jugular vein site.
Check for I.V. infiltration regularly throughout the resuscitation.
Follow all medications administered through a peripheral I.V. site with a 20 ml saline bolus and elevation of the
extremity containing the I.V. for 10–15 sec (if possible).
Consider central line placement if the resuscitation is prolonged.
Intravenous line All cardiac arrest Be aware of all I.V. infusions the patient is receiving.
difficulties patients
Stop all nonessential medications that had been started before the cardiac arrest.
During the resuscitation, the only infusions the patient should receive are normal saline, blood products (if clinically
indicated), and pertinent medications necessary to assist with return of spontaneous circulation.
Pulmonary artery catheters and central lines occasionally act as an arrhythmogenic focus within the right ventricle. If
applicable, deflate all relevant balloons on the catheter and withdraw the catheter to a superior vena cava position.
Make sure Synchronization Mode button is in the off position when defibrillating patients in pulseless VT or VF.
Make sure electricity is not arcing over the patient’s chest because of perspiration or smeared conducting gel; dry
patient’s chest with a towel except for areas directly beneath pads or paddles.
Do not administer shock through nitroglycerin paste or patches.
If the patient has an internal cardioverter-defibrillator (ICD) or a pacemaker, the patient may still be manually defibrillat-
Monitor defibrillator All cardiac arrest ed, but do not shock directly over the internal device. Under these circumstances, place the pads or paddles at
difficulties patients least 2.5 cm away from the patient’s internal device. If the ICD is intermittently firing but not defibrillating the patient
and if the ICD is thought to be compromising the resuscitation, turn the device off with a magnet so that manual
defibrillation may take place without interference.
Maximize the gain or electrocardiography “size” and check the rhythm in several leads (or change the axes of the
paddles if reading the rhythm in Paddles mode) to confirm asystole when the initial rhythm appears to be asystole.
ABG—arterial blood gas ET—endotracheal VF—ventricular fibrillation VT—ventricular tachycardia
prominent upper-extremity vein or the external jugular vein to opti- the arrest arrhythmia is asystole or PEA is slow), and miscellaneous
mize delivery of needed medications. If a peripheral line is not drugs used to treat specific problems contributing to the arrest
achievable, additional access possibilities include central line place- state, such as sodium bicarbonate (for severe metabolic acidosis, hy-
ment via the internal jugular, subclavian (via the supraclavicular ap- perkalemia, and certain drug overdoses), and calcium chloride (for
proach), or, less ideally, femoral vein; even intraosseous access is pos- hyperkalemia, calcium channel blocker drug overdose, or severe
sible (intraosseous access is a common emergency vascular access hypocalcemia) [see Table 4].
site in pediatric patients, but it is an unusual route of access in adults). Persons in cardiac arrest (which can result from pulseless VT,VF,
It is useful to remember, as already noted, that some important re- PEA, or asystole) require a vasopressor for as long as they remain
suscitation medications can be delivered via the ET tube in cases of pulseless.Typically, this consists of 1 mg of epinephrine intravenously
failed intravenous access; such medications include naloxone, atropine, every 3 to 5 minutes. Epinephrine stimulates adrenergic receptors,
vasopressin, epinephrine, and lidocaine (mnemonic: NAVEL). which leads to vasoconstriction and optimization of CPR-generated
The commonly used medications in cardiac resuscitation may be blood flow to the heart and brain.Vasopressin (40 units I.V. once only)
grouped into the following general categories: vasopressors (epi- is a reasonable alternative to epinephrine, at least initially.Vasopressin
nephrine or vasopressin), antiarrhythmics (amiodarone, lidocaine, in the recommended dose is a potent vasoconstrictor. It also has the
magnesium, and procainamide), anticholinergic agents (atropine, if theoretical advantage over epinephrine of not increasing myocardial
Table 7 Potentially Treatable Conditions That May Cause or Contribute to Cardiac Arrest3
Condition Clinical Setting Diagnostic and Corrective Actions
Obtain stat ABG.

Preexisting acidosis, diabetes, Reassess technical quality of CPR, oxygenation, and ventilation.
Acidosis diarrhea, drugs, toxins, prolonged Confirm correct endotracheal tube placement.
resuscitation, renal disease, shock Hyperventilate patient (PaCO2 of 30–35 mm Hg) to partially compensate for metabolic acidosis.
If pH < 7.20 despite above interventions, consider I.V. sodium bicarbonate, 1 mEq/kg I.V. slow push.
Initiate large-volume I.V. crystalloid resuscitation.

Hemorrhagic diathesis, malignancy, Confirm diagnosis with emergency bedside echocardiogram, if available.
Cardiac tamponade pericarditis, post cardiac surgery, Perform pericardiocentesis.
post myocardial infarction, trauma Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or
highly suspected clinically.
Adrenal insufficiency, alcohol abuse, Consider clinical setting and obtain finger-stick glucose or stat blood glucose measurements (may be obtained on
aspirin overdose, diabetes, drugs, ABG specimen).
Hypoglycemia
toxins, liver disease, renal disease,
sepsis, certain tumors If glucose < 60 mg/dl, treat: 50 ml = 25 g of D50W I.V. Follow glucose levels closely post treatment.*
Alcohol abuse, burns, diabetic

ketoacidosis, severe diarrhea, Obtain stat serum magnesium level.
diuretics, drugs (e.g., cisplatin,
Hypomagnesemia Treat: 1–2 g magnesium sulfate I.V. over 2 min.
cyclosporine, pentamidine),
malabsorption, poor intake, Follow magnesium levels over time, because blood levels correlate poorly with total body deficit.
thyrotoxicosis
Alcohol abuse, burns, central ner-

vous system disease, debilitated Obtain core body temperature.
and elderly patients, drowning, If severe hypothermia (< 30° C), limit initial shocks for pulseless VT/VF to three, initiate active internal rewarming and
†
Hypothermia drugs, toxins, endocrine disease, cardiopulmonary support, and hold further resuscitation medications or shocks until core temperature > 30° C .
exposure history, homelessness, If moderate hypothermia (30°–34° C), proceed with resuscitation (space medications at intervals greater than usual),
poverty, extensive skin disease, passively rewarm, and actively rewarm truncal body areas.
spinal cord disease, trauma
Initiate large-volume I.V. crystalloid resuscitation.

Obtain stat hemoglobin level on ABG specimen.
Major burns, diabetes, gastrointesti- Emergently transfuse packed red blood cells (O negative if type-specific blood not available) if hemorrhage or pro-
Hypovolemia, hemor- nal losses, hemorrhage, hemor- found anemia is contributing to arrest.
rhage, anemia rhagic diathesis, malignancy, preg-
nancy, shock, trauma Emergently consult necessary specialty for definitive care.
Emergency thoracotomy with open cardiac massage is a consideration if experienced providers are available for the
patient with penetrating trauma and cardiac arrest.
Reassess technical quality of CPR, oxygenation, and ventilation.

Hypoxia All cardiac arrest patients are at risk Confirm correct ET tube placement.
Obtain stat ABG to confirm adequate oxygenation and ventilation.
Consider in all cardiac arrest patients,

especially those with risk factors Review prearrest clinical presentation and ECG.
Myocardial for coronary artery disease, a his- Continue resuscitation algorithm; proceed with definitive care as appropriate for the immediate circumstances (e.g.,
infarction tory of ischemic heart disease, or thrombolytic therapy, cardiac catheterization/coronary artery reperfusion, circulatory assist device, emergency
prearrest picture consistent with cardiopulmonary bypass).
an acute coronary syndrome
(continued)
oxygen consumption or lactate production in the arrested heart.66 De- quired when spontaneous circulation does not return despite appro-
spite its potential advantages, however, in a study of 200 inpatient car- priate initial interventions.This situation poses a critical question to
diac arrest patients, vasopressin did not provide a better survival rate the resuscitators:Why is this patient dying right now? The intellectu-
than epinephrine.67 Vasopressin was also found to be comparable to al challenge of that question, which the resuscitators must try to an-
epinephrine in out-of-hospital cardiac arrests when the rhythm was VF swer expeditiously and at the bedside, is compounded by the emo-
or PEA but superior to epinephrine for patients in asystole.68,69 tional intensity that pervades most cardiac resuscitations.
During resuscitation with ongoing CPR, medication delivery The solvable problems that may interfere with resuscitation can
through an intravenous cannula needs to be followed by a 20 ml be grouped into three broad categories: technical [see Table 6], phys-
saline bolus; if the cannula is in a peripheral vein, the extremity con- iologic, and anatomic [see Table 7]. Technical problems consist of
taining the cannula should then be elevated for 10 to 15 seconds to difficulties with the resuscitators’ equipment or skills; such difficul-
augment delivery of the medication to the central circulation.This is ties include ineffective CPR, inadequate oxygenation and ventila-
especially important because of the low-flow circulatory state with tion, ET tube complications, intravenous access difficulties, and
closed-chest CPR. monitor-defibrillator malfunction or misuse. The physiologic and
anatomic problems consist of life-threatening but potentially treat-
Differential Diagnosis and Definitive Care able conditions that may have led to the cardiac arrest in the first
The most challenging part of the secondary survey, as well as car- place.This differentiation between physiology and anatomy is ad-
diac resuscitation management in general, is the problem-solving re- mittedly artificial, given that physiology is always involved in a car-
Table 7 (continued)
Condition Clinical Setting Diagnostic and Corrective Actions
Alcohol abuse, bizarre or puzzling be- Consider clinical setting and presentation; provide meticulous supportive care.
havioral or metabolic presentation,
Emergently consult toxicologist (through regional poison center) for resuscitative and definitive care advice, in-
classic toxic syndrome, occupational
Poisoning cluding appropriate antidote use.
or industrial exposures, history of in-
gestion, polysubstance abuse, psychi- Prolonged resuscitation efforts are appropriate. If available, immediate cardiopulmonary bypass should be
atric disease considered.
Metabolic acidosis, excessive administra- Obtain stat serum potassium level on ABG specimen.
tion, drugs and toxins, vigorous exercise,
hemolysis, renal disease, rhabdomyoly- Treatment: calcium chloride 10% (5–10 ml I.V. slow push [do not use if hyperkalemia is secondary to digitalis
Hyperkalemia
sis, tumor lysis syndrome, significant tis- poisoning]), followed by glucose and insulin (50 ml of D50W and 10 U regular insulin I.V.); sodium bicarbonate
sue injury (50 mEq I.V.); albuterol (15–20 mg nebulized or 0.5 mg I.V. infusion).‡
Alcohol abuse, diabetes, diuretic use,

drugs and toxins, profound gastroin- Obtain stat serum potassium level on ABG specimen.
Hypokalemia testinal losses, hypomagnesemia, ex- If profound hypokalemia (K+ < 2–2.5 mEq/L) is contributing to cardiac arrest, initiate urgent I.V. replacement
cess mineralocorticoid states, meta- (2 mEq/min I.V. for 10–15 mEq) then reassess.§
bolic alkalosis
Hospitalized patients, recent surgical pro- Review prearrest clinical presentation; initiate appropriate volume resuscitation with I.V. crystalloid and augment
cedure, peripartum, known risk factors with vasopressors as necessary.
for venous thromboembolism (VTE), Attempt emergency confirmation of diagnosis, depending on availability and clinical circumstances; consider
Pulmonary history of VTE, prearrest presentation emergency cardiopulmonary bypass to maintain patient viability.
embolism consistent with acute pulmonary Continue resuscitation algorithm; proceed with definitive care (thrombolytic therapy, embolectomy via interven-
embolism tional radiology, or surgical thrombectomy) as appropriate for immediate circumstances and availability.
Post central line placement, mechanical

Tension ventilation, pulmonary disease (includ- Consider risks and clinical presentation (prearrest history, breath sounds, neck veins, tracheal deviation).
pneumothorax ing asthma, COPD, necrotizing pneu- Proceed with emergency needle decompression, followed by chest tube insertion.
monia), post thoracentesis, trauma
*Unrecognized hypoglycemia can cause significant neurologic injury and can be life threatening, but caution with I.V. glucose is appropriate in the setting of cardiac arrest. Available evidence
indicates that hyperglycemia may contribute to impaired neurologic recovery in cardiac arrest survivors.
†Active internal or core rewarming includes warm (42˚–46˚ C) humidified oxygen delivered through the endotracheal tube; warm I.V. fluids; peritoneal lavage; esophageal rewarming tubes;
bladder lavage; and extracorporeal rewarming if immediately available. Active external rewarming includes warming beds, hot-water bottles, heating pads, and radiant heat sources applied
externally to the patient.
‡Glucose is not necessary initially if patient is already hyperglycemic, but glucose levels should be followed closely after administration of I.V. insulin because of the risk of hypoglycemia
(especially in patients with renal failure, because of the long duration of action of I.V. insulin in such patients). Sodium bicarbonate is most helpful in patients with concomitant metabolic aci-
dosis; it is less effective in lowering serum potassium in dialysis-dependent renal failure patients. High-dose nebulized albuterol should lower serum potassium by 0.5 to 1.5 mEq/L within 30
to 60 min, but administration during cardiac arrest may be difficult.
§In a non–cardiac arrest situation, usual I.V. potassium replacement guidelines for patients requiring parenteral therapy are generally 10 to 20 mEq/hr with continuous electrocardiographic
monitoring. If profound hypokalemia is contributing to cardiac arrest, however, these usual replacement rates are not timely enough, given the critical nature of the situation. Under these
circumstances, potassium chloride, 2 mEq/min I.V. for 10 to 15 mEq, is reasonable, but reassessment and careful attention to changing levels, redistribution, and ongoing clinical circum-
stances are essential to prevent life-threatening hyperkalemia from developing.
ABG—arterial blood gas COPD—chronic obstructive pulmonary disease D50W—50% dextrose in water ET—endotracheal VF—ventricular fibrillation VT—ventricular tachycardia
diac arrest, but it has some usefulness as a teaching and problem- ECG showed prominent ST segment elevation in leads V1 through
solving tool. Physiologic problems classically include hypoxia, aci- V4 consistent with a large anterior myocardial infarction, if the pa-
dosis, hyperkalemia, severe hypokalemia, hypothermia, hypoglycemia, tient’s resuscitation is failing despite appropriate interventions, and
and drug overdose. Anatomic problems are hypovolemia/hemor- if there appear to be no technical problems hampering the resusci-
rhage, tension pneumothorax, cardiac tamponade, myocardial in- tation, a working diagnosis of massive myocardial infarction can be
farction, and pulmonary embolism.41 made; intravenous thrombolytic therapy may then be a reasonable
Whenever possible, the patient’s medical and surgical history and and needed step in such a resuscitation.70
the circumstances and symptoms immediately before the cardiac Thoughtful consideration of the possible reasons why a resuscita-
arrest should be sought from family members, bystanders, or hospi- tion is failing will regularly push the code-team captain’s and resus-
tal staff as the resuscitation proceeds.This information may contain citation team’s expertise and clinical skills to the limits. Neverthe-
important clues to the principal arrest problem and how it may be less, the failure to consider these formidable issues will deprive the
expeditiously treated. For example, a patient who presents to an patient of an optimal opportunity to survive the cardiac arrest.
emergency department with chest pain and then suffers a VF car-
diac arrest is probably dying of a massive myocardial infarction, pul-
monary embolism, or aortic dissection, with tension pneumothorax Cardiac Resuscitation Based on Rhythm Findings
or cardiac tamponade also being possibilities. When a monitor-defibrillator arrives at the scene of a cardiac ar-
Specific questions to consider include the following: Does the pa- rest, the patient’s rhythm is immediately analyzed.This step consti-
tient have risk factors for heart disease, pulmonary embolism, or tutes the beginning part of the defibrillation stage, or step D, of the
aortic disease? What was the quality of the patient’s pain and its ra- AHA’s primary survey.There are four rhythm possibilities [see Figure
diation before the cardiac arrest? What were the prearrest vital signs 1]: (1) pulseless VT; (2) VF; (3) organized or semiorganized electrical
and physical examination findings? What did the prearrest ECG activity despite the absence of a palpable carotid pulse, which defines
show (if available)? Can any of this information be used now, at the PEA; and (4) asystole.The detailed management of these different
bedside, to dictate the needed resuscitation interventions during the cardiac resuscitation scenarios is based on the recommendations of
D phase of the secondary survey? For example, if the prearrest the AHA49 and the International Liaison Committee on Resuscita-
tion.71 In following these guidelines, the clinician should remember volved, it is exceptionally difficult to perform high-quality research
that, with the exception of early CPR and early defibrillation for VF in cardiac resuscitation.
and pulseless VT, many of the recommendations that form the
foundation of modern resuscitation are evidence supported or con-
PULSELESS VENTRICULAR TACHYCAR-
sensus based (rather than evidence based, as would be ideal). Be-
DIA OR VENTRICULAR FIBRILLATION
cause of the nature of cardiac arrest and the multiple variables in-
The appearance of either VF or
pulseless VT on the rhythm monitor in
a a patient with ongoing CPR is a rela-
tively favorable finding, because there is
reasonable hope for a successful out-
come with these rhythms. In addition,
the interventions and medications se-
quentially used in the resuscitation are
plainly delineated, and the initial course
b of action is clear.VF and pulseless VT are managed identically.
Initiation of Defibrillation
Defibrillation with 200 joules should be attempted immediately.
However, if the time from onset of arrest to CPR to the availability
of defibrillation is estimated to be longer than 5 minutes, it may be
reasonable to continue CPR for another 3 minutes before initiating
c defibrillation [see Defibrillation, above]. If the VF or VT persists after
the initial shock, subsequent attempts should be made with 200 to
300 joules and then 360 joules.
A lower, nonescalating equivalent biphasic energy level is accept-
able, if the defibrillator offers this option. Manually checking the
patient’s carotid pulse between shocks is no longer recommended,
but the displayed rhythm on the monitor must be carefully assessed
after each defibrillation attempt. If there are any doubts concerning
d the rhythm or if there is suspicion of a dysfunctional lead or paddle
cable, then a manual pulse check would be appropriate. If VF or
pulseless VT persists, CPR is resumed, the patient endotracheally
intubated, correct ET tube placement confirmed, and the tube se-
cured. Simultaneously, intravenous access should be established.
Initiation of Drug Therapy
e In patients with ongoing VF, drug therapy begins with the ad-
ministration of a vasoconstrictor (either epinephrine or vaso-
pressin) [see Table 4]. If there is no intravenous access, the drug can
be given endotracheally. After each intravenous dose, drug delivery
is followed by a 20 ml saline bolus and the extremity containing the
I.V. line is elevated. Rescuers continue CPR for 30 to 60 seconds to
allow the drug to reach the heart, then attempt defibrillation again
f with one to three shocks at 360 joules each. As long as the patient
remains pulseless, epinephrine is administered every 3 to 5 min-
utes, with each dose followed by one to three attempts at defibrilla-
tion.When vasopressin is the chosen initial drug, only a single dose
is given; if the resuscitation continues 10 minutes or longer after vaso-
pressin is administered, epinephrine should be substituted for vaso-
pressin for the remainder of the code. If VF or pulseless VT persists
g despite the initial administration of a vasoconstrictor and repeated
defibrillation attempts, parenteral antiarrhythmic drug therapy is
added; amiodarone or lidocaine is an appropriate agent [see Choice
of Antiarrhythmic Drugs, below].Throughout all of these steps, the
code-team leader is also actively looking for and correcting any
technical and physiologic or anatomic problems that may be pre-
venting a successful resuscitation [see Tables 6 and 7].
Figure 1 The sudden cardiac arrest arrhythmias. (a) Ventricular tachy- Emergency Laboratory Tests
cardia. (b) Ventricular fibrillation. Pulseless electrical activity encompasses
any of several forms of organized electrical activity in the pulseless patient; If spontaneous circulation does not return after the first round of
these include (c) normal sinus rhythm, (d) junctional rhythm, (e) bradycardic antiarrhythmic drug therapy, the resuscitation team must also en-
junctional rhythm, and (f) idioventricular rhythm. (g) Asystole. deavor to identify and treat the clinically relevant conditions causing
or contributing to the cardiac arrest [see Table 7]. In theory, the inter- diovascular cause in 233 patients in prehospital and emergency de-
ventions conducted to this point should have resulted in a perfusing partment settings.77 No benefit was found with thrombolytic thera-
rhythm.The code team must ask why this has not occurred and then py for PEA in this study; the proportion of patients with return of
attempt to answer this question as the resuscitation continues. spontaneous circulation was 21.4% in the t-PA group and 23.3% in
Emergency laboratory studies that may prove helpful include a stat the placebo group.
ABG measurement and measurements of hemoglobin, potassium,
ASYSTOLE
magnesium, and blood glucose levels (most of which can be ob-
tained from the ABG specimen). The prognosis for asystole is generally
regarded as dismal unless the patient is
Choice of Antiarrhythmic Drugs hypothermic or there are other extenuat-
Four antiarrhythmic drugs are used in cardiac resuscitation: ing but treatable circumstances.The se-
amiodarone, lidocaine, magnesium (if the patient is thought or quence of resuscitation steps in the man-
proved to be hypomagnesemic), and procainamide (for intermittent agement of asystole is as follows:
or recurrent VT or VF that initially responds to defibrillation).72 It is activation of the emergency medical or
not known which one of these drugs or which combination of them code response, primary survey (CPR,
will optimize the chances of patient survival to hospital discharge. rhythm evaluation, and asystole confir-
Despite many years of routine use, there are no controlled studies mation), and secondary survey (intuba-
demonstrating a survival benefit with lidocaine, versus placebo, in tion and confirmation of correct ET tube placement, optimal oxy-
the management of VF or pulseless VT.Two studies in patients with genation and ventilation, I.V. access with epinephrine and atropine
shock-refractory prehospital VF showed that survival to hospital ad- administration, immediate transcutaneous pacing, if available, and
mission was better with amiodarone than with placebo (44% versus problem solving for technical difficulties and establishment of the
34%; P = 0.03)73 or with lidocaine (22.8% versus 12.0%; P = cause of cardiac arrest). The two core drugs for asystole manage-
0.009).74 Neither of these studies demonstrated an improved sur- ment are epinephrine (repeated every 3 to 5 minutes for as long as
vival to hospital discharge in the amiodarone groups, but neither the patient is pulseless) and atropine (up to 3 mg over time). As with
study had the statistical power to demonstrate such a difference. PEA, vasopressin appears to be a reasonable and possibly beneficial
Amiodarone is also considerably more expensive than lidocaine. substitute for epinephrine in asystole. A single dose of aminophylline
The optimal role and the exact benefit of antiarrhythmic medica- (250 mg I.V.) may also be beneficial in atropine-resistant asystole.78
tions in cardiac resuscitation are yet to be fully elucidated.According Potentially treatable causes of asystole include hypoxia, acidosis, hy-
to AHA guidelines, either amiodarone or lidocaine is an acceptable pothermia, hypokalemia, hyperkalemia, and drug overdose. Resusci-
initial antiarrhythmic drug for the treatment of patients with VF or tation efforts should stop if asystole persists for longer than 10 minutes
pulseless VT that is unresponsive to initial shocks, CPR, airway man- despite optimal CPR, oxygenation and ventilation, and epinephrine
agement, and administration of epinephrine or vasopressin plus or atropine administration; if extenuating circumstances (e.g., hy-
shocks. On the basis of available evidence, however, amiodarone may pothermia, cold-water submersion, or drug overdose) are not pre-
be the antiarrhythmic agent of first choice in the setting of prehospi- sent; and if no other readily treatable condition is identified.
tal refractory VF, allowing for optimal survival to hospital arrival.72-74
PULSELESS ELECTRICAL ACTIVITY Immediate Postresuscitation Care
Community ACLS providers are en- Even when the resuscitation is successful, the patient’s situation
countering nonventricular arrhythmias remains tenuous and continued meticulous patient care is essential.
(i.e., PEA and asystole) with increasing When the cardiac monitor indicates what should be a perfusing
frequency. Classically, the prognosis for rhythm, the rescuer should immediately confirm that the patient
PEA has been poor, with outpatient sur- has a palpable pulse. If there is a pulse, the patient’s blood pressure
vival rates generally reported as 0% to is then obtained. Simultaneously, resuscitation team members need
7%.75,76 The sequence of resuscitation to quickly reassess the adequacy of the patient’s airway, the ET tube
steps in the management of PEA is as position, oxygenation and ventilation, and the patient’s level of con-
follows: activation of the emergency med- sciousness and comfort.
ical or code response, primary survey If the patient is hypotensive, appropriate blood pressure manage-
(CPR and rhythm evaluation), and secondary survey (intubation ment depends on the presence or absence of fluid overload, as judged
and confirmation of correct ET tube placement, optimal oxygena- at the bedside. If the patient is clinically volume overloaded or in frank
tion and ventilation, establishment of I.V. access, epinephrine ad- pulmonary edema and hypotensive, dopamine is started at inotropic
ministration, and, finally, problem solving for technical difficulties doses (5 µg/kg/min I.V.) and titrated to a target systolic blood pres-
and establishment of the cause of the cardiac arrest).The two core sure of 90 to 100 mm Hg. If the patient’s clinical status suggests nor-
drugs for PEA management are epinephrine (repeated every 3 to 5 movolemia or hypovolemia, intravenous crystalloid boluses (in 250 to
minutes for as long as the patient is pulseless) and atropine (up to 500 ml increments) can be administered instead of dopamine to sup-
3 mg over time if the PEA rhythm on the monitor is inappropriate- port adequate tissue perfusion. In patients who are regaining con-
ly slow). Although not currently on the AHA PEA algorithm, vaso- sciousness, their level of comfort mandates careful assessment and
pressin is probably a reasonable alternative to epinephrine.The best administration of analgesia and sedation, as appropriate.
hope for a successful resuscitation is to find and treat the cause of If the arrest rhythm was either VT or VF, the parenteral antiar-
PEA; therein lies the exceptionally challenging aspect of PEA resus- rhythmic drug used immediately before the return of spontaneous
citation management [see Tables 6 and 7]. Because coronary artery circulation is continued as a maintenance infusion (amiodarone, 1
thrombosis and pulmonary thromboembolism are common causes mg/min for 6 hr, then 0.5 mg/min for 18 hr as blood pressure al-
of cardiac arrest, a trial evaluated the efficacy of tissue plasminogen lows; or lidocaine, 2 to 4 mg/min). If an antiarrhythmic drug has
activator (t-PA) in the setting of PEA of unknown or presumed carnot yet been administered, it is usually started at this point to pre-
vent the recurrence of VF or pulseless VT.There are important extenuating circumstances suggest otherwise), full resuscitation efforts
ceptions to this guideline, however. If the perfusing postarrest ar- take place at the scene of the arrest in preference to rapid transport
rhythmia is an idioventricular rhythm or third-degree heart block to an emergency department. A prehospital resuscitation that has
accompanied by an idioventricular escape rhythm, an antiarrhyth- been appropriately conducted but has not resulted in at least tem-
mic medication should not be started at this time, because the an- porary return of spontaneous circulation to the patient may be dis-
tiarrhythmic agent could eliminate the ventricular perfusing focus continued. It is important that certain criteria are adhered to, how-
and return the patient to a pulseless state. ever, including the following: high-quality CPR provided, an
Initial postresuscitation studies usually include an ECG; portable adequate airway successfully placed, appropriate oxygenation and
chest radiography; and measurement of ABGs, a serum electrolyte ventilation delivered, intravenous access established, appropriate
panel, fingerstick or blood glucose, serum magnesium and cardiac medications specific to the arrest scenario administered, and resus-
enzyme levels, and hemoglobin and hematocrit. The resuscitated citation attempted for at least 10 minutes; in addition, the patient
patient requires urgent transfer to the optimal site for continued de- must not be in persistent VF, and there can be no extenuating cir-
finitive care. Depending on the circumstances, this may be either cumstances that mandate in-hospital continuation of the resuscita-
the cardiac catheterization laboratory or the intensive care unit. tion (e.g., hypothermia, drug overdose). The decision whether to
Ongoing research continues to look at optimal postresuscitation cease resuscitation efforts in the field is bolstered by direct discus-
management strategies to improve neurologic outcome and survival sion with EMS physicians. It is also essential that social services be
to hospital discharge.79 Hyperthermia and hyperglycemia compro- available to provide immediate assistance and support to the family
mise postresuscitation neurologic outcome, whereas mild to moder- and loved ones of the patient who has now died.
ate induced hypothermia appears to improve neurologic outcome Discontinuing in-hospital resuscitations is advisable when three
and decrease mortality.80-83 criteria are met: (1) the arrest was unwitnessed, (2) the initial
rhythm was other than VF or VT, and (3) spontaneous circulation
does not return after 10 minutes of ongoing resuscitation.86 In a
Ending a Resuscitation Attempt study of this three-component decision rule, only 1.1% of patients
Throughout the resuscitation, the team leader must speak with (three out of 269) who met these criteria survived to hospital dis-
calmness and authority, and all resuscitations should be orchestrat- charge, and none of the three survivors were capable of indepen-
ed with clarity and finesse. If possible, the code captain should make dent living.87 In a study of 445 prospectively recorded resuscitation
clinical decisions without directly performing specific procedures. attempts in hospitalized patients, no patient survived who suffered a
Cardiac arrests are emotionally charged, but the leader must insist cardiac arrest between 12 A.M. and 6 A.M. if the arrest was unwit-
on a composed, orderly, and technically sound resuscitation. It is nessed and if it occurred in an unmonitored bed.38
appropriate to invite suggestions from team members and to ensure A resuscitation attempt in a persistently asystolic patient should
that all members are comfortable with the decision to stop the re- not last longer than 10 minutes, assuming all of the following condi-
suscitation, should that time arrive. tions apply: asystole is confirmed through proper rhythm monitor-
The decision whether to stop a cardiac resuscitation is burdensome. ing and assessment; high-quality CPR is taking place; ET intuba-
Clearly, the circumstances of the event, patient comorbidities, the nation is correctly performed and confirmed; adequate oxygenation
ture of the lethal arrhythmia, and the resuscitation team’s ability to cor- and ventilation are provided; intravenous access is secured; appro-
rectly identify and treat potential contributing causes of the arrest are priate medications (epinephrine or vasopressin and atropine) have
all important considerations. Resuscitation efforts beyond 30 minutes been administered; and the patient is not the victim of hypothermia,
without a return of spontaneous circulation are usually futile unless the cold-water submersion, drug overdose, or other readily identified
cardiac arrest is confounded by intermittent or recurrent VF or pulse- and reversible cause.
less VT, hypothermia, cold-water submersion, drug overdose, or other After all resuscitation attempts, the code-team captain should debrief
identified and readily treated contributing conditions.84,85 the team so that all may learn from the experience. Finally, marked
With nontraumatic cardiac arrest in the prehospital setting (as- empathy and skill are needed to carefully and compassionately in-
suming proper equipment and medications are available and no ex- form family members about the outcome of the resuscitation.88
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45. Halperin HR: Mechanisms of forward flow during tidal carbon dioxide monitoring during cardiopul- 2000 for CPR and ECC: a consensus on science.
external chest compression. Cardiac Arrest: The monary resuscitation. JAMA 257:512, 1987 Circulation 102(8 suppl):I1, 2000
8 CRITICAL CARE 2 ACUTE CARDIAC DYSRHYTHMIA — 1
2 ACUTE CARDIAC DYSRHYTHMIA

Caesar Ursic, M.D., and Alden H. Harken, M.D.
Management of Acute Dysrhythmias
After successful cardiopulmonary resuscitation (CPR) or any mal heart, the so-called atrial kick adds almost nothing to cardiac
myocardial ischemic event, the most common source of hemody- output.2 If normal sinus rhythm is abolished and atrial fibrillation
namic instability is an abnormal heart rhythm. This chapter out- is electrically induced in a young healthy patient, the ventricles
lines the approach to a patient with an apparent acute cardiac and the rest of the cardiovascular system compensate almost
dysrhythmia. immediately to prevent a fall in cardiac output.3 On the other
The purpose of the heart’s electrical activity is to induce hand, loss of synchronous atrial activity in patients with end-stage
mechanical activity. Abnormal electrical activity that occurs in cardiac decompensation may decrease cardiac output by as much
the absence of hemodynamic compromise should be examined as 40%4; fortunately, such a degree of end-stage cardiac compro-
but treated with forbearance because therapy itself poses some mise is rare.
hazards: all antidysrhythmic agents, except oxygen, are nega-
tively inotropic. In the evaluation of a patient who appears to CARDIOVERSION
exhibit an acute cardiac dysrhythmia, four questions should be Cardioversion delivers sufficient electrical energy to the pre-
asked: cordium (or directly to the heart) to depolarize cells, even those
1. Does the patient actually have a cardiac dysrhythmia? in a relatively refractory state. Cardioversion imposes electrical
2. Does the patient require any therapy (i.e., is the patient suffi- reorganization on the heart. In theory, after this massive depolar-
ciently stable that treatment is NOT indicated)? ization, all the myocardial cells will repolarize simultaneously and
3. How soon should therapy be started (i.e., how unstable is the then reinstitute a synchronous beat [see Sidebar The Intracardiac
patient)? Cardioverter Defibrillator].
4. Which therapy is the safest and most effective? Certain precautions are necessary with cardioversion.The pro-
cedure is of no use in patients who are in asystole or who have
fine ventricular fibrillation (VF), because these patients have no
Patient Is Hemodynamically cardiac activity to organize—though, again, cardioversion does no
Unstable harm in such cases (as it is said, “you cannot fall off the floor”).
The choice of therapy is determined Supraventricular dysrhythmias such as atrial flutter can be con-
by the stability of the patient and the verted with extremely low energy levels (e.g., ≤ 5 joules), but
origin of the dysrhythmia. An electro- such low levels should not be employed in emergency situations.
cardiogram is helpful but not required. For a hemodynamically unstable patient, the initial cardioversion
Patients with asystole require CPR [see should be with 100 joules; if the dysrhythmia is not abolished, the
8:1 Cardiac Resuscitation]. All hemody- voltage should be increased rapidly (to a maximum of 360
namically unstable patients who have a joules).
dysrhythmia other than asystole should be treated immediately
by cardioversion. Actually, cardioversion of asystole will do no
Patient Is Hemodynamically
harm; it just will not help, because there is no underlying rhythm
Stable
to reorganize. If in doubt, therefore, one should proceed with
cardioversion.
VENTRICULAR RATE IS SLOW
The two primary goals in the management of an acute dys-
rhythmia are to control the ventricular rate and to maintain a nor- If the patient is bradycardic before
mal sinus rhythm. It is important to note that hemodynamic or after cardioversion, atropine should
instability in a patient who has a ventricular rate between 60 and be administered in a 0.5 mg I.V. push.
100 beats/min is almost certainly not the result of a cardiac This dose may be repeated at 2-
rhythm disturbance. Furthermore, heart rates in excess of 100 minute intervals. Because the effects of
beats/min do not necessarily require therapy. Most patients can atropine are transient, a temporary internal or external pacemak-
remain hemodynamically stable—and, in fact, increase their car- er should be used to maintain the heart rate. Insertion of an inter-
diac output—while raising their heart rate to 220 beats/min nal pacemaker consistently takes longer than predicted; an exter-
minus their age. In addition, it is not critical to reestablish normal nal pacemaker is a very effective temporizing maneuver [see
sinus rhythm in all cases.1 In a young, healthy patient with a nor- Sidebar Troubleshooting a Pacemaker].
Management of Acute Dysrhythmias
Patient has a cardiac dysrhythmia
Patient is hemodynamically stable Patient is hemodynamically unstable
Determine whether ventricular rate is slow or fast. Cardiovert (100–400 joules) all
(If at any time the patient becomes hemodynamically dysrhythmias except asystole.
unstable, proceed with cardioversion, 100–400 joules,
for all dysrhythmias except asystole.)
Ventricular rate is slow (< 60 beats/min) Ventricular rate is fast (> 100 beats/min)
Give 0.5 mg atropine I.V.; repeat at 2-min Obtain a full 12-lead ECG plus a long rhythm
intervals if necessary. Proceed to insertion of strip (any lead with good voltage).
temporary transvenous pacemaker. Determine whether QRS complex is narrow
Remember: External pacing can reverse or wide.
bradycardia rapidly and can be extremely
effective in an emergency.
QRS complex is wide (> 0.08 sec, QRS complex is narrow If QRS width is confusing Patient becomes
or 2 small boxes on ECG paper) (< 0.08 sec) and you cannot tell whether hemodynamically unstable
it is < or > 0.08 sec
Cardiovert (starting with an energy Give verapamil. Cardiovert (100–400 joules)
level of 100 joules), and give Mix 10 mg verapamil in 10 ml Give 6 mg adenosine I.V. all dysrhythmias except
lidocaine, 100 mg I.V. saline; give 1 mg/min until bolus × 2. asystole.
ventricular rate slows and begin
digitalization.
Ventricular rate slows Ventricular rate does

not slow
Treat as narrow-complex Treat with cardioversion as
Ventricular rate Ventricular rate slows (< 0.08 sec) tachycardia. a wide-complex (> 0.08 sec)
breaks suddenly tachycardia.
The patient has sinus tachycardia;
Begin digitalization. treat the underlying causes (e.g.,
fever, infection, hemorrhage,
stress, and pain).
The Intracardiac Cardioverter Defibrillator

Over 30 years ago, Michel Mirowski developed the first automatic intracar- heavy (though newer batteries are becoming lighter), and circuitry, which is
diac cardioverter defibrillator (ICD), a device that detects dangerous tachy- light, with a total weight of less than 100 g. Most implanted defibrillators are
arrhythmias and delivers a cardioverting shock.55 In the intervening time, it currently placed without a thoracotomy. A sensing and defibrillating lead
has become abundantly clear that some of the 400,000 Americans who die system (14 French) is inserted percutaneously via the subclavian vein into
“suddenly” of tachyarrhythmias each year could have been identified as high right ventricular–right atrial position. The distal electrode tip senses ventric-
risk, although they could not have been saved by pharmacologic or surgical ular fibrillation and tachycardia. The cardioverting energy is then discharged
treatment. For these patients, an ICD can be lifesaving.56 between a coil electrode on the diaphragmatic surface of the right ventricle
The ICD identifies dangerous rhythm patterns by means of two algo- and another coil electrode positioned in the superior vena cava.
rithms. The first of these algorithms analyzes the patient’s heart rate. The It is now clear that ICDs really do work and are capable of extending life.
patient’s maximum attainable sinus rate must be determined by exercise The most effective predictor of outcome in patients with ICDs is the severi-
testing before the device is implanted; the ICD is then programmed to de- ty of heart failure.60 The ICD does not prevent malignant arrhythmias: it is, in
tect heart rates above this value. (The ICD can be externally programmed essence, a safety net that cardioverts ventricular tachycardia or VF when it
to detect rates between 155 and 200 beats/min.57) occurs. Therefore, it must still be used in conjunction with antidysrhythmic
Using rate criteria alone, however, the ICD cannot discriminate between drugs.61,62
sinus tachycardia and ventricular or supraventricular tachycardia. Inappro- It is easy for a surgeon to become spooked by an ICD. The most effec-
priate shocks are the Achilles heel of the ICD: almost one third of patients tive strategy for managing a patient with an ICD is simply to ignore the ICD.
experience at least one inappropriate shock annually, when the device de- If such a patient is being transported to the OR, however, the device should
tects an episode of sinus tachycardia in which the rate exceeds the thresh- be inactivated before the electrocautery is used: the ICD will misinterpret
old programmed earlier. The ICD misinterprets the event as ventricular the cautery current as VF and respond by delivering a shock to the patient.
tachycardia and delivers a shock to the hemodynamically stable patient.58 The aura of mystery surrounding the ICD may be instantly eliminated by
Patients liken this to being punched hard in the chest. Although rarely of turning off the device (see below). Once the ICD is inactivated, the patient
electrophysiologic significance, an inappropriate shock can be psychologi- can be treated as any other patient would be. If external cardioversion is in-
cally crippling.59 dicated, the ICD can be disregarded; external cardioversion will not harm or
Although computer circuitry is facile and rapid, an ICD recognizes patterns activate it.
poorly. Fine (or even coarse) VF may not exhibit enough positive spikes to be
recognized as a tachyarrhythmia by the ICD. A second algorithm (the prob- How to Turn the ICD Off
ability density function algorithm) was developed to analyze electrophysio- 1. If you can find the industry representative to program the device to re-
logic data and improve the specificity of the ICD’s sensing circuitry. A unique main off, do so. Then treat the patient exactly as you would if the ICD
feature of ventricular fibrillation is the virtual absence of isoelectric time. were not present.
Conversely, during sinus tachycardia and supraventricular tachycardia, the 2. If you cannot find the representative or the situation is urgent:
ECG is at the isoelectric baseline much of the time. The probability density a. Palpate the ICD generator, which is typically implanted in the left
function algorithm enables the ICD to determine the proportion of time that subcostal region.
the ECG is spending at the isoelectric baseline and thereby to detect ven- b. Place a heavy pacemaker (or, better yet, an ICD magnet) over the
tricular fibrillation. upper corner of the device, toward the patient’s left shoulder. Older
The ICD typically requires more than 5 seconds to appreciate ventricular devices used to emit a soft beep (synchronous with the heartbeat) in
tachycardia or fibrillation. It then charges its energy storage capacitors for 15 response to a magnet when they were active. Unfortunately, that
seconds and delivers a 30-joule cardioverting shock. If necessary, the device feature has since been engineered out, and newer ICDs are silent.
will deliver a second, third, fourth, and fifth countershock. If the rhythm disor- c. Tape the magnet in place over the upper border of the device. As
der persists after the fifth countershock, the device will not recycle. long as the magnet is in place, the ICD is off and the electrocautery
ICD systems are not complex. The device consists of a battery, which is can be used safely.
VENTRICULAR RATE IS FAST

access the high-velocity Purkinje fibers as rapidly as a normal
If a patient is hemodynamically sta- impulse, and ventricular activation is delayed. The QRS complex
ble, a full 12-lead electrocardiogram is arising from an ectopic ventricular locus is therefore wider, signi-
helpful; a long rhythm strip should be fying aberrant ventricular conduction [see Figure 1].
obtained as well. The best ECG lead to Because dysrhythmias of supraventricular origin typically dis-
use for evaluating acute dysrhythmias is play a narrow QRS complex, the width of the QRS can generally
one that has good-voltage QRS com- be used to distinguish dysrhythmias of ventricular origin from
plexes and maximal P waves, if the lat- those of supraventricular origin [see Figure 2]. A wide QRS, how-
ter are present at all. ever, may also be produced by an impulse that originates in the
atrium and is aberrantly conducted to or through the ventricles
Electrocardiography (supraventricular rhythm with aberrancy). Such rhythms are rel-
A cardiac impulse produces a positive, or upward, deflection on atively uncommon, constituting approximately 10% of all wide-
the monitor or oscilloscope as it approaches an ECG electrode complex tachycardias; more important, these patients will not
and a negative, or downward, deflection as it moves away from the suffer if their dysrhythmias are treated as though they were of ven-
electrode. The important factor in dysrhythmia recognition, how- tricular origin.
ever, is not the direction of the impulse but its duration and loca- When the ventricular rate is fast and the QRS is narrow, the
tion. Normal conduction velocity is fast: an impulse is transmitted 12-lead ECG should be searched for P waves, which indicate the
by healthy Purkinje fibers at a rate of 2 to 3 m/sec.3 Hence, when presence of atrial activity. If P waves are absent and the QRS
an impulse that arises in the atrium (supraventricular) is transmit- complexes occur at irregular intervals [see Figure 3], the patient
ted via the atrioventricular (AV) node to the high-velocity Purkinje probably has atrial fibrillation. It is not crucial to know this, how-
system, the entire ventricle is electrically activated in 0.08 second ever; the focus should be on the width of the QRS complex. A cal-
(80 milliseconds; or two small boxes on ECG paper). An impulse cium channel blocker (verapamil or diltiazem) should be admin-
that is generated at an ectopic ventricular site, however, cannot istered to control the ventricular rate. For verapamil, 10 mg is
Patient with pacemaker experiences palpitations or presyncope
Obtain 30-second rhythm strip to assess pacing and sensing functions.
All wide (paced) QRS complexes Heart rate is adequate, and Some or all pacemaker artifacts
are preceded by pacemaker no pacemaker artifacts are visible are not followed by wide (paced)
artifacts QRS complexes
Place magnet over pacemaker
Pacing function is normal. to inactivate sensing circuit and Ventricular pacing threshold is
convert to fixed-rate mode. higher than pacemaker output.
No pacemaker artifacts Pacemaker artifacts that appear Pacemaker artifacts that appear
are visible with magnet at appropriate distances from at appropriate distances from
prior QRS complexes (i.e., outside prior QRS complexes (i.e.,
Pacemaker battery is dead. refractory period) provoke paced outside refractory period) do not
QRS provoke paced QRS
Sensing and pacing functions Consider two possibilities:

are normal. • Adequate pacemaker output may
not be reaching an excitable
portion of the ventricle, or
• Ventricular pacing threshold is
higher than pacemaker output.
Troubleshooting a Pacemaker
Few industries have benefited more from the United States space pro- Obtain drug history to rule out an increase in ventricular
gram than has the cardiac pacemaker industry. Much of the microcircuit- threshold caused by antidysrhythmic agents.
ry developed for the space shuttle is directly applicable to pacemakers. Obtain chest x-ray to determine whether endocardial
Yet the array of programmable parameters that has become standard in lead has been fractured or dislodged.
most implanted pacemakers, while providing therapeutic flexibility to
electrophysiologists, can be intimidating to the mere mortal surgeon. The
purpose of this discussion is to delineate simple methods for identifying
problems with the two dominant pacemaker functions: pacing and sens- Endocardial lead is intact and in good anatomic position
ing (see above and right).
Any of the following situations might prompt evaluation of pacemaker Reprogram pacemaker to higher output.
function: (1) the patient informs you that he or she has a pacemaker, (2)
you note a pacemaker bulge in the pectoral area, (3) a chest x-ray re-
veals a pacemaker with a wire descending onto the diaphragmatic sur-
face of the right ventricle, or (4) a patient with an implanted pacemaker All pacemaker artifacts are Intermittent capture
notes symptoms of palpitations or presyncope. At this point, you need followed by a paced beat persists
to obtain a 30-second rhythm strip to determine whether the pacemak-
er can capture the patient’s ventricle—that is, whether the pacemaker Relocate endocardial lead
emits an impulse that stimulates the ventricle to depolarize. to lower threshold site.
(continued)
mixed into 10 ml of saline, and 1 mg/min is given until the ven- Verapamil and diltiazem act by producing profound AV nodal
tricular rate slows. For diltiazem, 0.25 mg/kg—15 to 20 mg is a blockade (see below); however, they are also peripheral vasodila-
reasonable dose for the average patient—is given over 2 minutes; tors.6 Moderate to profound systemic hypotension can be antici-
the dose can be repeated in 15 minutes at 20 to 25 mg (0.35 pated until the patient converts to sinus rhythm.
mg/kg) over 2 minutes. A patient with a wide-complex tachycar- Much has been written about the risks of using calcium chan-
dia—or any patient who is hemodynamically unstable—is treated nel blockers in patients who are already receiving beta blockers.
by cardioversion (see above), commonly followed by administra- Abrupt and complete AV block rarely occurs, however, and in the
tion of lidocaine, 100 mg I.V., whereas a patient with a narrow- vast majority of patients, persistent supraventricular tachycardia
complex tachycardia should be treated with verapamil3,5 or dilti- poses a greater risk than the possibility of third-degree heart
azem to retard impulse conduction through the AV node. block. Therefore, previous beta blockade should not be consid-
Therefore, it is not necessary to identify the specific type of dys- ered a contraindication to the use of a calcium channel blocker.
rhythmia in order to treat it effectively. Some clinicians may prefer to use adenosine.
Troubleshooting a Pacemaker (continued)

Ventricular Capture heart rate has recovered, and the rhythm strip will look like rhythm strip b. In
a a patient in whom heart rate is adequate and no pacemaker artifacts are
visible, it is necessary to override the pacemaker’s sensing circuit to deter-
mine whether the pacemaker is capable of emitting a pacing impulse that
will capture the ventricle. The pacemaker’s sensing circuit may be inactivat-
ed by placing a magnet over the pacemaker. Alternatively, the pacemaker
may be reprogrammed to a paced rate that is faster than the patient’s in-
trinsic heart rate. In this fashion, capture may easily be assessed. (Unfortu-
nately, the programmers are expensive and are therefore often locked in
some inaccessible closet. Programmers have great theoretical value but
very little practical value to the surgeon.)
c
Note the pacemaker artifact (↑) that precedes each wide QRS complex in
rhythm strip a, above. The QRS complex is wide because ventricular acti-
vation does not originate from the AV node, and ventricular conduction is
therefore aberrant. At this point, you know that your patient is pacing, and
you can determine the pacing rate. You do not, however, know the pacing
threshold (i.e., the minimum voltage required for ventricular capture) or the
safety margin between pacemaker output and pacing threshold. At this
moment (and presumably yesterday and tomorrow), this pacemaker is ap-
propriately discharging its most important function—pacing the heart and Magnet
maintaining an adequate rate.
In rhythm strip c, above, a magnet has converted the patient’s pacemaker
Ventricular Sensing from the demand mode to the fixed-rate mode. The pacemaker artifacts
b that precede the wide (paced) QRS complexes in this rhythm strip (black
arrows) show that the pacing function of this pacemaker is intact. Occa-
sionally, a pacemaker artifact occurs during the electrical refractory period
that immediately follows the QRS complex (red arrows). Pacing during the
refractory period will not result in ventricular capture. Pacing during the re-
fractory period should not result in ventricular capture and must not be in-
terpreted as intermittent capture. In a patient whose pacemaker seems to
be sensing appropriately (as in rhythm strip b), the magnet permits assess-
ment of ventricular capture. Rhythm strip c demonstrates normal ventricu-
lar capture in the presence of a magnet.
Some or All Pacemaker Artifacts Are Not Followed by Wide QRS
In rhythm strip b, above, normal P waves are followed by regular QRS com- Complexes
plexes, and no pacemaker artifacts are evident. It is most likely that this pa- If a pacemaker impulse that occurs outside the refractory period is not fol-
tient’s pacemaker has been programmed to fire at a paced rate that is lowed by a wide QRS complex, two possibilities should be considered.
slower than this patient’s intrinsic heart rate, and the pacemaker is thus ap- First, an adequate pacemaker impulse may not be reaching an excitable
propriately sensing each QRS complex. It is unlikely but possible, however, portion of the ventricle because of fracture or dislodgment of the endocar-
that the pacemaker is not sensing appropriately. Instead, one of the follow- dial lead. This problem can usually be identified by a chest x-ray. Second, if
ing problems may be occurring: (1) the pacemaker battery is dead, which the chest x-ray shows that the lead is intact and in good anatomic position,
is unlikely unless the battery was implanted more than 5 years ago, (2) the the pacemaker output is not sufficient to reach the pacing threshold. Occa-
intracardiac electrode has been fractured, which is also unlikely, because sionally, this problem is caused by fibrosis at the endocardial electrode tip. If
current leads are remarkably durable, (3) the intracardiac electrode has the pacemaker can be reprogrammed to a higher output, the capture prob-
been dislodged (this is an uncommon late problem that typically results in lem should resolve. Otherwise, the lead must be repositioned to a site at
pacemaker artifacts unrelated to each QRS complex), or (4) the patient is which the pacing threshold is lower.
taking an antidysrhythmic drug that has profoundly depressed ventricular
excitability below threshold level for capture (this problem is very rare and Occasional Pacemaker Artifacts Closely Follow a Spontaneous QRS
can be excluded by taking a drug history). It is overwhelmingly likely, there- Complex
fore, that rhythm strip b simply demonstrates that the pacemaker is sensing If the patient’s rhythm strip looks like rhythm strip c, in the absence of a
appropriately. magnet, the pacemaker is not sensing properly. In the demand mode, most
pacemakers require at least a 2.5 mV signal to suppress output. Thus, if
Assessing Ventricular Capture When the Spontaneous Heart Rate Is the pacemaker emits stimuli in spite of a normal spontaneous heart rate, an
High adequate QRS signal either is not being sensed (the lead tip may be lodged
Typically, by the time you see the syncopal patient in the emergency de- at the site of a prior myocardial infarction or scar) or is not being transmitted
partment or recovery room, the patient is sufficiently excited that his or her to the pacemaker (because of lead fracture or dislodgment).
Adenosine (see below) produces conduction delay in the AV utes, by a final 12 mg I.V. push over 2 seconds.2,7
node and deserves recognition as a second very good option Patients receiving adenosine complain of a frightening feeling
(albeit only a transiently effective one) for treatment of paroxys- of breathlessness and pressure that is not angina or dyspnea.This
mal narrow-complex tachycardia or for diagnosis of supraventric- feeling typically resolves within 30 seconds. Facial flushing is also
ular tachycardia with aberrancy (including Wolff-Parkinson-White common. Unlike verapamil, adenosine is associated with
syndrome). Adenosine is given in a 6 mg I.V. push, followed 2 hypotension in fewer than 1% of patients.Transient atrial or ven-
minutes later by a 12 mg I.V. push and then, after another 2 min- tricular ectopy, with varying degrees of AV block, occurs in more
ventricular rate between 60 and 100 beats/min is the ultimate

goal of antidysrhythmia therapy).
Adenosine
Adenosine is an endogenous nucleoside that has differential
antidysrhythmic effects in both supraventricular and ventricular
tissue. The appeal of adenosine as a therapeutic and diagnostic
tool is that it depresses automaticity and conduction within the
SA and AV nodes.9 Two clinically relevant types of adenosine
Figure 1 This tracing depicts frequent ventricular ectopic depo- receptors are present in cardiac tissue: (1) A1 receptors, which are
larizations interspersed among depolarizations from a supraven- present on AV nodal tissue and cardiomyocytes and which thus
tricular source. Note that the QRS depolarizations of supraven- mediate AV block and even bradycardia; and (2) A2 receptors,
tricular origin are narrow, whereas the QRS complexes of ectopic which reside on vascular endothelial and smooth muscle cells and
ventricular origin are wide. mediate coronary vasodilatation.10 A3 receptors are present in the
myocardium, and selective activation of these has a cardioprotec-
tive (cardiac preconditioning) effect; however, these receptors are
not relevant in antidysrhythmic therapy.11
Adenosine and acetylcholine exhibit identical cardiac effects
and share similar receptor-effector coupling systems. Adenosine
and acetylcholine provide an opposing balance to the sympathet-
ic neurotransmitters norepinephrine and epinephrine. Thus, pre-
dictably, the adenosine antagonists caffeine, theophylline, and
aminophylline provoke tachycardia and ectopy.
Because of the rapid intravascular metabolism of adenosine
Figure 2 In a wide-complex tachycardia, each impulse is con- (half-life, 6 seconds), an intravenous bolus of adenosine (6 mg or
ducted aberrantly through the ventricles. The QRS complex is 100 µg/kg) produces a negligible effect on systemic blood pres-
therefore prolonged to more than 0.08 second and occupies more sure, as confirmed by multiple clinical studies.Thus, adenosine is
than two small boxes on the ECG tracing.
safe, but its effects are transient.
Adenosine is useful in blocking AV nodal conduction. Intra-
than half of patients. None of the side effects of adenosine neces- cardiac recordings exhibit prolongation of the A-H interval with no
sitate therapy. alteration in conduction distal to the His bundle and on into the
Compared with calcium channel blockers, adenosine has cer- ventricular myocardium (the His-Purkinje system is unaffected).
tain advantages. Because of its rapid onset and short duration of In more than 90% of cases, adenosine is effective in terminat-
action, and because its side effects are trivial and self-limited, ing supraventricular tachycardia. Interestingly, adenosine has
adenosine can be used diagnostically. If, as is often the case, the proved as effective at terminating atrioventricular reentry (85%) as
QRS width is confusing and it is therefore uncertain whether the at terminating atrioventricular node reentry (86%).9 Because of
rhythm disorder is supraventricular (QRS < 0.08 second) or ven- adenosine’s short half-life, however, the supraventricular dysrhyth-
tricular (QRS > 0.08 second), a 6 mg I.V. bolus of adenosine may mia is likely to recur within minutes in up to one third of patients.
be infused, and repeated if necessary. If the dysrhythmia slows or For that reason, adenosine is often used diagnostically, to discrim-
breaks, it was supraventricular. If it does not break, proceed to inate supraventricular from ventricular dysrhythmias (see above).
cardioversion (see above). On the other hand, even if a dysrhyth- Several clinical studies have compared adenosine with vera-
mia responds to adenosine, the profound neuroendocrine and pamil for therapeutic AV nodal blockade, with predictable results.
electrolyte perturbations that provoked the dysrhythmias in the Both agents block the AV node and control the ventricular rate:
first place—perturbations that are very common in the surgical cumulative efficacy with either agent is more than 90%.
intensive care unit—are likely to persist, and the dysrhythmia dis- Postconversion dysrhythmias in the two groups were similar.
order typically recurs. Continuous (therapeutic) infusion of Spontaneous reinitiation of supraventricular dysrhythmias occurs
adenosine (150 to 300 µg/kg/min) is rational from a physiologic more frequently with adenosine, whereas systemic hypotension is
standpoint but is frighteningly expensive. Therefore, if adenosine more commonly associated with verapamil (at least until the dys-
works transiently, it is appropriate to follow with one of the rhythmia breaks). Thus, for help in seconds (approximately 20
longer-acting calcium channel blockers. seconds), use adenosine (6 mg I.V. bolus, may be repeated); for
help in minutes (3 to 5 minutes), use verapamil (1 mg/min I.V. up
Calcium Channel Blockers
Both the sinoatrial (SA) node and the AV node are activated by
the movement of calcium through the so-called slow calcium
channels.8 Calcium channel blockers are the most powerful
agents currently available for blocking the transmission of im-
pulses across the AV node. A supraventricular dysrhythmia pro-
duces an acceleration in the ventricular rate because impulses
generated by an ectopic source above the AV node are transmit-
ted too rapidly to the ventricle [see Figure 4]. Calcium channel
blockers produce a pharmacologic blockade of the AV node, Figure 3 P waves are absent and the QRS complexes are narrow
reducing the number of impulses reaching the ventricles and and irregular in this ECG tracing from a patient with atrial
thereby controlling the ventricular rate (Remember, keeping the fibrillation.
arrest.16 Amiodarone also proved superior to lidocaine (78% ver-

sus 27%) for termination of ventricular tachycardia in a random-
ized, prospective study of 29 patients with ventricular tachycardia
refractory to external shock therapy.17
Another prospective, double-blind study comparing amio-
darone with ibutilide (another class III antiarrhythmic agent)
showed the drugs to be equally efficacious in the conversion of
Figure 4 In a narrow-complex tachycardia, the entire ventricle is atrial fibrillation to sinus rhythm and in the subsequent mainte-
activated in less than 0.08 second. Presumably, the impulse origi- nance of sinus rhythm.18 Although two patients (10%) in the
nated at a supraventricular source and accessed the ventricle via amiodarone group experienced hypotension during treatment,
the high-velocity Purkinje system. long-term maintenance therapy using the oral form of amiodarone
may make it the drug of choice for this purpose, given ibutilide’s
to 10 mg); and for help in hours, infuse digoxin, 0.5 mg I.V. lack of oral bioavailablity. Amiodarone was also found superior to
Although digitalis effectively blocks the AV node, it should be both sotalol and propafenone in preventing the recurrence of atri-
remembered that digitalis actually increases automaticity and al fibrillation in a randomized, prospective multicenter study of
excitability in both the atrium and the ventricle. The calcium 403 patients with a mean follow-up period of 16 months.19
channel blockers are superior to digoxin in controlling the ven- Although gratifyingly effective, amiodarone has significant side
tricular rate.8 effects.20 In trials of low-dose amiodarone (200 mg/day), thyroid,
The adverse effects of adenosine, like the beneficial effects, are neurologic, cutaneous, ocular, bradycardic, and hypotensive
transient.9 Facial flushing, chest pressure (adenosine has been problems were statistically more frequent; interestingly, pul-
implicated in the sensation of angina), and transient third-degree monary fibrosis was not.21
heart block are very common. Significant side effects are rare. For the first 24 hours, the recommended dosages for adults are
Nebulized adenosine can cause bronchoconstriction, especially in a loading dose of 150 mg I.V. over the first 10 minutes (15
asthmatic patients. Bronchoconstriction has not been reported mg/min) followed by 360 mg I.V. over the next 6 hours (1
after intravenous administration of adenosine. mg/min); a maintenance infusion of 540 mg (0.5 mg/min) is
given over the remaining 18 hours. The maintenance infusion
Magnesium may be continued for up to 3 weeks, at the rate of 0.5 mg/min, or
Magnesium is the second most abundant cation in humans. It the patient may be converted to oral dosing at 400 to 1,600 mg
is involved in many enzymatic reactions that influence the produc- daily, depending on the duration of the preceding I.V. infusion.
tion and utilization of cellular energy. Abnormalities in electrolyte
homeostasis (potassium and calcium in particular) are associated
Cardiac Dysrhythmias during Pregnancy
with a robust increase in cardiac myocellular excitability and auto-
maticity, especially when these abnormalities are concurrent with Fortunately, cardiac dysrhythmias are not frequent in young
myocardial ischemia.12 Multiple clinical studies confirm the effica- women of childbearing age. When rhythm problems do occur,
cy of intravenous magnesium infusion even when the measured they tend not to be hemodynamically destabilizing. The most
serum values are normal.The mechanism is unknown.When con- commonly used obstetric drug with electrophysiologic side
fronted with a patient exhibiting either supraventricular or ventric- effects is magnesium sulfate.22 When magnesium is infused intra-
ular ectopy, it is safe (and often effective) to administer magnesium venously into the mother, the fetus may exhibit a dose-dependent
chloride at a dosage of 7 g or 100 mg/kg I.V. over 1 to 3 hours. It bradycardia and a progressive decrease in healthy heart rate vari-
is not necessary to measure the serum magnesium concentration ability.23,24 Antidysrhythmic (indeed, any) drugs should be avoid-
first; the serum value will not influence therapy. ed during the first trimester of pregnancy, although most anti-
dysrhythmic agents carry relatively little risk.22 Quinidine, pro-
Amiodarone cainamide, lidocaine, digoxin, adenosine, and beta blockers all
Amiodarone is a class III antiarrhythmic drug that exerts its pri- have a long record of safety during pregnancy. Flecainide has
mary effect by prolongation of the myocardial action potential and proved to be effective in treating fetal supraventricular tachycar-
refractory period and by delay of both SA node function and AV dia complicated by hydrops. Phenytoin and amiodarone have
conduction.Amiodarone is also unique among these compounds by been associated with congenital abnormalities.22
virtue of exhibiting, to varying degrees, the pharmacologic traits of The important point is that if the mother is hemodynamically
all four classes of antiarrhythmic drugs [see Discussion, Anti- unstable and exhibits a dysrhythmia, direct current cardioversion
dysrhythmic Agents, below].13 Among these is its ability to inhibit is safe and effective.
alpha- and beta-adrenergic stimulation without the classic side
effects associated with beta receptor blockade. It also reduces trans-
Proarrhythmia with Antidysrhythmic Drugs
mural proarrhythmic heterogeneity (which predisposes to arrhyth-
mias) in the human heart [see Discussion, Pathophysiology of Proarrhythmic manifestations of ostensibly antiarrhythmic
Cardiac Dysrhythmias, Reentrant Dysrhythmias, below].14 drugs have been linked primarily to agents that prolong repolar-
Intravenous amiodarone was approved in the United States for ization. Early afterdepolarizations associated with agents that
use against malignant ventricular tachyarrhythmias in 1995. retard repolarization or an increase in spatial and temporal dis-
Rates of effective suppression for ventricular arrhythmias have persion of repolarization are the putative mechanisms of drug-
been reported to be as high as 91% in uncontrolled trials.15 induced or drug-enhanced arrhythmias.25,26
Intravenous amiodarone has also proved effective against refrac- The class III antidysrhythmic agents have traditionally been
tory ventricular tachycardia and VF. In one double-blind, ran- the agents most likely to cause dysrhythmias.26 The best way of
domized, placebo-controlled trial, amiodarone significantly preventing dysrhythmias, however, is to follow the general policy
improved survival in patients suffering out-of-hospital cardiac of not using drugs at all if they are not needed.27
Discussion
Antidysrhythmic Agents
or ventricular muscle. At therapeutic levels, digitalis has an anti-
Verapamil (or another calcium channel blocker), lidocaine, and dysrhythmic action that is mediated almost exclusively via the
adenosine are the only drugs essential for the acute treatment of vagus nerve. Toxic doses of digitalis, however, may produce an
cardiac dysrhythmias. Because patients may already be taking oral increased automaticity characterized by multifocal premature
agents for chronic dysrhythmias, however, it is important to be ventricular depolarizations [see Pathophysiology of Cardiac Dys-
aware of the actions and side effects of these drugs when treating rhythmias, below]. Caution must be observed in digitalizing a
an individual with an acute dysrhythmia. Antidysrhythmic drugs patient who is prone to atrial dysrhythmias, because digitalis
have been classified on the basis of their dominant electrophysio- increases atrial excitability and hence increases the risk of atrial
logic effect28; this classification has been reviewed and placed in a ectopy. Because digitalis also induces AV nodal blockade mediat-
clinical context.5 Adenosine has a unique receptor that modulates ed by the vagus nerve, however, any atrial dysrhythmias produced
cyclic adenosine monophosphate (cAMP), resulting in choliner- by digitalization will be less clinically significant.31,32
gic activity. It is not similar to other antidysrhythmic agents and is
therefore unclassified.
Cellular Electrophysiology
CLASS I AGENTS (MEMBRANE ACTIVE)
Electromechanical activity of all muscle, including the heart, is
Class I agents are fast sodium channel blockers. All class I determined by the concentration and flow of ions, particularly
agents—which include lidocaine, procainamide, quinidine, and calcium, potassium, and sodium. Knowledge of cardiac electro-
disopyramide—are local anesthetics. These agents block the fast physiology can serve as a conceptual framework on which to build
inward sodium current and thereby decrease both the amplitude a rational therapeutic program. Direct observation of cellular elec-
of the action potential, or phase 0 depolarization (see below), and trical activity using a glass microelectrode reveals that the cell
conduction velocity. These agents also depress the rate of sponta- membrane is semipermeable: it permits easy passage of cations
neous phase 4 depolarization, or automaticity, and thus are useful such as sodium, potassium, and calcium but provides a barrier to
for abolishing premature ventricular contractions (PVCs); class I anions and proteins. Negatively charged intracellular proteins that
agents are sometimes termed PVC killers. Because these agents cannot cross the cell membrane create a transmembrane potential
slow the conduction velocity, they can actually increase the likeli- in which the interior of the cell is negatively charged relative to the
hood of reentrant cardiac dysrhythmias in some patients.25,27 exterior. The membrane potential of a cell, EK, is proportional to
the difference between the logarithms of the intracellular potassi-
CLASS II AGENTS (BETA BLOCKERS)
um concentration, [K]i, and the extracellular potassium concen-
Class II agents are beta blockers and include such drugs as pro- tration, [K]o:
pranolol. Sympathetic hyperactivity, marked by increased release
EK = c(log [K]i – log [K]o)
of catecholamines, is one of the major causes of cardiac dysrhyth-
mias that result from increased automaticity (hyperexcitabili- The proportionality constant, c, varies with temperature, but at
ty).25,27,29 Beta-adrenergic blockade has produced a decrease in 37° C it is –60 mV. Thus, under physiologic conditions,
such automatic dysrhythmias under both clinical and experimen-
EK = –60 mV × log [K]i / [K]o
tal conditions.29
This relation, termed the Nernst equation, can be used to cal-
CLASS III AGENTS (TO PROLONG REPOLARIZATION)
culate the myocardial cell membrane potential if the potassium
Class III agents, such as bretylium, act directly on the myocar- concentrations are known. For example, if the potassium concen-
dial cell membrane to delay phases 2 and 3 of repolarization and tration is normal—that is, 150 mEq/L intracellularly and 3.8
thereby prolong refractoriness. Bretylium is effective in terminat- mEq/L extracellularly—then the membrane potential is
ing reentrant dysrhythmias because it prolongs the refractory peri-
EK = –60 mV × log 150 / 3.8
od of the ectopic focus to beyond the point at which an impulse
EK = –90 mV
reenters the circuit.1,2 Bretylium apparently has no effect on either
automaticity or conduction velocity.30 If, however, the serum potassium concentration rises to 6.0
mEq/L, then the membrane potential also changes:
CLASS IV AGENTS (CALCIUM CHANNEL BLOCKERS)
EK = –60 mV × log 150 / 6.0
Class IV agents, of which verapamil and diltiazem are the most
EK = –80 mV
effective, block the movement of calcium across the slow calcium
channels but have virtually no effect on the so-called fast sodium Thus, the resting membrane potential is determined primarily
channels.28 Because both the SA node and the AV node are com- by the concentration gradient for potassium across the cell mem-
posed of slow-response fibers that are activated by the movement brane. The transmembrane potential can be calculated if the
of calcium ions across the slow channels, the class IV agents are transmembrane potassium concentrations are measured with a
particularly effective in preventing unwanted supraventricular glass microelectrode. Under clinical conditions, however, only the
impulses from reaching the ventricles. These agents decrease the serum potassium level can be measured.This value does not pro-
conduction velocity through the AV node and increase the refrac- vide an adequate guide to the transmembrane electrical voltage,
tory period of the AV node. because many physiologic factors are capable of altering the intra-
cellular potassium concentration.13 Such factors include elec-
CLASS V AGENTS (UNCLASSIFIED)
trolyte and acid-base balance, the level of osmotic and metabolic
The vagus nerve innervates the SA node, the atria, and the AV activity, and the serum levels of glucose and insulin.
node, but it has almost no influence over the His-Purkinje system Any factor that causes osmotic movement of water into the cell
+50 ents. An energy-dependent (ATP-dependent) sodium-potassium

pump counteracts a significant influx of sodium and efflux of
potassium in the resting cell to maintain this resting membrane
potential. As noted, when the extracellular potassium concentra-
tion rises from a typical value of 3.8 mEq/L to 6.0 mEq/L, the
Phase 1 resting membrane potential increases from –90 mV to –80 mV.
This effect would tend to increase automaticity, but it is super-
Membrane Potential (mV )
0 seded by the effect of hyperkalemia on the sodium current. A rise

Phase 2 in the extracellular potassium level progressively impairs the flux
of sodium through sodium-specific channels, leading to an over-
all decrease in myocardial excitability.34
Phase 0
Phase 0
Phase 3 During phase 0, an electrical stimulus causes the sodium-spe-
– 50 cific fast channels and the calcium-specific slow channels to open,
Threshold usually for no longer than 1 msec. As positive ions rush in, depo-
larization occurs as the membrane potential rises to threshold, or
–60 mV, and an action potential is generated [see Figure 5]. Under
normal physiologic conditions, the stimulus that produces an
action potential is electrical, but any stimulus—electrical, physical
Phase 4 (such as a precordial thump), or chemical—that depolarizes a
–100 membrane up to threshold (again, –60mV) can generate an
0 500 1,000 action potential. There are various abnormalities that can cause
Time (msec) the resting membrane potential to move toward threshold. For
example, conditions that produce a decrease in energy supply (or,
Figure 5 The standard Purkinje (or ventricular muscle) action alternatively, an increase in energy demand) will have this effect
potential has five distinct phases: phase 0, rapid depolarization; because energy is required to maintain the potassium and sodium
phase 1, early repolarization; phase 2, plateau; phase 3, rapid
gradients across the resting membrane. Under such conditions,
repolarization; and phase 4, diastole.
automaticity is enhanced because lesser stimuli can achieve the
threshold potential, and the cardiac muscle is said to be hyperex-
will dilute and thus decrease the intracellular potassium concen- citable, or irritable.
tration.The transmembrane gradients of sodium and calcium are
Phases 1 and 2
maintained by energy-requiring pumps in the cell membrane.
When these pumps are inactivated, as during myocardial Phase 1 is characterized by repolarization to the plateau phase,
ischemia,12 sodium and calcium can leak into the cell. If, as often or phase 2. During phase 2, the slow calcium channels as well as
occurs, sodium leaks into the cell faster than potassium leaks out, the fast sodium channels are activated, and the membrane poten-
water will be drawn in, producing myocardial edema. Tissue aci- tial remains relatively constant for as long as 100 msec.35 The long
dosis can also alter the transmembrane potassium gradient. In duration of this plateau phase is the most dramatic difference
acidosis, hydrogen ions can leak into the cell in exchange for between an action potential in cardiac muscle and one in skeletal
potassium, thereby decreasing the intracellular potassium con- muscle. During this interval, termed the effective refractory peri-
centration and increasing the membrane potential. Variations in od, the myocardium is relatively resistant to further excitation.
glucose transport can also affect the potassium gradient. Under
the influence of insulin and epinephrine, glucose may move across Phase 3
the membrane into the myocardial cell, drawing in water by During phase 3, potassium channels reopen to promote efflux
osmosis. The decline in intracellular potassium concentration of potassium from the cell. Rapid repolarization ensues, and the
stimulates the sodium pump to exchange extracellular potassium resting membrane potential is reestablished at –90 mV.
for intracellular sodium. Concurrent administration of glucose
and insulin is the standard method for treating hyperkalemia Spontaneous Phase 4 Depolarization
because it shifts potassium from the extracellular fluid back into Unlike ordinary atrial and ventricular muscle, the Purkinje
the cells. fibers do not have a stable phase 4 diastolic potential [see Figure
6]. Instead, these fibers undergo continuous depolarization dur-
ACTION POTENTIAL GENERATION
ing diastole as a result of deactivation of the potassium efflux cur-
Stimulation of either cardiac muscle or skeletal muscle pro- rent.35,36 If the Purkinje fibers reach the threshold voltage, they
duces an action potential. Unlike a skeletal muscle action poten- will fire an action potential. Under normal conditions, however,
tial, which lasts only several milliseconds, a cardiac action poten- the SA and AV nodes exhibit faster diastolic depolarization and
tial may persist for as long as several hundred milliseconds.33 The reach threshold sooner than the Purkinje fibers. Because the cells
standard Purkinje, or ventricular muscle, action potential has five in the SA node normally reach threshold first—winning the race,
discernible phases [see Figure 5]. so to speak—the SA node typically assumes the pacemaker func-
tion of the heart. Premature ventricular contractions develop
Phase 4 when a hyperexcitable cell or fiber in ventricular myocardium
In phase 4, the resting membrane potential, or diastolic poten- undergoes rapid diastolic depolarization and reaches threshold
tial, of the cell is generated by active metabolic processes that pro- before the cells in the SA node.This cell or fiber then assumes the
duce substantial transmembrane potassium and sodium gradi- pacemaker function of the heart for that beat. The PVCs (or,
+ 50
or automaticity.37,38 Hypokalemia also increases the size of the
sodium channels, however, thereby promoting more rapid influx
of sodium during phase 0. Because the net result of hypokalemia

0 is increased automaticity, the effect of hypokalemia on sodium
influx appears to override its effect on membrane hyperpolariza-
tion. Hypokalemia is one of the most easily treated (and overtreat-
Threshold ed) forms of hyperexcitability.
– 50
Hypercalcemia
Phase 4 Calcium is a potent inotropic agent, mediating the interaction
–100
between actin and myosin that produces muscle contraction.35
Figure 6 In normal cardiac Purkinje fibers, the membrane High extracellular calcium levels may cause myocardial work to
potential does not remain flat during phase 4 but instead rises exceed the energy supply and thus impair the function of the
gradually. This spontaneous phase 4 depolarization is the result of membrane pump. As a result, the resting membrane potential
a resting potassium current. drifts up toward threshold, enhancing automaticity. Excess calci-
um also appears to promote spontaneous oscillations in mem-
brane potential [see Slow Afterdepolarizations, below].39 Because
more accurately, premature ventricular depolarizations) that of calcium’s inotropic effect, such oscillations are accompanied by
result from such ventricular ectopy can be abolished by overdrive muscle activity.
pacing. In this situation, a mechanical pacemaker is used to pace
the heart at a rate faster than that of the PVC (i.e., the R–R inter- Elevated Catecholamine Levels
val is shorter). The artificial device thereby wins the race; it Increased catecholamine levels also appear to predispose to
assumes the pacemaker function and regularizes the heart rate, automaticity, as evidenced by an increase in the incidence of mul-
producing a beneficial cosmetic effect on the ECG without alter- tiple PVCs reported in patients who have been infused with high
ing the hyperexcitability of the diseased cell. doses of catecholamines, such as epinephrine or dopamine.
Catecholamines increase both heart rate and contractility. As with
Pathophysiology of Cardiac Dysrhythmias hypercalcemia, elevated catecholamine levels may increase car-
diac work beyond the limits of energy supply and cause the mem-
All dysrhythmias are caused by enhanced automaticity, reentry, brane potential to move closer to threshold. This effect on the
or a combination of these two mechanisms. energy-dependent membrane pumps has been observed in isolat-
AUTOMATIC DYSRHYTHMIAS ed preparations of Purkinje muscle fibers. The addition of cate-
cholamines to preparations of Purkinje muscle fibers has
Any area of myocardial tissue that independently depolarizes, decreased the outward potassium current to the point that the
reaches threshold, and fires is termed automatic, and the electri- resting membrane potential was shifted as much as 25 mV toward
cal impulse that activates the adjacent myocardium generates an depolarization, enhancing automaticity.36,37 In addition to affect-
automatic rhythm. Acute dysrhythmias tend to be automatic; such ing the operation of the membrane pumps, catecholamines can
automatic dysrhythmias are frequently seen in patients in emer- produce large spontaneous oscillations in membrane voltage.36,40
gency departments and coronary care units and in patients under- Catecholamines are elaborated endogenously; a patient who is in
going surgery. Five common clinical phenomena that tend to pain, for example, may be releasing large amounts of epinephrine
increase automaticity have been identified: local myocardial into the circulation. In such cases, morphine can be used effec-
hypoxia, hypokalemia, hypercalcemia, increased catecholamine tively as an antidysrhythmic agent.40
levels, and drugs (most commonly digitalis).
Drugs
Local Myocardial Hypoxia
Digitalis is the prototypical cardiac stimulant. Typically, any
Energy-dependent cell membrane pumps maintain the resting
membrane potential, and when oxygen supply to myocardial tis-
sue is inadequate because of ischemia, the pumps fail to function
properly. Consequently, the potassium gradient declines, and the
membrane potential drifts closer toward threshold. Small mem-
brane potential fluctuations or stimuli of less than normal magni-
tude are then sufficient to bump the membrane potential up to
threshold and initiate an action potential.Ventricular muscle cells,
not only those cells in specialized conduction tissue, can sponta-
neously generate electrical fluctuations, or oscillations, in mem-
brane potential [see Slow Afterdepolarizations, below]. If the rest-
ing membrane potential is initially closer to normal because of
local myocardial hypoxia, then these spontaneous oscillations are
more likely to achieve threshold and fire an action potential.37
Hypokalemia
Figure 7 ECG demonstrates multifocal PVCs, indicating a dif-
Extracellular hypokalemia increases the resting membrane fuse hyperexcitability of the ventricles. Such hyperexcitability
potential, drawing it further away from threshold and producing may arise from a metabolic abnormality such as hypokalemia or
hyperpolarization. This effect tends to decrease tissue excitability, a pharmacologic cause such as digitalis toxicity.
Origin
a b c
Figure 8 Schematic diagram portrays a conceptual framework for understanding the generation of reentrant dysrhythmias. In
normal conduction (a), as in sinus rhythm or ventricular pacing, an impulse is propagated along two different anatomic pathways
and is extinguished at the bottom. In (b), one pathway has a region of slow conduction (red area), which results in a rate-depen-
dent block. In (c), the impulse is also blocked in the right limb (red area), but it travels over the alternative pathway sufficiently
slowly (zigzag line) for the origin to be able to repolarize before the initial impulse returns; the conducted impulse then depolar-
izes the origin and reenters the circuit.
agent other than oxygen that causes the heart to pump harder fronts and because all cardiac tissue has a long refractory period,
and faster also increases cardiac excitability. Digitalis toxicity can it is highly unlikely that any cells will remain excitable at the com-
produce diffuse myocardial hyperexcitability, manifested by so- pletion of each beat. However, disorders such as myocardial
called automatic ventricular ectopy. In this condition, the cardiac ischemia, fibrosis, and necrosis slow electrical conduction and also
impulse originates from multiple sites in the ventricle. In patients produce nonconductive areas that interrupt the normal electrical
with ventricular ectopy caused by digitalis intoxication, the whole wavefront.44 These conditions set up one of the requirements for
myocardium becomes hyperexcitable and spontaneous depolar- reentry: areas of differential myocardial repolarization.45
izations derive from multiple different sites.When the QRS com- A circuit whose length exceeds the duration of the reentrant
plex originates at multiple loci, the ECG will exhibit multiple impulse circuit is required for the initiation of reentry (i.e., in
morphologies, and multifocal PVCs are apparent on the ECG— order to sustain continuous conduction); such a circuit may
the classic multifocal ectopy of digitalis toxicity [see Figure 7].41-43 develop because of anatomic or physiologic heterogeneity in
myocardial tissue.44,45 Slow conduction, a shortened refractory
REENTRANT DYSRHYTHMIAS
period, and anatomic heterogeneity all favor reentry [see Figure
In the normally functioning heart, the rich cell-cell conduction 8]. The circuit wavelength of an impulse is the product of the
pathways promote uniform activation of the atria or ventricles in conduction velocity and the duration of the longest refractory
waves. Because activation occurs by means of large electrical wave period in the circuit.46 For example, for normal myocardium, the
Figure 9 In electrophysiologic testing, the electrical com-

plexes are spread out to facilitate the recognition of ventricu-
lar electrical morphology. In (a), critically timed paced stim-
uli capture one ventricle, but when pacing is stopped, the
rhythm reverts to sinus rhythm. In (b), critically timed paced
stimuli achieve rate-dependent block in one arm of a reen-
trant circuit. When the activation wave front returns to the
origin, this tissue is no longer refractory and undergoes depo-
larization. With reexcitation, the conditions for reentry are
met, and the impulse continues after pacing stops.
a +50 patient with a history of cardiac dysrhythmias can reveal whether

latent substrates of reentry are present. Because organized ven-
Early Afterdepolarization tricular reentry does not occur in normal myocardium, all reen-
Membrane Potential (mV)
trant dysrhythmias, whether they are induced or spontaneous, are

0 pathologic. Rapidly paced stimuli may provoke a decrease in
action potential duration and shorten refractoriness in myocardi-
um in which the conduction velocity has already been reduced.
Critically timed premature paced stimuli may then penetrate
– 50 selective zones of myocardium, leading to a reentrant dysrhyth-
mia [see Figure 9].48 A ventricular tachydysrhythmia that can be
induced by programmed stimulation carries an ominous progno-
sis unless it can be abolished by pharmacotherapy or surgery.48
–100
SLOW AFTERDEPOLARIZATIONS
b +50
Damaged atrial and ventricular muscle exhibits resting mem-
Late Afterdepolarization brane potential instability.49 The oscillations in membrane poten-
Membrane Potential (mV)
tial may at times be large enough to raise the membrane voltage

0 to threshold level and cause the cell to fire. The phenomenon of
oscillatory instability, which was first recognized in the 1940s,50 is
now thought to play an important role in the genesis of cardiac
dysrhythmias. Injury,49 elevated calcium levels,33 digitalis,41,42 and
catecholamines all promote membrane oscillatory instability,
– 50 which may be manifested as either early or late afterdepolariza-
tions. Both phenomena occur after an action potential; however,
an early afterdepolarization occurs before repolarization of the
–100 cell, whereas a late afterdepolarization occurs after repolarization
[see Figure 10]. Both early and late afterdepolarizations may be
Figure 10 Membrane oscillatory instability may be manifested followed by extreme membrane oscillatory instability that leads to
by either (a) early afterdepolarizations or (b) late afterdepolar- slow-response action potentials [see Figure 11]. If any of these
izations. If the late afterdepolarizations achieve the threshold slow potentials reach threshold, they may result in either orga-
voltage, they can fire an action potential (dotted lines). nized electrical activity (premature ventricular depolarization) or
disorganized electrical activity (fibrillation).
The recognition of slow potentials, depressed fast responses,
conduction velocity is 200 cm/sec and the refractory period is 0.4 and very slow conduction was originally based on in vitro studies
second; therefore, the circuit length for a normally conducted of cardiac tissue.51 For example, bathing superfused Purkinje
myocardial impulse would have to be 80 cm. Because the reen- fibers in a solution with a high potassium concentration inacti-
trant circuit would have to be extraordinarily tortuous to encom- vates the fast sodium channels and markedly alters normal phase
pass 80 cm, it would appear that concomitant slow conduction is 0 depolarization. Under such circumstances, slow potentials that
essentially mandatory to shorten the circuit wavelength and per- are less than 80 mV in amplitude, that depolarize at a rate of 1 to
mit initiation of a reentrant dysrhythmia. Regions such as the AV
and SA nodes normally exhibit slow conduction, and therefore,
any disturbance that produces minor additional slowing in these
+50
areas predisposes to reentry. It has also been suggested that Slow-Response Action Potentials
extreme anatomic heterogeneity might permit microreentry.45
For example, a tortuous path over stunned, slowly conducting
ventricular muscle in an individual with heterogeneous myocar-
dial infarction might achieve the prerequisites for reentry.

In vitro studies have investigated physiologic factors that might 0
produce changes in conduction and excitability that predispose to
reentrant dysrhythmias. For example, abnormal conduction has
been observed in a Purkinje network subjected to local changes
in potassium concentration.33,40 The decrease in conduction
velocity can vary in different areas of the Purkinje network, lead-
– 50
ing to functional conduction block.37,38 In T- or X-shaped
Purkinje preparations, the impulses either summate electrically
or, conversely, inhibit each other when they arrive at the same
junction simultaneously. It is difficult to study the cardiac
microenvironment in living animals or humans, but in these stud-
ies,47 electrical instability results when the Purkinje network is –100
subjected to potassium fluctuations (which certainly occur with Figure 11 Early afterdepolarizations may lead to slow-response
induced cardioplegia during cardiac surgery, and probably occur action potentials. If any of these potentials reach threshold, they
in myocardial ischemia). may lead to either organized electrical activity (premature ventricu-
Electrophysiologic testing with programmed stimulation in a lar depolarization) or disorganized electrical activity (fibrillation).
2 V/sec, and that last for up to 1 second are frequently docu- For example, even after extensive myocardial infarction, there are
mented.40,51 The amplitude and the overshoot of these slow often healthy Purkinje fibers overlying areas of damaged,
potentials can be magnified by increasing the extracellular calci- ischemic myocardium.52 Slow conduction and slow potentials are
um concentration and can be abolished by adding manganese, an characteristic of stunned myocardium.53,54
agent that blocks the slow calcium channels. These results sug- Slow potentials have been incriminated in the generation of
gest that the slow potentials are mediated by the slow calcium reentrant dysrhythmias for three reasons: (1) because they are
channels rather than by the fast sodium channels responsible for caused by an active calcium influx that produces 40 to 80 mV
routine phase 0 depolarization. Although extraordinary nonphys- depolarizations, they may be conducted long distances; (2)
iologic conditions are employed to induce such slow potentials in because the conduction velocity may be 1,000 times slower than
the laboratory, the myocardial microenvironment during the normal, the circuit wavelength is reduced accordingly; and (3)
peri-infarction and postinfarction periods as well as after cardio- because slow potentials leave a long refractory wake, they set up
plegia may well be similarly bizarre and equally nonphysiologic. zones of functional conduction block.53,54
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8 CRITICAL CARE 3 SHOCK — 1
3 SHOCK
James W. Holcroft, M.D., F.A.C.S., John T. Anderson, M.D., F.A.C.S., and Matthew J. Sena, M.D.
Approach to Management of Shock
Like a Carnot engine, the heart generates power (the product of lium gives inflammatory mediators access to the injured or infect-
pressure and flow), and under normal conditions, it does so in an ed tissues and helps promote wound healing and control of infec-
extremely efficient manner. The generated power is used to deliv- tion; on the other, it also leads to leakage of plasma into the inter-
er nutrients to and remove waste products from metabolizing tis- stitium, which results in hypovolemia and inadequate ventricular
sues, to carry heat from these tissues to the surface of the skin end-diastolic volumes.The second mechanism, which arises from
(where the heat is dissipated into the environment to help keep the need to offload heat generated by the inflammatory process, is
body temperature under control), and to transport hormones from a severalfold increase in blood flow to the skin. Blood pressure falls
one part of the body to another. If a patient’s heart becomes inca- because of cutaneous arteriolar dilation and because of sequestra-
pable of carrying out these functions, he or she is said to be in shock. tion of blood in the cutaneous venules and small veins.
For the purposes of treatment, it is helpful to classify shock into Other problems can arise from these two basic mechanisms.
six main types on the basis of the underlying processes responsi- Myocardial contractility may decrease, either as a result of inade-
ble for the shock state. Most cases of shock fall readily into one of quate coronary perfusion or as a direct cardiodepressant effect of
these six categories; however, some cases involve more than one the inflammatory mediators. The afterload may fall even further,
underlying process and thus belong to more than one category. presumably in an effort to produce the residual cardiac power
more efficiently.The heart rate may rise in an effort to increase the
cardiac output; alternatively, it may remain largely unchanged in
Classification an effort to allow more time for ventricular filling and perfusion of
the coronary vasculature during diastole.
HYPOVOLEMIC SHOCK
If the predominant feature of the shock state is loss of plasma
In hypovolemic shock, small ventricular end-diastolic volumes volume into the interstitium through a permeable microvascula-
lead to inadequate cardiac generation of both pressure and flow ture, the patient’s skin will be cool and clammy (hence the terms
(and thus of power). Causes include bleeding, protracted vomit- cold septic shock and cold inflammatory shock).The mean blood
ing or diarrhea, fluid sequestration in obstructed gut or injured tis- pressure and the cardiac output will both be inadequate. If, how-
sue, excessive use of diuretics, adrenal insufficiency, diabetes ever, the blood volume has been restored or the predominant fea-
insipidus, and dehydration. ture of the shock state is cutaneous vasodilatation, the patient’s
skin will be flushed and warm (hence the term warm inflammato-
INFLAMMATORY SHOCK
ry shock). The mean blood pressure will be low, but the cardiac
Inflammatory shock arises from the release of inflammatory output may be high as a consequence of the cutaneous arteriolar
and coagulatory mediators. It can be caused by ischemia-reperfu- dilatation and the reduced afterload.
sion injury, trauma, or infection (in which case it is sometimes
COMPRESSIVE SHOCK
referred to as septic shock). Clinical conditions capable of causing
inflammatory shock include pneumonia, peritonitis, cholangitis, In compressive shock, external forces compress the thin-walled
pyelonephritis, soft tissue infection, meningitis, mediastinitis, chambers of the heart (the atria and the right ventricle), the great
crush injuries, major fractures, high-velocity penetrating wounds, veins (systemic or pulmonary), the great arteries (systemic or pul-
major burns, retained necrotic tissue, pancreatitis, anaphylaxis, monary), or any combination of these. Compression of any of
and wet gangrene. these structures can drastically decrease ventricular production of
For inflammatory shock to develop, the infected or traumatized both pressure and flow.
or reperfused tissues must be in proximity to a robust drainage of Clinical conditions capable of causing compressive shock in-
blood from the tissues. An avascular infection (e.g., a contained clude pericardial tamponade, tension pneumothoraces, positive
abscess), in which the inflammatory mediators do not have access pressure ventilation with large tidal volumes or high airway pres-
to the circulation, will not cause inflammatory shock, whereas an sures (especially in a hypovolemic patient), an elevated
uncontained abscess (e.g., a ruptured appendiceal abscess or an diaphragm (as in pregnancy), displacement of abdominal viscera
acutely drained subphrenic abscess), which allows vascular dis- through a ruptured diaphragm, and the abdominal compart-
semination of the mediators, can do so. Similarly, dry gangrene, ment syndrome (e.g., from ascites, abdominal distention,
because of its poor vascular supply, will not cause inflammatory abdominal or retroperitoneal bleeding, or a stiff abdominal wall,
shock, whereas wet gangrene can. as in a patient with deep burns to the torso).
The hemodynamic problems in inflammatory shock are caused
INTRAVASCULAR OBSTRUCTIVE SHOCK
by two basic mechanisms.The first mechanism is disruption of the
microvascular endothelium, both at the inflammatory site and dis- Intravascular obstructive shock results when intravascular ob-
tally. On the one hand, the increased permeability of the endothe- struction, excessive stiffness of the arterial walls, or obstruction of
Patient appears to be in shock
Characteristic clinical markers:

• Hypotension • Oliguria
• Tachycardia or bradycardia • Myocardial ischemia
Approach to Management • Tachypnea • Metabolic acidemia
of Shock • Cutaneous hypoperfusion • Hypoxemia
• Mental abnormalities
Shock persists
Initiate specific therapy based on type of

shock present.
Hypovolemic or inflammatory shock Compressive shock
Control bleeding; obtain vascular access; infuse crystalloid (e.g., normal saline) Compression of heart or great vessels, as
in initial boluses of 60 ml/kg body weight; give RBCs to maintain [Hb] ≥ 9 g/dl; immediately life-threatening condition
treat pain, hypothermia, acidemia, and coagulopathy. Goals: resolution of (see above), should already have been
clinical abnormalities and generation of adequate pressure to perfuse CNS treated. Nevertheless, reassess periodically
and organs with obstructed arterial inflow. (specifically, for adverse effects of
If patient remains unstable, transfer to setting where MAP and CVP can be mechanical ventilation and for abdominal
transduced. Goal: resolution of shock without excessive CVP. If necessary, compartment syndrome).
give dobutamine (5–15 µg · kg –1 · min –1) or milrinone (loading dose followed If compressive shock is a possibility, insert
by infusion of 0.375–0.750 µg · kg –1 · min –1). Swan-Ganz catheter. Treat as for hypovolemic
Insert Swan-Ganz catheter if patient (1) requires excessive fluid, (2) requires or inflammatory shock (see left).
inotropes for > 30 min, (3) might need vasoconstrictors, (4) may have nonviable
myocardium, or (5) requires excessively high FIO2.
Decide on priority for subsequent resuscitation:
• To ensure tissue perfusion (even at the cost of possible edema formation and
increased ventricular O2 requirements), or
• To minimize edema and ventricular O2 requirements (even at the cost of
possible slow or incomplete resuscitation from shock).
Priority is ensuring resuscitation; edema is not Priority is minimizing edema formation and protecting heart;
a major problem, and myocardium is not at risk less than full resuscitation is acceptable
Infuse fluids. Goal: RVEDV and LVEDV ≥ normal Give fluids or diuretics (e.g., furosemide, 10–40 mg) as needed.
(2.5 ml/kg). Goal: either RVEDV or LVEDV (whichever is smaller) normal, with neither
Give inotropes. Goal: normal contractility in both volume below normal.
right ventricle (0.4 mm Hg/ml) and left (2 mm Hg/ml). If contractility is subnormal on either side, increase with dobutamine or
If absolutely necessary, and only as last resort, milrinone. If it is supranormal on both sides, give beta blocker, starting
give vasopressors, starting with vasopressin. with esmolol (loading dose followed by infusion of 50 µg · kg –1 · min –1,
If HR ≤ 89 beats/min, add dopamine increased as needed) and switching to metoprolol (5–15 µg q. 6 hr).
(2–20 µg · kg –1 · min –1). If HR ≥ 90 beats/min, Goal: normal contractility on both right and left.
use norepinephrine (2–12 µg/kg). Increase Adjust left ventricular afterload to equal 50% of contractility. If afterload
left ventricular afterload until it equals contractility; ≤ 49% of contractility, give dopamine or dobutamine. Rarely (as last resort),
do not let it exceed contractility except in use vasopressin and norepinephrine, but reassess frequently.
desperate cases.
If afterload ≥ 51% of contractility, reduce arterial stiffness with diuretic,
beta blocker, ACE inhibitor (e.g., enalaprilat, 1.25–5.0 mg q. 6 hr), and
nitroglycerin (5–200 µg · kg –1 · min –1).
If HR ≥ 90 beats/min, increase beta blockade until limited by hypotension
or wheezing. If HR is still too fast, add calcium channel blocker
(e.g., diltiazem, 5–15 mg/hr).
Identify and treat any immediately life-threatening

conditions:
• Dysrhythmias
• Airway compromise, inadequate ventilation or
compression of heart and great vessels (or both)
• Bleeding
• Medical emergencies
Shock resolves
Intravascular obstructive shock Neurogenic shock Cardiogenic shock
Reduce RVESP and LVESP by decreasing Place in Trendelenburg position. If RVEDV and LVEDV seem too large, initiate
arterial stiffness with diuretics, beta Infuse fluids as necessary, and give diuresis.
blockers, ACE inhibitors, and nitroglycerin. vasoconstrictors (dopamine if HR ≤ 89 Initiate beta blockade to keep HR ≤ 89 beats/min
If pressures remain too high, insert Swan- beats/min; norepinephrine if HR ≥ 90 unless patient is hypotensive or wheezing.
Ganz catheter. Treat as for hypovolemic beats/min). Control LVESP. Reduce arterial stiffness with
or inflammatory shock (see left). Periodically reassess for possibility of more aggressive diuresis, increased beta
If pulmonary vasculature is obstructed, hypovolemia or other cause of inadequate blockade, ACE inhibition, and nitroglycerin.
ventilator mode may have to be changed. end-diastolic volume (e.g., cardiac Goals: adequate MAP, adequate peripheral
If systemic vasculature is obstructed, compression). If such possibility is perfusion, and HR ≤ 89 beats/min, with no sign
aortic counterpulsating balloon pump significant, insert Swan-Ganz catheter. of myocardial ischemia.
may be needed. Treat as for hypovolemic or inflammatory
shock (see left). If efforts are unsuccessful, insert Swan-Ganz
catheter. Adjust left ventricular afterload to equal
50% of contractility. Balloon pump, coronary
angioplasty, or cardiac surgery may be required.
If problem is with right ventricle, adjustment of
ventilator may help.
the microvasculature imposes an undue burden on the heart.The Table 1 Clinical Markers of Possible Shock State
obstruction to flow can be on either the right or the left side of the
heart. Causes include pulmonary valvular stenosis, pulmonary
Clinical Marker Value or Findings Indicative of Shock
embolism, air embolism, acute respiratory distress syndrome
(ARDS), aortic stenosis, calcification of the systemic arteries, Systolic blood pressure
thickening or stiffening of the arterial walls as a result of the loss Adult ≤ 110 mm Hg
of elastin and its replacement with collagen (as occurs in old age), Schoolchild ≤ 100 mm Hg
and obstruction of the systemic microcirculation as a result of Preschool child ≤ 90 mm Hg
chronic hypertension or the arteriolar disease of diabetes. The Infant ≤ 80 mm Hg
blood pressure in the pulmonary artery or the aorta will be high;
the cardiac output will be low. Sinus tachycardia
Adult ≥ 90 beats/min
NEUROGENIC SHOCK Schoolchild ≥ 120 beats/min
Neurogenic shock arises from the loss of autonomic innerva- Preschool child ≥ 140 beats/min
tion of the vasculature. The arterioles, the venules, and the small Infant ≥ 160 beats/min
veins are the vessels most strongly affected by this denervation; the
Pale, cool, clammy skin with constricted
arteries may be affected as well, but not to the same extent. In Cutaneous vasoconstriction
subcutaneous veins
some cases, the denervation also involves the heart. Causes
include spinal cord injury, regional anesthesia, administration of Respiratory rate
drugs that block the adrenergic nervous system (including some Adult ≤ 7 or ≥ 29 breaths/min
systemically administered anesthetic agents), certain neurologic Child ≤ 12 or ≥ 35 breaths/min
disorders, and fainting. Infant ≤ 20 or ≥ 50 breaths/min
In some patients (e.g., those who have a spinal cord injury or
have received a regional anesthetic), the denervation is localized, Anxiousness, agitation, indifference,
Mental changes
lethargy, obtundation
which means that only the vasculature in the denervated areas will
be blocked. In other patients (e.g., those who have received a gen- Urine output
eral anesthetic), the vasculature throughout the body will be blocked. Adult ≤ 0.5 ml • kg–1 • hr –1
All patients in neurogenic shock have small ventricular end-dia- Child ≤ 1.0 ml • kg–1 • hr –1
stolic volumes because of the pooling of blood in the denervated Infant ≤ 2.0 ml • kg–1 • hr –1
venules and small veins. If the blockade is generalized or at a high
enough level, the denervation can also reduce myocardial contrac- Chest pain, third heart sound, pulmonary
Myocardial ischemia or failure
edema, abnormal ECG
tility and lower the heart rate. All patients also have low blood
pressures because of the arteriolar denervation and the depletion [HCO3–] ≤ 21 mEq/L
of the ventricular end-diastolic volumes. In cases of distal dener- Metabolic acidemia
Base deficit ≥ 3 mEq/L
vation, in which the heart is not involved, the cardiac output may
be high, depending on the offsetting effects of the decreased after- Hypoxemia (on room air)
load and the decreased end-diastolic volumes. In cases of gener- 0–50 yr ≤ 90 mm Hg
alized denervation, however, the cardiac output is low. 51–70 yr ≤ 80 mm Hg
≥ 71 yr ≤ 70 mm Hg
CARDIOGENIC SHOCK
In cardiogenic shock, the heart itself, because of an intrinsic

abnormality, is incapable of delivering blood into the vasculature at the midaxillary line and with the pressures referenced to the
with adequate power. Sometimes, the problem is with the muscle; atmosphere (as all physiologic pressures are unless otherwise specified).
sometimes, it is with the rhythm. Causes include bradyarrhyth- The brachial systolic pressure has several advantages in this
mia, tachyarrhythmia, myocardial ischemia, myocardial infarc- context: it is easy to measure and understand, it can be measured
tion, cardiomyopathy, myocarditis, myocardial contusion (rare), in almost any setting, and its measurement does not require expen-
cardiac valvular insufficiency, papillary muscle rupture, and sep- sive, complicated, or difficult-to-calibrate equipment. Moreover,
tal defects. The mean arterial pressure (MAP) is usually low, in the treatment of shock, it is the pressure with which most physi-
depending on the degree of compensatory constriction of the sys- cians feel most comfortable. Nonetheless, the brachial systolic
temic arterioles; the cardiac output is always low. pressure is not the most pertinent variable in the early stages of
resuscitation. The mean aortic root pressure is more relevant [see
Figure 1]. This pressure, however, usually is not available until a
Characteristic Clinical later stage of resuscitation, when it is possible to cannulate and
Markers directly monitor the intra-arterial pressures (see below).
The presence of a shock A low brachial systolic pressure can serve as an indicator of
state is typically signaled by shock, though what constitutes a significantly low value
one or more characteristic depends to an extent on the age of the patient [see Table 1]. In
clinical markers [see Table 1]. an adult, a low brachial systolic pressure (≤ 110 mm Hg) fre-
quently indicates shock; a very low brachial peak-systolic pres-
HYPOTENSION sure (≤ 89 mm Hg) almost always does, especially in a patient
In the initial assessment and resuscitation of a patient in shock, who is under stress. (Admittedly, many normal patients, espe-
it is usually necessary to rely on the brachial systolic pressure as cially young women, may have a systolic pressure of 89 mm Hg
measured by sphygmomanometry, with the manometer zeroed or lower when supine, but only when in an unstressed state.
The pain or stress associated with an injury or acute illness will relation to the patient’s age [see Table 1]—can serve as an indicator
drive that normally low pressure to much higher levels, partic- of shock.
ularly in well-conditioned patients who are ideally suited to The absence of tachycardia should not, however, be taken as a
deal with threats to the cardiovascular system. A patient whose sign that the patient is not in shock. A slow or normal heart rate
brachial systolic pressure is low in the presence of stress can be may even indicate that decompensation is imminent. In severe
assumed to be in shock.) A sustained (> 30 seconds) systolic shock, the pulse rate may have to slow down to allow more time
pressure drop greater than 10 mm Hg in a patient who has both for ventricular filling and for coronary perfusion of the
arisen from a supine to an upright position can also be an indi- myocardium.
cator of underlying shock.
TACHYPNEA AND BRADYPNEA
The absence of hypotension does not, however, rule out shock.
Adrenergic discharge and the release of circulating vasoconstric- Any patient with tachypnea must be promptly evaluated not
tors (e.g., vasopressin and angiotensin) and locally produced vaso- only for possible pulmonary insufficiency but also for possible
constrictors (e.g., endothelin) often sustain blood pressure during shock.The rapid respiratory rate may be a response to a metabol-
shock despite volume depletion or depressed myocardial contrac- ic acidemia; it may also be a means of compensating for inade-
tility. As a result, visceral hypoperfusion may precede clinically evi- quate filling of the ventricles, in that it will lower the mean
dent changes in the supine blood pressure. In addition, some intrathoracic pressure and facilitate the influx of blood into the
forms of shock can even be associated with hypertension (as in a heart from the capacitance venules and small veins in the periph-
hypertensive crisis). Finally, the definition of hypotension can vary, ery. In severe decompensated shock, the respiratory rate may fall
depending on the patient’s usual blood pressure, which the physi- to very low levels, perhaps because of ischemia in the muscles pro-
cian may not know. For example, in a patient with severe preexist- viding the ventilation.1
ing hypertension, a brachial systolic pressure of 120 mm Hg might
CUTANEOUS HYPOPERFUSION
be an indicator of shock.
Diminished skin perfusion is often the first sign of shock. In all
TACHYCARDIA OR BRADYCARDIA
types of shock other than warm inflammatory shock and neuro-
The pulse rate—perhaps the most evident of all the physical genic shock, blood flow to the skin is reduced because of adrener-
findings in clinical medicine—can increase in shock, and the pos- gic discharge and high circulating levels of vasopressin and
sibility of shock should be considered in any patient with a tachy- angiotensin II. The result is the pale, cool, and clammy skin of a
cardia. An abnormally high pulse rate—with “high” determined in person exhibiting the fight-or-flight reaction. Cutaneous hypoper-
AORTIC ROOT RADIAL ARTERY

140
120
100
80
mm Hg
60
40
20
0
0 250 500 750 1,000 1,250 1,500 1,750 2,000 0 250 500 750 1,000 1,250 1,500 1,750 2,000
Time (msec) Time (msec)
Figure 1 The mean pressure is defined as the area under a pressure tracing divided by the time needed to produce
the tracing. A pressure wave in the ascending aorta with a blood pressure of 110/80 mm Hg will have the same mean
pressure as a pressure wave in the radial artery of the same patient, even though the radial artery pressure might be
140/75 mm Hg. The systolic pressure in the radial artery is usually inscribed more rapidly. Therefore, even though the
peak pressure in the radial artery is greater than that in the aorta, the areas under the tracings will be the same for
the two vessels. Sometimes, the mean pressure can be approximated by taking one third of the difference between the
systolic and diastolic pressures and adding that value to the diastolic pressure. Frequently, however, the formula does
not work. In this example, the mean aortic pressure would be approximated at 90 mm Hg, whereas the mean radial
artery pressure would be approximated at 97 mm Hg. Such results would be impossible: if the mean pressure in the
radial artery were greater than the mean pressure in the aorta, blood would flow backward. This confusion is avoided
by measuring the area under the curve and calculating the mean pressure exactly, which can be done with computer
circuits that are available in all modern pressure-monitoring systems. It should also be noted that the systolic pres-
sure in the radial artery is about 30 mm Hg higher than the systolic pressure in the aortic root. In extreme cases, it
can be as much as 80 mm Hg higher.
fusion is not specific for shock—it can also be the result of hypo- admixture of oxygen-poor blood results in a reduced oxygen satu-
thermia, for example—but it can be a warning that the patient may ration in the systemic arterial blood.
decompensate at any time.
MENTAL ABNORMALITIES Identification and
Patients in severe shock frequently exhibit mental abnormali- Treatment of
ties, which can range from anxiousness to agitation to indifference Immediately
to obtundation. These findings are not sensitive—indeed, they Life-Threatening
develop only in the late stages of shock—nor are they specific. Conditions
They are, however, a strong warning to the physician that some- If the patient shows signs
thing must be done quickly.The body protects the blood supply to suggestive of shock, the next
the brain at all costs. Changes in mental status as a result of severe step is to search for and treat
shock suggest impending circulatory collapse. any conditions that could be
immediately fatal, such as (1) dysrhythmias; (2) compromise of
OLIGURIA
the airway, inadequate ventilation, compression of the heart, com-
The stress imposed by all forms of shock—in the absence of pression of the great vessels, or any combination of these condi-
diuretic use, high alcohol levels, or administration of radiographic tions (they often go together); (3) acute intravascular obstruction
contrast agents—stimulates the release of vasopressin (antidiuret- of the great vessels; (4) bleeding; and (5) certain life-threatening
ic hormone) and aldosterone (through activation of the angio- medical conditions (e.g., anaphylaxis, severe electrolyte distur-
tensin system).2,3 The result is oliguria, which is a sign of stress at bances, and life-threatening endocrine abnormalities).
the very least and a sign of decreased blood flow to the kidneys in There are roughly 10 to 20 clinical entities (depending on how
extreme cases. one categorizes them) that can kill a patient quickly. Identification
Whenever the diagnosis of shock is being entertained, a Foley and management of these conditions requires early and continu-
catheter should be placed. Successful treatment should reduce the ous patient assessment and depends heavily on pattern recogni-
stress and decrease the plasma levels of vasopressin and aldos- tion. Although not all of these entities are immediately fatal, all are
terone. It should also increase renal blood flow if the shock is life-threatening. Delays in recognition will increase the duration of
indeed so severe that inadequate blood flow to the kidneys is com- hypoperfusion and may result in significant late morbidity and
promising their viability.With successful treatment, the urine out- mortality related to multiple organ failure.
put should improve; if it does not, further therapeutic measures
DYSRHYTHMIAS
are probably necessary.
Given that an ECG should be obtained promptly in any case of
MYOCARDIAL ISCHEMIA
suspected shock, any dysrhythmia present is usually recognized
Electrocardiography is indicated whenever the suspicion of early in the course of resuscitation. If the patient is agonal, car-
shock arises. The electrocardiogram may show signs of ischemia, dioversion should be performed. If the patient turns out to be in
which may be caused either by a primary myocardial problem or ventricular fibrillation, ventricular tachycardia, or atrial fibrillation,
by a secondary extracardiac problem (e.g., hypotension resulting cardioversion may restore him or her to life with full neurologic
from hemorrhage). In either case, the presence of myocardial function. Cardioversion takes precedence over all other resuscita-
ischemia should prompt quick action. tive efforts, including gaining airway control and obtaining I.V.
access (though if the team taking care of the patient can perform
METABOLIC ACIDEMIA
cardioversion, secure the airway, and gain I.V. access at the same
Metabolic acidemia, as a sign of shock, may be manifested by time, it should do so).The goal is to get blood flowing again to the
an increased respiratory rate. Serum chemistry may also demon- brain. Even if the initial reperfusion is with desaturated blood, it is
strate a decrease in the total concentration of carbon dioxide better than no perfusion at all. If the agonal patient turns out to be
(bicarbonate plus dissolved CO2), but analysis of blood gases is in asystole, cardioversion will be of no value. It is likely, however,
usually required for confirmation.The acidosis may take the form that no other treatment will restore an asystolic patient to life with
of either a low calculated bicarbonate level or a base deficit. Often, full neurologic function either. In the case of asystole, it rarely
it does not become evident until after the shock has been recog- makes any difference what mode of therapy is attempted—or,
nized and treatment is under way. In severe, untreated shock, the indeed, whether therapy is attempted at all.
anaerobic products of metabolism are confined to the periphery; A nonagonal patient should be treated in accordance with stan-
they may not be washed into the central circulation until resusci- dard resuscitation routines [see 8:1 Cardiac Resuscitation and 8:2
tation has reestablished some flow to the ischemic tissues. The Acute Cardiac Dysrhythmia].
degree of acidosis after resuscitation can, however, provide infor-
COMPROMISE OF AIRWAY, INADEQUATE VENTILATION, AND
mation about the duration and severity of the initial insult.
COMPRESSION OF HEART OR GREAT VESSELS
HYPOXEMIA
If a patient can talk in a full voice without undue effort, the air-
Shock may be associated with significant arterial hypoxemia. way can be assumed to be intact. Supplemental oxygen should be
Low flow results in marked desaturation of the blood leaving the given via a mask or nasal prongs; nothing else need be done.
metabolizing peripheral tissue, which eventually ends up in the If the patient cannot talk in a full voice, possible compromise of
pulmonary artery (yielding a low mixed venous oxygen saturation the airway and possible inadequate ventilation must be assumed.
[SmvO2]). In patients with coexisting pulmonary dysfunction and Causes range from loss of protective reflexes to mechanical
an intrapulmonary shunt, the markedly desaturated pulmonary obstruction to a host of other problems that can limit ventilation.
arterial blood is only partially saturated as it passes through the Sometimes, a jaw thrust is all that is needed for diagnosis and
lungs, ultimately mixing with fully saturated blood. The increased treatment of the problem. In cases of profound shock, however,
Table 2 Selected Cardiopulmonary Variables in

Resting Subjects of Different Age-Adjusted Weights
Approximate O2 Consumption Cardiac Output

Height (ft, in) Lean Weight (kg) Lean Weight (kg) (ml/min) (L/min) Tidal Volume (ml)
5´0´´ 48.9 50 175 5.0 350
5´6´´ 59.1 60 210 6.0 420
6´0´´ 70.4 70 245 7.0 490
6´6´´ 82.6 83 290 8.3 580
the patient should be intubated. Initially, the patient should be bronchial intubation is a possibility.The tube should be withdrawn
ventilated by using an Ambu bag with 100% oxygen; later, when into the trachea (or what one believes to be the trachea).
the situation has stabilized sufficiently, the patient should be If the endotracheal tube is obstructed by clotted blood or inspis-
switched to mechanical ventilation. sated secretions, the obstruction can usually be cleared by suctioning.
In the mechanical ventilation of a patient in severe shock, the If this measure is unsuccessful, the patient should be reintubated.
goal is to achieve ventilation and oxygenation without unduly Bleeding in the tracheobronchial tree (from injuries or from fri-
compromising cardiac production of pressure and flow. The venable bronchial mucosa or tumor tissue) can eliminate ventilation
tilator should be set so as to produce ventilation with a minimal from the lung segment supplied by the injured or obstructed
mean airway pressure (mean pressure being defined as the integral bronchus and flood the initially uninjured lung with blood. If the
of the pressure over time divided by the time over which the pres- bleeding is thought to be coming from the left lung, the endotra-
sure is produced). A respiratory rate of 12 to 15 breaths/min and cheal tube should be advanced into the right mainstem bronchus.
an initial tidal volume of approximately 7 to 8 ml/kg lean body Bleeding from the right lung is more problematic. Selective left
weight should result in sufficient alveolar ventilation to normalize mainstem intubation is usually impossible under emergency con-
the carbon dioxide tension (mild hyperventilation is acceptable if ditions. If selective mainstem intubation is not feasible or substan-
the patient has a profound acidemia) [see Table 2 and Sidebar tial bleeding continues on either side, definitive control of the bleed-
Expectations for Cardiopulmonary Values in Patients of Different ing will have to be obtained by means of either endobronchial tech-
Sizes and Ages]. Although a lung-protective ventilation strategy niques or open surgical intervention.
may ultimately be desirable in certain patients who have sustained Bleeding into the pleural cavity can eliminate ventilation of the
lung injury, the initial ventilatory settings should be adjusted so affected side and push the mediastinum into the nonbleeding side.
that respiratory acidosis is avoided during the acute resuscitation This problem is treated with insertion of a chest tube and, if nec-
phase.4 The end-expiratory pressure should be set at 0 mm Hg. essary, surgical intervention.
Oxygenation should be assured with a fractional concentration of Pneumothoraces may arise from injuries to the lung, from
inspired oxygen (FIO2) of 1.00. attempts to place a central venous line, or from positive pressure
When blood gas analysis becomes available, the ventilator should ventilation. They are treated by inserting a chest tube.
be adjusted to ensure adequate arterial oxygen saturation (SaO2) Tension pneumothoraces sometimes develop in a patient who is
and adequate alveolar ventilation. Managing the ventilator during breathing spontaneously; more often, however, they are created by
the acute resuscitation of a patient in severe shock is a dynamic superimposition of positive pressure ventilation on a previously
process. Close attention to the tidal volume and the airway pressure existing pneumothorax.The tension pneumothorax not only elim-
is necessary to ensure adequate gas exchange and avoid unneces- inates ventilation on the side of the pneumothorax but also limits
sary cardiovascular sequelae and potential lung injury [see 8:5 ventilation on the uninjured side and compresses the heart and great
Mechanical Ventilation and 8:4 Pulmonary Insufficiency]. vessels. Characteristic signs include decreased or absent breath
Even when intubation appears to have been successful and the sounds on the involved side, a hyperresonant hemithorax, and, if
ventilator seems to be functioning normally, there are still many the patient is normovolemic, distended neck veins. (A tracheal
things that can go wrong. Misplacement or displacement of the shift—a commonly described feature in patients with tension pneu-
endotracheal tube and malfunction of the ventilator can be hard mothoraces—is hard to detect and, in our experience, rarely help-
to detect. If the chest wall does not rise with inspiration, the ful in making the diagnosis.) A tension pneumothorax should be
patient should be removed from the ventilator, and the almost the first diagnosis considered in any patient who suddenly decom-
foolproof Ambu bag should again be used to ensure adequate air- pensates when placed on positive pressure ventilation. Treatment
flow through the endotracheal tube. Malfunction is rare with consists of needle decompression followed by tube thoracostomy.
modern ventilators, but it remains a potential problem that must Air leaks almost always mean loss of ventilation on the side of
be eliminated.The easiest way of dealing with ventilator malfunc- the leak. If they are large, they also mean loss of ventilation on the
tion is to change the ventilator. uninjured side, in that the administered air preferentially exits the
If increasing abdominal distention is apparent, the possibility of airway through the chest wall defect or the chest tube on the
esophageal intubation or displacement of the endotracheal tube injured side. A left-side leak can sometimes be treated by advanc-
into the hypopharynx should be considered. Whenever the place- ing the endotracheal tube into the right mainstem bronchus; a
ment of the tube is questionable, reintubation is mandatory. right-side leak usually necessitates surgical intervention, as does
Reintubation is obviously hazardous in these circumstances, but it any large leak that does not close quickly.
is clearly preferable to leaving a misplaced endotracheal tube in Acute pericardial tamponade is usually manifested by muffled
place. If breath sounds are absent on the left, right mainstem heart tones and occasionally by an exaggerated (> 10 mm Hg)
Expectations for Cardiopulmonary Values in Patients of Different Sizes and Ages
Some numerical descriptors of physiologic variables that can be altered could best be compared with those of another species by indexing to
in shock (e.g., blood pressure, body temperature, and arterial pH) are in- body weight raised to the three-fourths power. Such indexing seemed
dependent of the amount of metabolically active tissue the patient has; to reduce variability even more effectively than indexing to body sur-
others (e.g., tidal volume, minute ventilation, ventricular end-diastolic vol- face area did, though it was difficult to explain why.72
umes, stroke volume, cardiac output, oxygen consumption, carbon diox- Over the ensuing six decades, more and more accumulated evi-
ide production, and caloric needs) are not. dence came to support Kleiber's contention, but only in the past two
The question of how to interpret, or index, these size-dependent vari- decades have his observations been satisfactorily explained. It now
ables dates back at least to the 1800s. It seemed logical at that time (and seems established that the Kleiber hypothesis can be proved by using a
still seems so today) to index the variables to body surface area.69 The mathematical model that takes into account not only the thermodynamic
body surface, as the site where the body dissipates its heat into the envi- considerations just described but also the fractal geometry of the vascu-
ronment, plays a critical role in keeping the body from becoming over- lature in metabolizing organs and the thermodynamic constraints placed
heated. The amount of heat produced by the body in a resting condition on such systems. 73
depends on the mass of the metabolizing tissue. (During exercise or ill- Thus, the problem of correlating size-dependent cardiopulmonary
variables between species seems to be settled, and the different meta-
ness, more heat is generated from the same mass of tissue. Presumably,
bolic rates, cardiac outputs, and minute ventilations in different species
humans evolved so as to be able to deal with both resting and stressful
appear to be well explained. However, the practice of using body
conditions. In either type of condition, however, some surface area
weight raised to the three-fourths power does not solve the problem of
through which heat can be dissipated is necessary.) The amount and ac-
how to make comparisons between members of the same species
tivity of metabolically active tissue correlates with oxygen consumption.
(e.g., between a large mouse and a small one or between a linebacker
Thus, a patient’s body surface area should correlate with the amount of
and a ballerina). In addressing this second problem, some clinicians,
heat generated by his or her metabolizing tissue, the mass and activity of particularly those with a primary interest in the cardiovascular system,
the metabolizing tissue, and the oxygen consumption. continue to index cardiopulmonary variables to body surface area. Oth-
In the 1920s, when it became possible to measure cardiac output as ers, particularly those with a primary interest in the respiratory system,
part of metabolic studies, many investigators began to express cardiac favor indexing to body weight instead. A few prefer to use body weight
output, as well as metabolic rate, in terms of body surface area, on the raised to the three-fourths power. Still others choose not to index at all.
grounds that these two quantities should also be correlated. Although it Not only is there no consensus on the preferred indexing method,
was recognized that the relation was not necessarily a linear one, this ap- but there also is no agreement on how and whether to adjust for obesi-
proach to indexing worked, in the sense that it minimized some of the in- ty and aging. Body surface area is typically calculated on the basis of
herent variability observed in nonindexed values. By the end of the height and weight. Usually, the measured weight is used, which in-
1920s, body surface area had become the most commonly used param- cludes the weight of the fat. Thus, the calculation gives equal emphasis
eter for indexing both metabolic rate and cardiac output to body size.70,71 to metabolically active muscle and to metabolically inactive fat. Old age
In the 1930s, however, Max Kleiber made the empirical observation introduces a similar problem: for a given weight, older patients have
that the metabolic rates—and presumably the cardiac outputs and some less lean muscle mass and more fat than younger patients do. Some
of the ventilatory parameters—of members of one species of animals authors make an adjustment for age; others do not.
(continued)
decrease in systolic blood pressure on spontaneous breathing. If of ascites or edema or by exacerbating bleeding.5-7 The situation is
the patient is not hypovolemic, the neck veins are typically distend- made even worse because the increased venous pressures further
ed. Nowadays, the diagnosis is frequently confirmed by echocar- reduce the perfusion pressures (calculated as MAP minus the
diography (if that modality is immediately available). Treatment venous pressure) in the organs at risk.
consists of needle decompression or surgical creation of a pericar- Initial treatment of ascites consists of paracentesis of just enough
dial window. Chronic tamponade can also cause shock but may fluid to decrease the abdominal pressure, but no more. Treatment
not give rise to the findings characteristic of acute tamponade.The of intestinal edema may necessitate opening the abdomen. Bleed-
diagnosis usually is made by means of echocardiography. ing may be controllable by operative or endovascular means; if such
Treatment is the same as for acute tamponade. measures fail to control bleeding, the abdomen may have to be
Diaphragmatic rupture and the ensuing intrusion of abdominal opened and left open.Treatment of the burned abdominal wall may
viscera into the chest can compress the venae cavae, the heart, the involve escharotomies.
pulmonary arteries, the pulmonary microvasculature, the pul- Pregnancy can elevate the diaphragm and complicate a shock
monary veins, the left atrium, and the lungs.Treatment consists of state. If a woman in the late stages of pregnancy is thought to be in
operative reduction and repair. shock, she should be turned onto her left side to relieve compres-
The abdominal compartment syndrome can be caused by sion of the right common iliac vein and the inferior vena cava. If
ascites, intestinal distention or edema, intra-abdominal or retro- shock persists, one may consider attempting to induce labor or
peritoneal bleeding, or noncompliance of the abdominal wall (as in perform a cesarean section.
patients with deep burns of the torso).The result is compression of
INTRAVASCULAR OBSTRUCTION OF GREAT VESSELS
the vasculature of the organs within the abdomen and intrusion of
the diaphragm into the chest, which compromise ventilation and To treat pulmonary thromboembolism, aggressive anticoagula-
decrease ventricular end-diastolic volumes. If the patient is also tion with heparin, at the very least, is required; fibrinolytics, some-
hypovolemic, the hemodynamic consequences can be devastating. times infused through a pulmonary arterial catheter, may also be
Infusion of fluid can restore ventricular end-diastolic volumes but necessary [see 6:6 Venous Thromboembolism].
can also worsen the underlying problem, either by increasing the Right-side air embolism can arise either from penetrating injuries
central venous pressure (CVP) and encouraging the development to large veins in the upper part of the body or from percutaneous
Expectations for Cardiopulmonary Values in Patients of Different Sizes and Ages (continued )
Even though there is, at present, no unanimity on how best to deal with the predicted body weight that has been advocated for use in setting
these issues, it is obvious that some form of indexing (or nonindexing) is tidal volumes.4,75
necessary, both for the management of patients and for the creation of writ- We have found it useful to assign expected values for size-depen-
ten reference sources. Our current practice is to start with the assumption dent cardiopulmonary variables in subjects of different age-adjusted
that lean persons (e.g., those with a body mass index [BMI] of 21 or so) do lean weights who are resting, fasting, well conditioned, supine, sponta-
not have very much body fat. Assuming a BMI of 21, we then use the pa- neously breathing, and in a thermoneutral environment [see Table 2].
tient’s height to assign a weight, which we assume is mostly metabolically We make three assumptions in assigning these values, using the age-
active tissue. This assigned weight is employed in interpreting the size-de- adjusted lean weight for all of the calculations:
pendent variables. For patients 50 years of age or younger, we use the as-
1. The normal resting oxygen consumption is 3.5 ml • kg–1 • min–1.
signed weight as is. For patients 51 years of age or older, we calculate an
2. The normal resting cardiac output is 100 ml • kg–1 • min–1.
age-adjusted lean weight based on the assumption that 1% of body weight
3. The normal resting tidal volume is 7 ml/kg.
has been lost each year after the age of 50.74 (Although this loss is in fact
exponential in nature, we have not found it necessary to reflect this fact in In practice, we usually approximate the height to the nearest half-
the calculation.) As an example, with an 83-year old patient, we subtract foot [see Table 2], then approximate the lean weight for that approxi-
33% from the lean weight that the patient would have had at 50 years of mate height. Once this is done, the values for oxygen consumption,
age. For older subjects who have kept themselves in particularly good con- cardiac output, and tidal volume tend to come out in a pleasing, almost
dition, we assume that 0.5% of body weight has been lost each year after linear way. We then make any additional adjustments necessary—in
the age of 50. Finally, we make subjective adjustments if muscle mass particular, for age and cardiovascular variables.
appears to be either abnormally large (as in male patients who worked out An example will demonstrate how use of the age-adjusted lean
extensively when young) or abnormally small (as in malnourished patients weight can influence assessment and treatment. The hypothetical pa-
or patients with a preexisting prolonged critical illness). tient is an 83-year-old man with an admission weight of 80 kg and a
This practice means that we do not use the patient’s actual weight height of 5 feet 6 inches. If a Swan-Ganz catheter were in place, one
when setting up the ventilator or when managing the patient on the basis would expect a cardiac output of 8 L/min. The patient’s age-adjusted
of other size-dependent variables. The weight at the time of measure- lean weight, however, is 40 kg (60 kg was the lean weight at 50 years of
ment can be inflated by fluid resuscitation, the hardware used for fracture age, minus 33% for the subsequent 33 years—on the assumption the
fixation, bedclothes, or obesity. It can also be difficult to measure accu- patient did not work out much over the past few decades). One would
rately in critically ill patients, who often cannot easily be moved to a bed- expect a resting cardiac output of 4 L/min. (We would accept this value
side scale. We also do not adjust for gender. For longevity and freedom unless the patient had excessive metabolic needs.) This is not an un-
from debilitating illnesses, a BMI of 21 is close to ideal for both men and usual example; one could easily think of more extreme cases. The pa-
women (though it appears that a slightly higher fat percentage may be tient in this example has a BMI of 28, and there are many patients in the
appropriate for women). The value we use is also conveniently close to ICU today with indices that exceed this level.
puncture of a large central vein in the upper part of the body with penetrating thoracic injury suddenly and catastrophically decom-
a large-bore needle (if the needle is unintentionally left open to pensates after initiation of positive pressure ventilation. (The differ-
atmospheric pressure and air). In both situations, the air typically ential diagnosis in this case consists of tension pneumothorax and
gains access to the venous system during spontaneous deep breath- air embolism. Accordingly, the first therapeutic measure is to insert
ing. Patients are particularly vulnerable when upright. Right-side air chest tubes on both the right and the left. If it turns out that the
embolism can also arise as a complication of insufflation of gas into patient has not had a tension pneumothorax, the diagnosis of pos-
the peritoneal cavity during laparoscopy.8 sible air embolism should be kept in mind as other conditions are
In all of these situations, the air that gains access to the veins can ruled out.)
form an obstructing air bubble in the outflow tract of the right ven- Treatment consists of surgical control. In the case of a penetrat-
tricle.Treatable sources of air should be searched for and eliminating injury, the chest should be opened through an anterolateral tho-
ed, and 100% oxygen should be administered to wash out residual racotomy on the side with the suspected injury. The hilum of the
nitrogen in the trapped air. The patient should be placed in the injured lung should be cross-clamped. Then, if the right side was
Trendelenburg position with the left side down to induce transloca- opened first, the incision should be extended into the left chest.The
tion of air from the outlet of the right ventricle to the apex of the heart should be massaged while the descending thoracic aorta is
chamber. A long central venous catheter should then be advanced compressed.Vasoconstrictors should be given to increase the aortic
centrally to allow aspiration of any air that may be present. pressure and to drive the air bubbles through and out of the arteri-
Left-side air embolism can arise from right-side air embolism if al circulation. If neither side of the chest is known to have had a
the right-side air embolizes to the pulmonary microvasculature, penetrating injury, the left side should be opened first. The prima-
backs up blood in the right side of the heart, increases pressures in ry goal of treatment is to prevent further embolism.Thus, if the left
the right atrium, and opens up a potentially patent foramen ovale. chest is opened first and no injury to the lung is detected, yet the
It can also be the consequence of a penetrating injury to the lung diagnosis is certain (based on the finding of bubbles of air in the
parenchyma (either from trauma or from a needle puncture) in a coronary arteries), the incision should be carried into the right chest
patient placed on positive pressure ventilation: the positive airway in an effort to find a treatable injury there.
pressure can push air from an injured bronchus into an adjacent
BLEEDING
injured pulmonary vein. The air and its contained nitrogen can
occlude the vasculature of the brain and heart, as well as that of Bleeding should be controlled by any means necessary. In
other organs. The diagnosis is usually made when a patient with a some cases (e.g., bleeding from an easily accessible site in an
extremity), compression will suffice; in others, immobilization of vascular volume is restored may prevent cardiovascular collapse dur-
a fracture may be enough; in still others, operative control (e.g., ing anesthetic induction.
for a ruptured spleen), endoscopic control (e.g., for GI hemor- At the risk of belaboring the obvious again, it must be empha-
rhage), or endovascular control (e.g., for arterial hemorrhage sized that early resuscitation should be the goal. Delaying recogni-
after a severe pelvic fracture) may be possible. In any case, con- tion and treatment by as little as several hours may result in
trol is paramount: it makes no sense to infuse fluid or blood or increased mortality.9 Once resuscitation has been initiated and the
to persist with ancillary measures while controllable bleeding physiologic abnormalities addressed, source control becomes the
continues unabated. priority. From a practical standpoint, these two processes are fre-
quently performed in parallel—that is, resuscitation continues
MEDICAL EMERGENCIES
while the infectious or inflammatory source is being addressed.
In the appropriate clinical circumstances, early consideration
VASCULAR ACCESS
should be given to certain medical conditions that may cause
shock. In diabetic patients, severe hypoglycemia should always be On the assumptions that an airway has been established, that
considered. Rapid assessment with a bedside glucose monitor or the patient is being ventilated, and that bleeding is being con-
empirical I.V. dextrose therapy may prevent the neurologic conse- trolled, the next step is to obtain vascular access (this is frequent-
quences of prolonged hypoglycemia. Anaphylaxis can be addressed ly done simultaneously). If possible, superficial veins in the upper
with I.V. or subcutaneous epinephrine and antihistamine therapy extremities should be percutaneously cannulated with two large-
and may help prevent life-threatening airway and circulatory com- bore catheters. If this is impossible, venous access can be achieved
promise. In patients with significant renal dysfunction, life-threat- by means of cutdown on veins in the extremities or percutaneous
ening electrolyte abnormalities should always be considered. Finally, puncture of central veins; access to the bone marrow can be
whenever standard resuscitative measures are unsuccessful in obtained by means of percutaneous insertion of a thick needle
reversing shock, severe endocrine abnormalities (e.g., addisonian through cortical bone.
crisis and myxedema), though often difficult to diagnose, should Cutdowns in the upper extremity cause little morbidity. They
be considered. sometimes take time to perform, however, and the veins may be
thrombosed from earlier use. The cephalic vein at the shoulder is
less likely to be thrombosed, but it lies below the deep fascia and
Specific Treatment Based on Category of Shock is sometimes difficult to isolate. The external jugular vein is deep
If shock persists after immediately life-threatening conditions to the platysma and can be difficult to identify when the lighting is
have been treated, the next step is to categorize the shock state on poor. The saphenous vein at the ankle is readily exposed by cut-
the basis of the underlying physiologic abnormality and treat the down and is large and easy to cannulate; however, it cannot be
patient accordingly. used if there is extensive trauma to the extremity, and if the can-
As a rule, all that is needed to make this preliminary classifica- nula is left in place for more than 24 hours, superficial throm-
tion is the history, the physical examination, a chest x-ray, an bophlebitis is likely to develop.The saphenous vein in the groin is
ECG, and, in some cases, a complete blood count, electrolyte con- large and easy to cannulate, but the end of the catheter will lie in
centrations, a glucose level, and arterial blood gas analysis. The the external iliac vein. Iliofemoral deep vein thrombosis (DVT) or
categorization is seldom neat: more than one cause of cardiovas- even septic DVT is common; either can be a potentially fatal com-
cular inadequacy is usually present, as when a patient with a plication in a patient who becomes critically ill.
myocardial infarction requires mechanical ventilation or when a Percutaneous cannulation of the internal jugular vein or the
patient with a ruptured abdominal aortic aneurysm has a distend- subclavian vein not only affords access for infusion of fluids and
ed and tight abdomen. Nevertheless, classification is useful, in that drugs but also provides a port for central venous monitoring.
it focuses the physician’s attention on the primary problem, which Obtaining central venous access with percutaneous techniques,
should be treated first. however, can be difficult and risky, particularly in a hypovolemic
patient with collapsed central veins. The puncture can cause a
pneumothorax. An artery adjacent to the vein may be punctured.
Management of At times, an arterial puncture may not be recognized, and the
Hypovolemic or artery may even be dilated and cannulated. Once the vessel is can-
Inflammatory Shock nulated, the problem may initially go undetected. Furthermore,
blood drawn from a cannulated artery in a shock patient may be
CONTROL OF BLEEDING
flowing in a nonpulsatile fashion, giving the impression that the
AND ONGOING
targeted vein has been successfully accessed. In severe shock, the
INFLAMMATION
arterial blood may be blue, thereby supporting this mistaken
At first glance, it might impression. A damaged artery can also bleed into the pleural cav-
seem obvious that treatment ity, an untamponaded space. If this occurs in a patient who is
of the underlying causes of shock should have the highest priority. already compromised, the patient will probably die.
This is indeed the case with hypovolemic shock caused by hemor- Percutaneous puncture of the common femoral vein is among the
rhage; however, with inflammatory shock, a temporary delay in easiest of all venous access techniques and avoids the problems of
source control (e.g., abscess drainage or tissue debridement) may pneumothorax and bleeding into a pleural cavity. If this vein is can-
be warranted until the patient has been adequately resuscitated. nulated, the access site should be changed to a vein in the upper
This is a particularly important consideration when the process of body as soon as the patient is stable. The incidence of DVT and
source control is likely to result in further cardiovascular compro- septic complications is relatively high with femoral venous cannula-
mise. An obvious example is the patient who requires a laparoto- tion, and long-term use of this site should be avoided if possible.10-12
my for a hollow viscus perforation. In this situation, briefly delay- If the adjacent femoral artery is unintentionally cannulated, it is
ing administration of a vasodilating inhaled anesthetic while intra- sometimes best to use this vessel for vascular access. Intra-arterial
infusion of fluids is as effective as I.V. infusion. Care must be The colloid solution that has probably been the object of the
taken, however, to ensure that no air enters the system. The greatest amount of interest is albumin. Until comparatively recent-
catheter should be removed as soon as other access is gained. ly, no large, randomized trials of albumin had been done, and thus,
In pediatric patients, intraosseous access (e.g., via the proximal there was an ongoing controversy as to whether albumin should be
tibia, the distal femur, the iliac crest, or the sternum) is a useful given to critically ill patients.19,20 In 2004, however, the Saline ver-
means of gaining vascular access under difficult conditions. On sus Albumin Fluid Evaluation (SAFE) study, which randomly
rare occasions, this approach may be used in adults when other assigned nearly 7,000 critically ill patients to receive either 4% al-
sites are unavailable or in special situations.13-16 bumin or NS, found outcomes to be identical in the two groups.21
The first attempts at obtaining vascular access should be made In the light of these data, coupled with the relatively low availabil-
in the upper extremities with a percutaneous technique. If these ity and high cost of albumin, the use of albumin solution as a re-
attempts fail, one should fall back on a technique with which one suscitation fluid is probably not warranted unless logistical or en-
is comfortable. There is no single best approach. vironmental constraints limit the use of crystalloid solutions.
Hydroxyethyl starch solutions share the same theoretical ad-
INITIAL FLUID RESUSCITATION
vantages as albumin, but they are less expensive and are therefore
Once vascular access is obtained, a 20 ml/kg bolus of normal a more attractive alternative.They may have additional properties
saline should be infused. If the patient is in profound shock, the affecting inflammation and coagulation, the clinical significance of
fluid bolus should be given within 5 minutes if possible, and the use which is unknown.22-25 To date, no large, randomized trials have
of a rapid infusion device should be considered; if the situation is shown these solutions to have a significant beneficial effect on out-
less urgent, the bolus may be given over a period of 15 minutes or come when used in place of isotonic crystalloid. A 2004 meta-
so. If the shock does not resolve, two more boluses should be given. analysis (which, admittedly, included a relatively small number of
We consider normal saline (NS) the fluid of choice for initial patients) was unable to demonstrate any significant effect.26
resuscitation in most shock patients.The sodium concentration of Accordingly, the role of hydroxyethyl starch solutions in the resus-
NS (154 mmol/L) is close to that of normal serum. Its chloride citation of critically ill patients remains to be determined.
concentration (also 154 mmol/L) can induce hyperchloremic Hypertonic saline solutions containing up to 7.5% sodium
metabolic acidemia; however, this state is generally well tolerated chloride (compared with 0.9% for normal saline) show promise
and usually clears as renal perfusion is restored and bicarbonate is for resuscitating patients in situations where large-volume resusci-
regenerated. tation with isotonic solutions is impossible (e.g., combat, events
If the patient already has significant lactic acidosis or the chlo- involving mass casualties, and prehospital trauma care).27 Hyper-
ride concentration exceeds 115 mmol/L, lactated or acetated tonic solutions provide far more blood volume expansion than iso-
Ringer solution is used. Some favor initial use of lactated Ringer tonic solutions and result in less cellular edema. In addition, they
solution to reduce the chance that a hyperchloremic acidosis will may have favorable effects on the inflammatory response to in-
develop in the first place. Both lactate and acetate accept a proton jury.28-33 These solutions are approved for use and commercially
to form an organic acid, which is converted in the liver to CO2 and available in Brazil (where the idea originated), Chile, Argentina,
water.The CO2 is excreted by the lungs; the water, by the kidneys. and Europe; they are not currently approved for use in the United
As long as hepatic function and pulmonary function are adequate, States or Canada. Both hypertonic saline and hydroxyethyl starch
which is usually the case, the result of this process is buffering of have been recommended as first-line solutions for the resuscita-
the acidemia that can accompany the shock state. Both lactated tion of U.S. combat casualties in the field.34
and acetated versions of Ringer solution, however, are hypona-
TRANSFUSION
tremic and hypoosmotic; the latter is a potential problem in
patients at risk for increased intracranial pressure. Transfusion of red blood cells (RBCs) restores intravascular
Solutions containing glucose should not be used in the initial volume and increases hemoglobin concentration, both of which
stages of resuscitation unless the patient is known to be hypo- improve oxygen delivery. Accordingly, it is ideal for resuscitation
glycemic. Most patients in shock, in fact, are hyperglycemic as a of a patient in shock. Unfortunately, allogeneic blood falls far
result of high plasma levels of epinephrine and cortisol. Excessive- short of being the ideal resuscitation fluid. Factors such as the age
ly high plasma glucose concentrations can induce an inappropri- of the blood, the presence of allogeneic leukocytes, and the pres-
ate diuresis. ence of soluble factors have been implicated in the observed asso-
ciation between RBC transfusions and poor patient outcomes.35-40
Colloid and Hypertonic Solutions The data suggest that limiting RBC transfusions in critically ill pa-
Although crystalloid solutions have been the primary resusci- tients may lead to better patient outcomes.When this more restric-
tation fluid in the United States for many years, the use of colloid tive approach to transfusion was prospectively evaluated against a
solutions in the resuscitation of critically ill patients is still the sub- more liberal transfusion strategy in critically ill patients, it resulted
ject of debate. Factors such as the type of colloid used (albumin in equivalent or better patient outcomes.41
or hydroxyethyl starch), the timing of administration (early versus These findings provide useful guidance as to what an appropri-
delayed), and the environment of care (prehospital, battlefield, or ate transfusion strategy might be for the average critically ill
hospital) continue to be explored in laboratory, bedside, and field patient who is euvolemic, but they may not be applicable to the
settings. Colloid solutions have the advantage of producing a patient who is in shock. With shock patients, the first priority is
much greater intravascular volume expansion for a given volume restoration of intravascular volume.Volume replenishment should
of fluid infused than crystalloid solutions do, and this advantage be initiated with isotonic crystalloid; when clinical or laboratory
may be significant in prehospital, mass-casualty, or battlefield findings suggest significant anemia (hemoglobin concentration
environments. In addition, colloid solutions theoretically increase < 10.0 g/dl), transfusion of packed RBCs should be considered.
colloid osmotic pressure (in the absence of increased permeabili- In general, packed RBCs, reconstituted with normal saline, should
ty) and may decrease interstitial and cellular edema.17,18 be given to ensure that the patient’s hemoglobin concentration is
at least 7 g/dl, if not substantially higher. Certain patients require patient to have a normal body temperature, normal myocardial
higher concentrations. contractility, and intact coagulatory and immune function.
The following guidelines provide a reasonable approach to pa- The patient must be unclothed during the initial evaluation but
tients in all classes of shock, with the key variables being (1) the pos- should be covered afterward, with particular attention paid to cover-
sibility of a continued decrease in the hemoglobin concentration ing the head.The room should be kept warm, and any fluids admin-
(from bleeding or hemolysis) and (2) the estimated or measured istered should be prewarmed either in an oven or with heating devices.
values for the relation between oxygen supply and oxygen demand If the arterial pH is low, it should be raised to 7.20 by means of
(determined via mixed venous or central venous oximetry). either modest degrees of hyperventilation or administration of
bicarbonate. (Although agents other than bicarbonate can be given
1. A hemoglobin concentration of 7 g/dl is adequate in a young
to correct a metabolic acidemia, it is not clear that they have any
patient whose coronary arteries are in good shape and whose
more to offer than bicarbonate does.) No efforts should be made
bleeding is known to be under control.
to raise the pH above 7.20. Moderate degrees of acidemia are well
2. A hemoglobin concentration of 8 g/dl is adequate in a young
tolerated, and excessive administration of bicarbonate may worsen
patient who may be at slight risk for further bleeding.
intracellular acidosis [see Initial Fluid Resuscitation, above].47 In-
3. A hemoglobin concentration of 9 g/dl is required if the risk of
stead, efforts should continue to be directed toward managing the
bleeding is substantial.
underlying cause of shock.
4. A hemoglobin concentration of 10 g/dl should be the goal if
Coagulopathy should be treated with fresh frozen plasma and
overt ischemia is present or there is a significant risk of occult
platelets [see 1:4 Bleeding and Transfusion]. The decision whether
ischemic disease (e.g., in a patient with peripheral vascular dis-
to use these components should be based on observation of bleed-
ease), even in the absence of ongoing myocardial ischemia.
ing and clotting in the patient, not on laboratory measurements
In an emergency, O-negative RBCs should be given.There is no of coagulation or platelet counts, which can be normal even dur-
need for typing or crossmatching, and in the case of the confusion ing exsanguination.
that can attend the treatment of multiple casualties, there is no
MODULATION OF INFLAMMATORY RESPONSE
danger that a patient will receive the wrong type of blood.
However, with multiple casualties, there is a danger that the blood In the case of inflammatory shock, there has long been interest
bank will be rapidly depleted of O-negative cells. If the patient can in therapeutic approaches aimed at blocking or counteracting in-
wait a few more minutes and if there is minimal risk of giving the flammatory and coagulatory mediators released from the inflamed
wrong type of blood, type-specific blood should be given so as to tissues.To date, almost all of these approaches have failed to show
conserve the supply of O-negative blood. any benefit, and some have proved dangerous. A study published
Although whole blood can be administered more quickly than in 2001 yielded apparently more promising results, concluding that
packed RBCs can, its use in the civilian setting has almost become infusion of activated protein C seemed to improve survival in some
a matter of purely historical interest. Use of packed RBCs has the patients with severe sepsis. Since that study was published, sever-
advantage of conserving the blood bank’s supply of fresh frozen al other trials have been carried out in an attempt to define the role
plasma and platelets. Under austere conditions, however, whole- of activated protein C in the treatment of severe sepsis with more
blood transfusions may be more practical.42,43 precision.48-50 Taken as a whole, the current data suggest that in
From a conceptual perspective, the use of blood substitutes for view of the side-effect profile and potential complications of activat-
resuscitation is an attractive option. Multiple preparations of ed protein C, its use should be considered only in patients who have
hemoglobin-based oxygen carriers (HBOCs) have been devel- severe sepsis and are at high risk for death.51 We do not currently use
oped, several of which have been tested clinically. Although the this agent in the treatment of surgical patients with severe sepsis.
results obtained with an early HBOC were disappointing, those The use of corticosteroids in the treatment of sepsis has been
obtained with newer, polymerized HBOCs have been encourag- studied extensively over the past several decades. Older regimens
ing. In the light of the potential risks and the limited availability of frequently involved administering these agents in high doses, and
allogeneic blood, HBOCs appear to be a promising alternative to the bulk of the evidence suggested that such regimens were not
RBC transfusion that will play a growing role in the future.44,45 beneficial and might actually have had an adverse effect.52 Newer
regimens have been developed that employ lower steroid doses,
MANAGEMENT OF PAIN, HYPOTHERMIA, ACIDEMIA,
and the results have been encouraging. A multicenter study pub-
AND COAGULOPATHY
lished in 2002 found that administration of modest doses of hy-
Once blood volume has been at least partially replenished, drocortisone and fludrocortisone to patients in septic shock with
pain should be treated with small I.V. doses of narcotics. On the impaired adrenal function led to improvements in mortality.53 Al-
one hand, pain relief can reduce the stress response associated though these data are compelling, it remains the case that cortico-
with shock and perhaps mitigate the severity of its late seque- steroids have well-established potential side effects in this setting.
lae.46 On the other, narcotics can also decrease tone in the Further study will be required before the role of steroids in the
venules and small veins, thereby exacerbating the shock state. management of critically ill patients can be fully defined.
Accordingly, one should titrate the doses and be ready to reverse
ASSESSMENT OF AND GOALS FOR CARDIOVASCULAR VARIABLES
the effect with a narcotic antagonist if necessary. A drop in blood
pressure after administration of a narcotic suggests that the In most cases of shock, regardless of category, the initial
patient may still be hypovolemic, in which case more aggressive approach just described is all that is needed. Some patients, how-
resuscitation may be indicated. ever, will not respond. These patients should be transferred to a
If hypothermia is present initially, it should be corrected; if not, setting in which cardiovascular pressures can be transduced and
it should be kept from developing. Hypothermia slows metabolic monitored. A systemic artery, usually a radial artery, should be
processes. In some situations (e.g., cold-water drowning), this cannulated, and central venous access should be obtained. An
effect may be beneficial, but in most cases, it is better for the attempt should be made to assess the cardiac output.
Mean Arterial Pressure

side of giving more fluids to keep the blood pressure high. In the
Arterial cannulation provides blood for analysis of blood gases case of an obtunded patient with no indications of possible carotid
and allows reliable measurement of the MAP [see Figure 1], which disease or obstructed blood supply to the spinal cord, an arbitrary
is more useful in managing shock than the peak systolic brachial value can be assigned. A reasonable MAP might be 60 mm Hg for
pressure is. The MAP is the pressure that drives the perfusion of a younger patient (or somewhat higher for an older patient).
the noncardiac tissues. It is close to the mean diastolic aortic root If it is possible that the arterial supply to an actively metabo-
pressure and is thus a good approximation for the pressure that lizing organ is obstructed, some assessment of the organ must be
perfuses the myocardium. Finally, it is the pressure that provides made. For the heart, the absence or resolution of chest pain with
the energy required to drive the blood back to the right atrium and resuscitation and the absence of ischemic changes on the ECG
ventricle. suggest that pressure and perfusion are adequate. For the gut,
The mean pressure in the transducer used to monitor the arte- the absence of pain and the presence of bowel activity are reas-
rial pressure is the same as the mean pressure in the monitored suring. For the kidneys, adequate urine output and excretion of
artery. Furthermore, the mean pressure in the monitored artery is creatinine are generally indicative of acceptable pressure and
the same as the mean pressure in the aortic root, unless there is perfusion. For the extremities, physical examination of the skin
arterial obstruction between the aortic root and the monitored usually suffices.
artery or spasm of the proximal conducting arteries (as may be the
Mean Central Venous Pressure
case in severe shock). Thus, knowing the MAP is as close as one
can get to knowing the pressure that is providing perfusion for the As a rule, the tip of the catheter used to measure the CVP
body. Accordingly, one should focus on the MAP, once it can be ends up in either the superior vena cava or the right atrium.The
accurately determined by intra-arterial monitoring. pressures at these sites vary both with the cardiac cycle and with
In treating a patient who is unresponsive to initial care, the goal ventilation. These variations can be substantial, depending on
is to generate an adequate MAP and an adequate cardiac output atrial activity and on the pressures produced by the labored
without producing an undue degree of peripheral edema (i.e., breathing of the critically ill patient or by the effects of mechan-
without driving the CVP to unnecessarily high levels). However, it ical ventilation.
can be difficult to determine what constitutes an adequate MAP. With respect to prevention of unnecessary edema, the mean
To begin with, the MAP must be high enough to perfuse the CVP is the most pertinent variable. In addition, we consider the
CNS. The brain and the spinal cord have high metabolic rates, mean CVP the most useful measurement for assessing the right
and their vasculature is chronically dilated. (An injured CNS is ventricular end-diastolic volume (RVEDV) (i.e., for making an
capable of autoregulation, but only over a relatively narrow range initial assessment of the adequacy of volume restoration). The
of blood pressure.) A fall in the perfusion pressure can lead to a mean CVP is close to the ventricular end-diastolic pressure aver-
profound loss of flow. aged over the ventilatory cycle. It is also the simplest central pres-
In addition, the MAP must be high enough to perfuse organs sure to obtain.Typically, the number is read directly off the digital
supplied by arteries obstructed by preexisting disease.The micro- readout on the monitor; if the transducer is calibrated and zeroed
vasculature of the gut in a patient with an occluded superior properly, interobserver variation should be nonexistent.
mesenteric artery is maximally dilated, and thus, a fall in proximal Care must be exercised, however, in extrapolating from the mean
pressure can shut off critical perfusion. The same is true in the CVP (or the ventricular end-diastolic pressure) to the ventricular
case of a kidney with an obstructed renal artery, an extremity with end-diastolic volume. All measurements of central or vascular
obstructed proximal arteries, or a heart with obstructed coronary pressures, whether mean or end-diastolic, are measured with
arteries. However, if these non-CNS organs have an unobstruct- respect to the atmosphere (i.e., to the outside of the body). It
ed arterial supply, they are protected from hypotension, unless the would be useful to know the transmural pressure—the pressure
hypotension is profound. All of the organs in the body, except for inside the ventricle minus the pressure immediately outside—
the brain and the spinal cord, have some degree of chronic resting because the end-diastolic transmural pressure correlates best with
arteriolar constriction. A fall in the perfusion pressure, in conjunc- the end-diastolic volume. Unfortunately, it is not possible to deter-
tion with the expected production of local ischemia and accumu- mine the transmural pressure accurately in this setting, because
lation of waste products of metabolism, causes reflex dilation of the extramural pressure is not known.
the arterioles in the organ at risk. Unless the hypotension is ex- Some assumptions can, however, be made about the extramur-
treme, this dilation permits compensatory flow. As noted, the al pressure. In a normal, supine, spontaneously breathing person,
CNS does not enjoy this luxury, but then, the cardiovascular sys- the mean pressure immediately outside the heart, measured with
tem is designed to maintain a normal pressure for the brain: it is respect to the atmosphere, is usually on the order of − 3 mm Hg.
no accident that the primary baroreceptors are placed at the The intracavitary right ventricular end-diastolic pressure
carotid bifurcations. (RVEDP), measured with respect to the atmosphere, is approxi-
If a patient is alert and able to move all extremities, and if there mately 5 mm Hg.Thus, the end-diastolic transmural pressure will
is no reason to suspect that any of the major arteries are obstruct- be about 8 mm Hg. This level of transmural pressure is usually
ed by preexisting disease, any MAP that is high enough to main- enough to generate an adequate RVEDV. In a normal patient who
tain full neurologic function is adequate. Determining the ade- is undergoing mechanical ventilation, the mean pressure outside
quacy of the MAP in obtunded, sedated, or anesthetized patients, the heart is on the order of 4 mm Hg; an RVEDP of 12 mm Hg
however, can be a challenge. produces a transmural pressure of 8 mm Hg and usually suffices
In certain cases, one might know that at some previous point, to produce an adequate RVEDV.
perhaps during the same hospitalization, the patient was alert and These values work for patients with essentially normal lungs.
neurologically intact with a given MAP (e.g., 50 mm Hg). If so, it Unfortunately, most patients on mechanical ventilators do not
can be assumed that the same pressure would still be adequate now. have normal lungs. In such patients, the lungs can form a stiff
If, however, one does not have this information, one must err on the compartment around the heart that does not give.The problem is
compounded when the diaphragm is elevated, as it is in many sur- 90 beats/min in an older patient, or exceeding 75 beats/min in a
gical patients. The heart can be trapped between the inflated stiff patient with coronary artery disease).
lungs and the elevated stiff diaphragm, and the extramural pres-
sures can be very high. Swan-Ganz Catheter
Furthermore, the stiffness of the ventricular wall during diastole In this setting, inotropes can usually be used safely for 30 min-
must be taken into account. A ventricle with stiff musculature (or utes or so. If it appears that inotropes may be needed for a longer
low compliance) during diastole needs a high intracavitary pres- period, that more fluids will have to be given despite a high CVP,
sure to achieve an adequate end-diastolic volume. The conditions that the myocardium is at risk (as suggested by chest pain or signs
that can increase diastolic stiffness are manifold and include of ischemia on ECG), that a vasoconstrictor may be needed, or
myocardial ischemia, tachycardia in a patient with preexisting that the patient requires an excessively high FIO2, then a decision
coronary artery disease, edema, fibrosis, and hypertrophy. must be made about what the goals of resuscitation will be from
Thus, to extrapolate from the intracavitary mean CVP to the this point forward.There is no general agreement on precisely how
RVEDV (and to an initial assessment of the adequacy of volume this decision should be made, but we believe that the decision-
resuscitation), one must consider not only the measurement making process frequently benefits from considering measure-
recorded but also the patient’s clinical condition. In some patients, ments obtained by means of a Swan-Ganz catheter.
the intracavitary CVP may have to be as high as 20 mm Hg to
achieve adequate filling of the ventricle. Measurements and derived values obtained via Swan-
Ganz catheter The Swan-Ganz catheter can provide an enor-
Cardiac Output mous amount of information about the cardiovascular system. In-
In two clinical scenarios—warm inflammatory shock and neu- sertion of the catheter is described elsewhere [see 8:26 Cardio-
rogenic shock—the adequacy of cardiac output can be assessed by pulmonary Monitoring], as are details and caveats about the mea-
means of physical examination, as long as the MAP is adequate. surements that can be made with it.
Physical examination will determine whether the cutaneous arte- The SmvO2 can be directly measured by an oximeter on the end
rioles are dilated. If they are, there will be a short circuit in the vas- of the catheter. An excessively low value (< 60%) is cause for con-
culature. Hindrance to ventricular contraction will be minimal; cern. It can arise from an inadequate cardiac output, an excessive-
cardiac output will be robust. In other scenarios, however, one ly low hemoglobin concentration, marked desaturation of systemic
cannot be sure about the cardiac output without more sophisticat- arterial blood, or, in rare cases, from excessive and unnecessary
ed monitoring. consumption of oxygen (as in a patient who is shivering).
The cardiac output can be measured directly with thermodilu-
INDICATIONS FOR ADDITIONAL MEASURES
tion technology,54 and the stroke volume can be calculated by
dividing the cardiac output by the heart rate.
Fluids The intracavitary mean CVP can be measured through a port
If the patient is still in shock—that is, if it appears that the MAP, in the superior vena cava or the right atrium. It can be taken as a
cardiac output, or both may be inadequate for tissue perfusion— very close approximation of the mean pressure in the right ventri-
additional fluids should be infused until, in one’s best judgment, cle and of RVEDP. The RVEDV can be measured directly with
the RVEDV is probably normal. thermodilution technology.55 The end-systolic pressure in the root
of the pulmonary artery and the right ventricular end-systolic
Inotropes pressure (RVESP) can be approximated as 90% of the directly
If the patient is still in shock and further fluid administration is measured peak systolic pressure in the pulmonary artery, mea-
unlikely to be beneficial, an inotrope should be given. Dobutamine sured through the port on the end of the catheter (provided that
is a good first choice in this situation. The dosage should be 5 µg • the catheter monitoring system is properly set up [see 8:26
kg–1 • min–1 initially, then be increased as needed, to an upper limit Cardiopulmonary Monitoring]).The mean pulmonary arterial pres-
of 15 µg • kg–1 • min–1. If necessary, milrinone may be added, admin- sure (MPAP) can be directly and accurately measured through the
istered in a 50 µg loading dose followed by infusion of 0.375 to 0.75 same port.
µg • kg–1 • min–1. Neither agent has any vasoconstrictor effects, and The LVEDP can be approximated from the pulmonary arteri-
both are safe, at least for a short time.The goal is to achieve an ade- al wedge pressure (PAWP) [see 8:26 Cardiopulmonary Monitoring].
quate MAP without producing signs of peripheral constriction To smooth out variations introduced by both ventilation and the
(e.g., cutaneous hypoperfusion) or causing tachycardia (defined as cardiac cycle, we use the mean value for the pressure, which is typ-
a heart rate exceeding 110 beats/min in a young patient, exceeding ically 1 or 2 mm Hg lower than the end-diastolic pressures aver-
Table 3 Influence of Body Size on Selected Cardiovascular Parameters*
End-Diastolic Stroke Volume End-Systolic Contractility Afterload

Weight (kg) Volume (ml) (ml) Volume (ml) (mm Hg/ml) (mm Hg/ml)
50 125 83 42 2.4 1.2
60 150 100 50 2.0 1.0
70 175 117 58 1.7 0.85
80 200 133 67 1.5 0.75
*On the assumptions that (1) ventricular end-diastolic volume is 2.5 ml/kg, (2) stroke volume is 1.67 ml/kg, and (3) ventricular end-systolic
pressure is 100 mm Hg.
aged over several ventilatory cycles. The LVEDV can be estimat- in the radial artery, then cautiously extrapolate back to the cor-
ed on the basis of the PAWP, in conjunction with all the available responding pressures in the root of the aorta. To this end, the
clinical information (including physical examination, chest x-ray, equipment used to measure the radial artery pressure must be
and ventilator settings). It must be kept in mind that the PAWP satisfactorily matched to the physical characteristics of the artery
and the LVEDP are both intracavitary pressures. For extrapola- [see 8:26 Cardiopulmonary Monitoring]. Once the peak systolic
tion to the LVEDV, the pressure applied to the outside of the heart pressure in the radial artery is known, several clinical scenarios
and the stiffness of the ventricular wall during diastole must be may be considered.
taken into account. If the arteries supplying the upper extremity are stiff or calcified
The information from the right ventricle can be used to esti- (as they will be in many older patients or in diabetics), the peak
mate the pressure outside the left ventricle. If a reasonably low systolic pressure in the radial artery will be as much as 80 mm Hg
CVP generates a reasonably large directly measured RVEDV, it higher than that in the root of the aorta. If the arterioles in the
follows that the extracardiac pressures are not excessively high. hand are constricted (as they may be in hypovolemic, compres-
The information from the right ventricle can also be (cautiously) sive, obstructive, or cardiogenic shock), the peak systolic pressure
used to estimate the stiffness of the left ventricular wall during in the radial artery may be 40 mm Hg higher than that in the aor-
diastole (i.e., ventricular diastolic compliance). If a low CVP gen- tic root. If the arteries are in spasm, the difference may be greater;
erates a generous RVEDV, it follows that the right ventricular dia- in severe spasm, all of the pressures in the radial artery are lower
stolic compliance is large. Often, one can tentatively assume that than the central pressures. If the microvasculature in the hand is
the values measured in the right ventricle reflect the status of the dilated (as in warm inflammatory shock), the proximal and distal
left ventricle as well. This is not always the case, however: many systolic pressures will be nearly the same.
patients with ischemic heart disease have a stiff diastolic left ven- The peak aortic root pressure can also be estimated by
tricle and a normal right ventricle. extrapolating from the MAP, which will always be less than the
The estimates of end-diastolic volume can sometimes be con- systolic pressure.58 In young patients with compliant arteries
firmed by increasing the filling pressures of the heart with a fluid and no abnormal arteriolar constriction, the peak systolic pres-
bolus and assessing the cardiovascular response.The fluid should sure in the aortic root is usually about 20 mm Hg higher than
be given rapidly, in an amount sufficient to effect changes in the the MAP. In patients with stiff or calcified arteries, the central
filling pressures. Increases in stroke volume, especially if associat- peak systolic pressure can be much higher than the MAP. In
ed with increases in pulmonary and systemic arterial pressures, patients who are in warm inflammatory shock or neurogenic
suggest that the initial end-diastolic volumes were small. shock, the central systolic pressure may be only 10 mm Hg
If increases in filling pressures have minimal effects on the higher than the MAP.
stroke volume and pressures, there are two possibilities. The first Thus, although it is necessary to estimate the LVESP so that
is that the end-diastolic volumes were already generous. If so, a ventricular oxygen requirements and left ventricular afterload
diuretic can be given; if stroke volumes and blood pressures do not can be assessed, one must be wary in doing so, just as one must
decrease, further diuresis is indicated. The second possibility is be careful in treating a patient on the basis of the estimated
that the volumes were small but the diastolic compliances were LVEDV.
poor or the extramural pressures large. In either case, caution The mean aortic root pressure is usually the same as the mean
should be exercised in giving additional fluid (though there may pressure in the radial artery. It can be misleading if the patient
be little choice). In the case of poor diastolic compliance, it may has an obstruction in a proximal artery. To rule out the possibil-
be possible to find and treat a potentially correctable cause of the ity of a subclavian stenosis, the pressures in the two arms should
stiffness (e.g., myocardial ischemia). In the case of high extramur- be measured at the beginning of hospitalization. In severe shock,
al pressures, it may be possible to find and treat the underlying the arteries may go into spasm that is severe enough to narrow
causative condition. (Admittedly, neither problem is easy to deal the lumina; if this occurs, the mean pressures in the extremities
with, but the effort should be made nonetheless.) will be lower than those in the aortic root. Otherwise, however,
It cannot be assumed that the LVEDV is the same as the direct- the MAP in the extremities, as a surrogate for the mean aortic
ly measured RVEDV. In fact, the two volumes are frequently dif- root pressure, is one of the most reliable measurements made in
ferent in critically ill patients. Studies comparing RVEDVs (mea- clinical medicine.
sured with a fast thermistor) with LVEDVs (measured with trans- Right ventricular contractility, in the absence of congestive fail-
esophageal echocardiography) have shown that right ventricular ure, can be approximated as the RVESP divided by the right ven-
values are often larger than left ventricular values in patients in tricular end-systolic volume (RVESV), which is obtained by sub-
inflammatory shock, sometimes by a factor of 3.56 In patients with tracting the stroke volume from the RVEDV. A normal value for a
left-side congestive heart failure, however, left ventricular values 60 kg person is 0.4 mm Hg/ml [see Table 3]. Contractility can rise
can be substantially larger than right ventricular values. Thus, the to double that value with full adrenergic stimulation, and it can
volume of one chamber is not necessarily an accurate indicator of probably fall to levels as low as 50% of normal.
the volume of the other chamber, though the clinical scenario can The right ventricular afterload can be approximated as the
provide some guidance in this regard. RVESP divided by the stroke volume. Because only a few condi-
The aortic root end-systolic pressure (or the left ventricular tions need be met to obtain these two measurements, the approx-
end-systolic pressure [LVESP]) is the most important pressure to imation is quite accurate. A normal value is 0.2 mm Hg/ml [see
consider in estimating left ventricular oxygen requirements and in Table 3].With severe respiratory failure, the right ventricular after-
assessing the left ventricular afterload. The LVESP can be rough- load can increase by a factor of 5.
ly approximated as 90% of the estimated peak pressure in the aor- Left ventricular contractility, in the absence of congestive fail-
tic root.57 ure, can be approximated as the LVESP divided by the left ven-
Estimating the peak aortic root pressure can be a difficult tricular end-systolic volume (LVESV). A normal value for a 60 kg
process. One approach is to measure the peak systolic pressures person is 2.0 mm Hg/ml. This value is approximately five times
greater than the corresponding value for the right ventricle, which Once a priority is decided on, the planned treatment should be
is to be expected, given that the wall of the left ventricle is approx- adjusted to take into account the particular needs of individual
imately five times thicker [see Table 3]. Left ventricular contractili- patients.
ty can double with adrenergic stimulation and can fall to levels as
low as 50% of normal in severe congestive failure. Priority Is Ensuring
Frequently, the clinical scenario gives the physician some idea Resuscitation: Edema Not
of the state of left ventricular contractility. In most cases of mild or a Major Problem and
moderate shock (except cardiogenic shock), it can be assumed Myocardium Not at Risk
that contractility is normal or slightly above normal. In cases of Fluid infusion If pri-
severe shock, however, this assumption cannot be made. Often, ority is given to the periph-
contractility is reduced as a consequence of poor perfusion of the ery, fluid administration is
coronary vasculature or downregulation of the beta receptors in probably necessary.The ini-
the myocardium. tial goal should be to achieve
The calculated value for left ventricular contractility must a CVP in the low teens and a PAWP in the midteens (on the
always be considered in terms of the clinical context. It is not as assumption that the patient is undergoing mechanical ventila-
reliable as the calculated value for right ventricular contractility, tion). As therapy progresses and more measurements are
because the approximations for the LVESP and the LVESV are made, this goal may have to be modified. Ultimately, however,
not highly accurate. Potential inaccuracies notwithstanding, the the goal is not to produce any specific filling pressures but,
calculated left ventricular contractility can be useful for following rather, to produce generous right and left ventricular end-dia-
upward or downward trends. stolic volumes.
The left ventricular afterload can be approximated by dividing
the LVESP by the stroke volume. A normal value is 1.0 mm Hg/ml Administration of inotropes Inotropes (e.g., dobuta-
[see Table 3]. With normal physiologic adjustments in intense mine and milrinone) can be safely used for a few days if neces-
isometric exercise, the left ventricular afterload can temporarily sary, provided that the patient is being monitored with a Swan-
increase by a factor of 4. It can also rise by a similar factor in Ganz catheter. These agents increase myocardial oxygen
patients who have hypertensive disease or who have received requirements, but this is not a problem in a patient with a
excessive doses of vasoconstrictors. Under less extreme circum- strong heart. The goal is to increase ventricular contractility to
stances (e.g., aerobic exercise), it increases by no more than a fac- normal or slightly supranormal levels. Supranormal contractil-
tor of 2. ity leads to increased ventricular production of power, but the
The power available for perfusing the lungs and filling the left additional power is rarely needed. The dosages should be kept
atrium and ventricle during diastole is the MPAP multiplied by low enough that the heart rate does not exceed 110 beats/min
the product of the heart rate and the stroke volume (i.e., cardiac in younger patients or 90 beats/min in older patients.
output). The power available for perfusing the systemic tissues,
including the heart (on the assumption that the MAP is approxi- Administration of vasopressors: last resort There are
mately equal to the mean diastolic pressure in the aortic root), and only two indications for the administration of vasoconstrictors
for filling the right atrium and ventricle during diastole is the MAP to patients in whom the primary concern is perfusion of the
multiplied by the product of the heart rate and the stroke volume periphery: (1) a MAP that may be inadequate for perfusion of
(i.e., cardiac output). the CNS and (2) hypotension in a patient who has a critical
stenosis in the cerebral, coronary, hepatic, mesenteric, or renal
DETERMINATION OF PRIORITIES FOR SUBSEQUENT
arteries or in the arteries supplying the spinal cord or an
RESUSCITATION
ischemic limb. If a vasoconstrictor is indicated, low-dose I.V.
Increases in heart rate, ventricular end-diastolic volume, con- vasopressin should be given first. If the heart rate is 89
tractility, and afterload all increase ventricular oxygen require- beats/min or slower, dopamine, 2 to 20 µg • kg–1 • min–1, should
ments.They also increase the power production of the ventricle, as be added. The heart rate should not be driven above 110
long as afterload is not allowed to exceed contractility. If afterload beats/min, even in young patients. If the initial heart rate is 90
is allowed to exceed contractility, the power production falls off. beats/min or higher, norepinephrine, 2 to 12 µg/kg, may be
That is, increased ventricular power production almost always given.
means increased myocardial oxygen requirements. There is no In either ventricle, the afterload should not be allowed to
thermodynamic free lunch. exceed the contractility, except in desperate circumstances.
At this point, therefore, if the patient still has not responded to Matching the afterload to the contractility produces the maxi-
resuscitative measures, one must decide whether the priority for mum attainable work on the aortic root for a given end-diastol-
subsequent treatment should be (1) to increase ventricular power ic volume. Allowing the afterload to exceed the contractility
production, at the cost of possible edema and increased myocar- causes a rise in the blood pressure but a sharp fall in the stroke
dial oxygen requirements, or (2) to minimize edema formation volume. The afterload should be increased to this degree only if
and myocardial oxygen requirements, at the cost of possible com- there appears to be no other way to perfuse the CNS or organs
promise of ventricular power production. with an obstructed arterial supply. If this is the case, the vaso-
This fundamental decision must be made on clinical grounds. constrictor should be given and the effect on the perfusion of
Occasionally, the decision is straightforward, as in a young trauma the organ in question evaluated. If the increased pressure does
patient with extensive noncardiac injuries and a robust myocardi- not produce the desired effect, the vasoconstrictor dosage
um or in an older patient with an uncomplicated MI. More often, should be reduced. Again, the goal is to achieve adequate per-
however, the choice is not so clearcut, because most initially non- fusion, not to reach an arbitrary numerical pressure value. The
responding patients do not fall cleanly into either category. great fear in using vasoconstrictors is that they can lead to
Nevertheless, it is necessary to choose one priority or the other. ischemia and even necrosis of the skin, the kidneys, the gut, and
Management of
the liver. Accordingly, they should be used in this context only
Compressive Shock
as a last resort.
In many cases, extracardiac
Priority Is Minimizing compressive and extracardiac
Edema and Protecting obstructive shock, being con-
Heart ditions that can kill quickly,
Fluid administration will already have been treated
versus diuresis Fluid man- by this point in management.
agement must be finely It is wise, however, to keep these two causes of shock in mind as
tuned in patients who have workup proceeds: they often develop secondarily. Examples of prob-
both inadequate peripheral lems that can arise as treatment progresses are a tension pneumo-
perfusion and marginal myo- thorax that develops in a mechanically ventilated patient who is being
cardial reserve. On the one hand, too-large end-diastolic volumes worked up or treated for some nonpulmonary problem and an
unnecessarily increase myocardial oxygen requirements and pro- abdominal compartment syndrome that develops in a patient who is
duce edema; on the other, too-small end-diastolic volumes make being resuscitated after a major injury or burn. In patients with more
it impossible for the ventricles to produce adequate pressure and complicated problems (e.g., possible abdominal compartment syn-
stroke volumes. In some patients, diuresis (e.g., with furosemide, drome), a Swan-Ganz catheter should be inserted. When dealing
10 to 40 mg I.V.) is indicated; in others, fluids should be given. with the conflicting demands made on the cardiovascular system in
Sometimes, it is necessary to rely on trial and error. compressive shock, one needs all the information one can get.
Adjustment of contractility If pressures and stroke vol-

umes are still inadequate after end-diastolic volumes have appar- Management of
ently been optimized, measures for adjusting contractility may be Intravascular Obstructive
considered. Shock
If contractility seems to be reduced on either side, inotropes The immediately life-
such as dobutamine or milrinone should be tried (cautiously, in threatening problems caused
view of their effect on myocardial oxygen requirements). If, by by intravascular obstruction
chance, contractility seems to be excessively high in either ventri- should already have been
cle (or both), a beta blocker should be given. Esmolol is a good treated by this point. The
first choice because it has a short duration of action. A 500 µg/kg pharmacologically treatable problems (e.g., systemic hyperten-
loading dose is given, followed by a 50 µg • kg–1 • min–1 infusion, sion) should be treated with diuresis, beta blockade, ACE inhi-
which is increased as necessary. Metoprolol, 5 to 15 mg every 6 bition, and nitroglycerin, as described (see above). If hyperten-
hours, may be given later if it is clear that beta blockade was need- sion persists and inadequate ventricular production of power is
ed and still is. The goal is normal contractility on both the right a possibility, a Swan-Ganz catheter should be inserted. The goal
side and the left. is to adjust the afterload for each ventricle so that it is approxi-
mately 50% of the contractility.
Adjustment of afterload with respect to contractility This goal can be particularly difficult to achieve for the right
Left ventricular afterload should be adjusted so that it is 50% ventricle and the pulmonary vasculature. In patients with severe
of left ventricular contractility.This ratio does not produce the ARDS, there is some evidence to suggest that administration of
maximum transfer of energy to the aortic root, but it is effi- prostacyclin or inhaled nitrous oxide may help reduce excessive
cient, in that it produces the greatest amount of work per mil- right ventricular afterload,59 though these interventions have not
liliter of oxygen required by the ventricular musculature. been particularly successful in our own experience. In any case,
If left ventricular afterload is less than or equal to 49% of one should always attempt to address the underlying problem
left ventricular contractility, vasopressin, dopamine, and nor- causing the ARDS. One can try to adjust the ventilator in an effort
epinephrine should be given as necessary. The heart rate to relieve the potentially confounding problem of extravascular
should not be driven above 90 beats/min. As with any patient obstruction of the vasculature.
receiving vasoconstrictors, frequent reassessment is essential. To achieve the desired goal in the systemic vasculature, it may
The goal is to wean the patient from the drugs as soon as pos- be necessary to employ aortic balloon counterpulsation to deal
sible. If left ventricular afterload is equal to or greater than with the reflected waves generated by the transmission of energy
51% of left ventricular contractility, the stiffness of the arter- into these vessels. This measure can be extremely effective; how-
ies should be decreased by performing further diuresis, by ever, it puts the perfusion of the limb with the cannulated artery
increasing the beta blocker dosage, by adding an angiotensin- at risk. Furthermore, it is only a short-term solution: the underly-
converting enzyme (ACE) inhibitor (e.g., enalaprilat, 1.25 to ing problem will have to be dealt with eventually [see Management
5 mg every 6 hours), or by adding nitroglycerin, 5 to 200 µg • of Cardiogenic Shock, below].
kg–1 • min–1.
If the heart rate exceeds 90 beats/min after these adjustments,
the beta-blocker dosage should be increased, and a calcium Management of
channel blocker (e.g., diltiazem, 5 to 15 mg/hr) should be added. Neurogenic Shock
Maintenance of a slow heart rate is the single most important The initial management
factor for minimizing myocardial oxygen requirements, but as of neurogenic shock is
with the other interventions mentioned (see above), it usually much the sam

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ACS Surgery: Principles and Practice

more profound meaning. According to Webster’s Third New

Measures are expedient and inexpensive

Measures reflect care that patients actually

Risk-adjusted mortalities Face validity Sample sizes are limited

CABG—coronary artery bypass grafting

Hospital volume (AHRQ, LF)

Mortality (%), 1998–99

dure-specific measures of morbidity or mortality. For example, a a

Risk-Adjusted Mortality (%)

is threatened by imperfect risk adjustment with administrative

3 PATIENT SAFETY IN SURGICAL

Robert S. Rhodes, M.D., F.A.C.S.

Failures of Rule-Based Performance Performance and Error in Clinical Context

Accordingly, it is not surprising that the variable incentives and

Assessment of Surgical Risk

Table 1 American Society of Anesthesiologists’ Physical Status Classification: Nonemergency Surgery6

Classification Description Examples

Patient with mild systemic disease—a mild to moderate

Organic heart disease with signs of cardiac insufficiency; unstable angina;

Table 5 Selected Surgical Procedures Stratified by Ambulatory electrocardiography Preoperative ambula-

delayed wound healing, decreased immunologic competence, Hematologic States

5 Functional status Age

Patient is scheduled to undergo major noncardiac operation

Procedure is semiemergency (e.g., Procedure is elective

No cardiac risk factors noted Cardiac risk factors are noted

Patient is poor historian, is diabetic, Patient has classic

Perform exercise ECG or, if patient

Stress test is negative Stress test is positive

Perform cardiac catheterization.

Standard indications Standard indications for Evidence of severe

Contraindications to beta blockade No contraindications to beta blockade are present

Proceed with noncardiac operation.

Figure 1 Algorithm depicts recommended approach to cardiac assessment before non-

Table 2—Surgical Categories

Table 3 American Society of Anesthesiologists’ Physical Status Classification

Classification Description Examples

Patient with mild systemic disease—a mild to moderate

Organic heart disease with signs of cardiac insufficiency; unstable angina;

Table 4—Guidelines for Selection of Outpatient versus Inpatient Surgery

Outpatient procedure with Outpatient procedure with general

Outpatient procedure with Outpatient procedure with local,

Inpatient procedure (unless operation

Inpatient procedure (unless operation

*Patient must be watched carefully.

Abrupt withdrawal of clonidine, which is used to treat chronic

Alcohol and Drug Abuse

Table 9 Local Anesthetics for Infiltration

Short-acting Procaine 1%–2% 800 15–30 1,000 30–90

Lidocaine 0.5%–2.0% 300 30–60 500 120–360

Long-acting Bupivacaine* 0.25%–5.0% 175 180+ 225 240+

*Not recommended for children younger than 12 yr.

Postoperative Care Patient Sign Criterion Score

The cornerstone of postoperative care in outpatient surgery is Able to move 4 extremities* 2

approach is being adopted more frequently in ASCs, where

structions regarding medications if the surgical procedure may

Persistent nausea and vomiting Persistent uncontrolled pain

6 FAST TRACK SURGERY