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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Excessive tension in an abdominal incision line may lead to fascial necrosis and wound sepsis. We utilized two alternative approaches to wound closure in 13 patients with severe abdominal trauma (2 blunt, 11 penetrating) whose midline incision could not be closed primarily without excessive tension at the initial operation because of massive visceral edema. In five patients synthetic mesh was used to bridge the fascial defect. Four patients survived the early postoperative period but had large open midline wounds that required one or more delayed procedures to close the wound or cover the visceral mass with skin graft. Two patients currently have large abdominal wall hernias. In the other eight patients the skin was reapproximated over the visceral mass utilizing towel clips at the initial operation. Six patients survived to be reexplored within 48-96 hours. Acute hemorrhage had stopped, the edema of the bowel and retroperitoneum had largely resolved, and the fascia could be closed primarily without excessive tension. All wounds went on to heal satisfactorily. When massive edema makes fascial closure at the initial operation difficult or impossible, closure of the skin over the visceral mass promotes resolution of the edema and often allows satisfactory primary closure within 48-96 hours. Synthetic mesh should be reserved for cases of abdominal wall tissue loss or dehiscence associated with wound sepsis.
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PMID:Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema. 173 67

Beyond infancy, pneumatosis cystoides intestinalis (PCI) is rare. Data concerning pathogenesis and treatment are limited. Our experience with 12 children was examined to define predisposing factors, presentation, treatment, and outcome. Nine children were immunosuppressed, thus identifying an important etiologic subgroup. Presentation was variable but included abdominal pain, distention, diarrhea and hematochezia. Clostridium difficile was found in 3 patients and cytomegalovirus in 1. Radiographs showed free air in 3. Nine were treated with antibiotics and bowel rest, 1 with bowel rest alone, 1 with oral metronidazole, and 1 with observation. PCI resolved in 7 of 9 treated with antibiotics, although 1 child with leukemia had severe hematochezia secondary to colonic ulceration and required hemicolectomy. No other patient required laparotomy. The free air resolved in 2 of 3. There were 2 deaths, both from sepsis. One had free air on admission but no perforation was found at autopsy. Treatment recommendations remain unclear; however, C difficile and cytomegalovirus are important pathogens that should be identified and treated promptly. In symptomatic patients, bowel rest and antibiotics seem beneficial. Operative intervention should be reserved for patients with peritoneal signs, progressive deterioration, obstruction, or persistent, severe bleeding. Free air alone is not an indication for operative management in children with PCI.
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PMID:Pneumatosis cystoides intestinalis in children beyond the first year of life: manifestations and management. 176 11

In order to determine the utility of amniocentesis for detecting subclinical chorioamnionitis in asymptomatic afebrile women in preterm labor with intact membranes, we enrolled 47 women between 27-32 weeks' gestation in a prospective study. After enrollment, 38 women fulfilled all clinical and laboratory criteria for the study; nine women were excluded because they had a leukocyte count exceeding 15,000/microL. None of the 38 asymptomatic afebrile women had a positive culture from the amnionic fluid for bacteria, fungi, Mycoplasma hominis, Ureaplasma urealyticum, Chlamydia trachomatis, or any viruses. Sepsis was not proved in any of the 38 infants delivered to these patients. There was a clear relationship between histologic evidence of chorioamnionitis and failure of tocolytic therapy. Fetal lung profiles were mature in 29% of the amnionic fluid samples from 30-32 weeks' gestation, but in none of the amnionic fluid samples before 30 weeks. Amniocentesis does not seem useful to detect chorioamnionitis in asymptomatic afebrile women with preterm labor and intact membranes at 27-32 weeks' gestation, and should be reserved for those cases in which information about fetal lung maturity would be helpful.
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PMID:Low incidence of positive amnionic fluid cultures in preterm labor at 27-32 weeks in the absence of clinical evidence of chorioamnionitis. 198 86

Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.
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PMID:Esophageal perforation. 280 86

The use of tracheostomies in burned patients with inhalation injuries is now reserved for specific indications rather than as prophylactic airway management. A 5-year burn center experience with tracheostomies used in this fashion is presented. Ninety-nine tracheostomies were performed in 3246 patients who had indications of prolonged respiratory failure or acute loss of airway. Although colonization of the sputum was universal, neither rates of pulmonary sepsis nor mortality were significantly increased in patients who underwent tracheostomies. Twenty-eight patients developed late upper airway sequelae, including tracheal stenosis (TS), tracheoesophageal fistula (TEF), and tracheoarterial fistula (TAF). Duration of intubation correlated only with development of TAF, whereas patients in whom TEF developed were significantly older and more likely to have evidence of tracheal necrosis at the time of tracheostomy. The pathogenesis of upper airway sequelae in these patients as divergent responses to the combined insults of inhalation injury, infection, and intubation is considered.
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PMID:Tracheostomies in burn patients. 293 Feb 91

Diverticulitis represents a spectrum of clinical entities ranging from minimal pericolitis in the adjacent mesentery to uncontrolled intra-abdominal sepsis and septic shock. The presentation most often described is left lower quadrant abdominal pain, fever, chills, and left lower quadrant tenderness associated with a mass. Unusual presentations occur when infection tracts to distant locations. Diverticulitis is a common cause of intra-abdominal sepsis associated with high morbidity and mortality. The pathogenesis of intra-abdominal sepsis is not well understood, but likely involves circulating host inflammatory mediators. The role of computed tomography in the early diagnosis of diverticulitis is increasing and supersedes barium enema in the assessment of the extracolonic extent of disease. Also, computed tomographic-directed percutaneous drainage of intra-abdominal abscesses is, in most cases, as effective as surgical drainage. Predictably, the micro-organisms involved are representatives from the commensal flora of the lower gastrointestinal tract. These bacteria are usually sensitive to a wide range of antimicrobial agents that are effective against facultative and obligate anaerobic gram-negative bacilli. Surgical intervention is reserved for those individuals who do not respond to therapy, or for generalized peritonitis, uncontrolled sepsis, free viscus perforation, and fistulas.
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PMID:Diverticulitis. 304 50

When a patient presents with sepsis and no clear etiology, the abdomen can hide a focus of infection and must be considered in the course of the evaluation (Fig. 1). There are certain groups of patients who do not exhibit the usual signs and symptoms of intra-abdominal infection and therefore constitute the population at risk for occult abdominal sepsis. These patients, for one reason or another, have an unreliable history or physical exam. Once intra-abdominal infection is suspected, certain basic laboratory and radiographic evaluations should be undertaken. Treatment delays are not tolerated and the performance of diagnostic tests when a laparotomy appears inevitable is not indicated. CT of the abdomen should not be used as a screening exam and should be reserved for those cases potentially having an infected fluid collection. If a thorough evaluation of the abdomen reveals a possible source, a measured medical and surgical approach can be undertaken, depending on the etiology. If no source is found, the question of a diagnostic laparotomy arises in certain cases (Fig. 2). This procedure should be reserved for those patients having some type of underlying abdominal surgery or pathology. Without a previous history of abdominal surgery or pathology, and with no other clinical evidence of intra-abdominal infection, a nondirected laparotomy can be safely performed when organ failure is not present but usually will not reveal a treatable lesion. Multiple organ failure may indicate the presence of a hidden abdominal source of infection; however, the window for successful surgical intervention may have already passed. Multiple organ failure does not mandate laparotomy when there is no clinical or radiographic basis for suspecting an abdominal source of infection. This is especially true if an alternative source of sepsis has been defined.
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PMID:The abdomen as a source of occult sepsis. 304 53

The records of 115 patients with a duodenal injury have been reviewed. The majority of the patients (83 percent) were treated with primary repair of the injury. Twelve patients underwent duodenal diverticulization. The mortality rate in all 115 patients was 12 percent, in 105 patients who survived more than 48 hours 4 percent, and in 26 patients with pancreaticoduodenal injury 15 percent. Vascular injury was the major cause of early death. Enteric perforations were present in 75 percent of the patients with sepsis. The majority of patients with associated pancreatic injury had primary repair and did not have pancreaticoduodenal complications. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy and feeding jejunostomy are useful adjuncts. A more complex operation should be reserved for a highly select group of patients with severe duodenal injury.
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PMID:Injuries of the duodenum. 311 Dec 86

A review of 399 resuscitation efforts in 329 patients within one year at the Houston Veterans Administration Medical Center indicated that an age of 70 years or greater is associated with poor outcome after in-hospital cardiopulmonary resuscitation (CPR). Basing their conclusions on a detailed analysis of the methods and results of their study, the authors argue that CPR should be reserved for those who have a reasonable chance of survival until discharge, while admitting that the definition of this standard will vary. They recommend that patients 70 years or older, and patients with cancer or sepsis, should be identified as candidates for CPR only after considerable reflection by families and clinicians.
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PMID:In-hospital cardiopulmonary resuscitation. 291 48

This article describes the infectious complications that occurred among four of the longest-term recipients of the Jarvik-7 artificial heart. Infection arising from the drive lines, with spread to the mediastinal periprosthetic space, was the major limiting factor in long-term use of the device in these patients. Periprosthetic infections were due to coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas aeruginosa, and other Pseudomonas species. Other infectious complications incurred by some of the patients included pneumonia, empyema, urinary tract infection, and intravascular line sepsis with Candida. Intensive antimicrobial therapy for prolonged periods seemed to suppress but not to eradicate infection and was accompanied by the appearance of multiresistant bacterial strains. Complications of antimicrobial therapy included diarrhea secondary to overgrowth with Clostridium difficile in two patients. Use of the current device for more than 30 days should be considered extraordinary and should be reserved for patients for whom no other form of life support is available.
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PMID:Infectious complications in four long-term recipients of the Jarvik-7 artificial heart. 333 99


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