American journal of surgery
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Late acute respiratory distress syndrome (ARDS), characterized by progressive pulmonary interstitial fibroproliferation, is associated with mortality > 80%. Although previous large prospective trials failed to show a benefit of steroids in early ARDS, recent small reports describe improved survival in patients with late ARDS. Recognizing the pathogenetic differences between early and late ARDS, we employed steroid therapy in patients with refractory late ARDS. ⋯ Steroid therapy appears to be effective in patients with refractory late ARDS. Prospective trials are needed to define the indications, timing of intervention, dose and duration, and precautions of steroid therapy.
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Unplanned extubations are common, but can be life-threatening. ⋯ Our data support the use of water resistant tape to secure endotracheal tubes and the routine use of hand restraints.
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Medical practice guidelines have been promoted as a way to improve the cost-effectiveness of medical care. Algorithms for the transfusion of red blood cells, plasma, and platelets may be especially useful in the surgical setting if they incorporate point-of-care information that is both physiologic and patient-specific for transfusion decision making. Therefore, the goals of guidelines for surgical blood management should be twofold. They should (1) acknowledge patient-specific variability while addressing physician- and institution-dependent variables; and (2) improve blood component management by developing more physiologic clinical indicators of the need for allogeneic red blood cell transfusion.
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Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury. ⋯ Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.
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The potential merits and dangers of orotracheal and nasotracheal intubation in patients with injury to the cervical spine or spinal cord continue to be debated. To address this issue, a prospective study was conducted at a level 1 trauma center in patients with respiratory embarrassment and either or both of these injuries. ⋯ In trauma victims with or at high risk of cervical spinal cord injury, orotracheal intubation is a rapid, safe means of achieving airway control.