All posts by TheTraumaPro

Prone Positioning After Laparotomy

Patients with serious abdominal injury may require a laparotomy, and a subset of these may need a temporary closure for damage control surgery. Concomitant spine injury may have your spine surgeons asking “is it safe to prone the patient who is postop with a midline incision or an open abdomen.” What to tell them?

There’s not much guidance out there in the literature. One paper from 2000 looked at four patients who were proned for severe ARDS and found that one suffered a wound dehiscence. However, this patient had severe generalized edema and was on several pressor agents. 

The use of temporary abdominal closure techniques has revolutionized the early management of severely injured trauma patients and has greatly decreased the incidence of complications from abdominal compartment syndrome. Several authors have now demonstrated that putting those patients in the prone position is well tolerated. 

As far as patients who have a closed laparotomy, proning appears to be well tolerated as well. One caveat: consider carefully if the patient is having wound complications or if they are morbidly obese.

The bottom line: Consider the risks and benefits carefully in any post-laparotomy patient you are considering prone positioning for. Other than in morbidly obese, it is generally considered safe, even in patients with damage control dressings in place. However, make sure the trauma surgeon re-evaluates the wound again as soon as the patient is returned to the supine position.

References: 

1. The “open abdomen” is not a contra-indication to prone positioning for severe ARDS (abstract). Schwab, et al. Chest. 1996;110:142S.

2. Complications of Prone Ventilation in Patients with Multisystem Trauma with Fulminant Acute Respiratory Distress Syndrome. Offner et al. Journal of Trauma-Injury Infection & Critical Care. 48(2):224-228, February 2000.

3. The Management of the Open Abdomen in Trauma and Emergency General Surgery: Part 1-Damage Control. Diaz et al. Journal of Trauma-Injury Infection & Critical Care. 68(6):1425-1438, June 2010.

NEW: Indexed Archive for the Trauma Professional’s Blog!

Over the past several months, I’ve wanted to refer to older blog entries while teaching our surgical and emergency medicine residents. However, I’m not completely satisfied with the search system available here on Tumblr, my blog host. And although the Archive View feature is fun (you can see a snapshot of entries by month), it’s still tough to drill down to a specific post.

I’m excited to announce an indexed version of the archive, which is now available at www.regionstrauma.org/blogs. This link opens a list of posts that are indexed by topic area. It’s now much easier to find something you are looking for, and it helps me avoid duplicating posts.

I have received occasional requests for a post on a specific topic, and I really enjoy responding to them. If you have a question about some trauma-related topic that you are “dying” to know the answer to, please email me or use the ask link to the right. 

Probiotics in Trauma Care

Probiotics are live micro-organisms that can be taken orally that can restore balance to the intestinal microflora. These bacteria or yeasts can also produce nutrients and anti-oxidants that fight bacterial endotoxin and activate the lymphoid tissue found in the intestine.

Probiotics come in a variety of forms and can cost very little or quite a lot. The simplest and cheapest forms are live culture yogurts found in the grocery store. Oral supplements are also available that are just a little more expensive. A few specialty products are available for critically ill patients that cost quite a lot.

Going along with probiotics are so-called prebiotics, which are dietary fibers that can help with fluid absorption and diarrhea, and with keeping bowel movements regular and of reasonable consistency. Use of prebiotics has been shown to decrease catheter related sepsis in ICU patients.

A newer concept is the use of probiotics when antibiotics are given for the treatment of infection. Any antibiotic can wipe out portions of the normal gut flora, leaving room for pathogenic bacteria (such as C. Diff.) to go wild. The thought is that the probiotics help recolonize the colon with “good bacteria” and avoid the development of an infectious diarrhea.

The last time I reviewed the literature on this topic, there was no clear data that probiotics reduce antibiotic associated diarrhea. There was evidence that it helped some other infectious and inflammatory conditions. Well, things have changed and new meta-analyses have been released in the last 6 months that do show a benefit. Both lactobacillus strains (found in yogurt and the usual supplements) and Saccharomyces boulardii (a yeast found only in certain supplements in this country) show statistically significant reduction in antibiotic associated diarrhea. 

Bottom line: Given the fact that these supplements are cheap and have few side effects, it is probably beneficial to administer a probiotic during and for a few days after discontinuation of antibiotics. Use should be limited to reasonably healthy, non-immunocompromised patients, since high dose Saccharomyces can cause fungemia in the critically ill. The use of prebiotics (fiber) is probably also beneficial, especially for patients on narcotic pain medications.

References:

  1. Role of Lactobacillus in the prevention of antibiotic-associated diarrhea: a meta-analysis. Kale-Pradhan PB, Jassal HK, Wilhelm SM. Pharmacotherapy. 2010 Feb;30(2):119-26.
  2. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. McFarland LV.World J Gastroenterol. 2010 May 14;16(18):2202-22.

PulseCheck: Hot Topics In EMS Handout

PulseCheck EMS logo

PulseCheck: Hot Topics in EMS is going on today at the Holiday Inn Select in Bloomington! The program includes TV anchor Don Shelby speaking on the evolution of Primary Service Areas in Minnesota.

I will be giving a presentation on pediatric trauma. This talk was added to the program on short notice, so no handout was available to participants. 

To download a copy of the slides I presented, click here.