Category Archives: General

Interesting Concept: Predicting Recovery From Surgery With A Blood Test

Most people recover from major surgical procedures in a predictable fashion. However, as anyone who manages these patients knows, there are always a few outliers. A negative laparotomy patient who has an ileus for over a week. Hip fracture patients who take forever to get out of bed.

We usually chalk this up to human variability or varying degrees of frailty. But could there be more to it? Could it even be predictable?

A group of anesthesiologists and immunologists at Stanford used a new cell-mapping technique to attempt to correlate immune system signatures in blood during the first hours after operation with recovery time. They used a technique called mass cytometry, which flushes different tagged antibodies through a blood sample. This allowed the investigators to determine which immune cells were present, as well as which signalling molecules were being produced.

Here are the factoids:

  • 32 patients undergoing hip replacement surgery were studied at various times up to 6 weeks after the procedure
  • Antibodies directed at 21 cell surface proteins and 10 intracellular proteins associated with the immune response
  • Recovery from fatigue, pain, and recovery of hip motion were quantified using validated objective scoring tools
  • As expected, there was a considerable amount of variability in recovery parameters among the patients
  • Activation of CD14+ monocytes accounted for 40-60% of the variability in recovery times observed
  • Patients with higher activations were more likely to take at least 3 weeks to recover. Those with low activation recovered more quickly.

Bottom line: This is heady stuff, and it is based on a very small group of patients. However, it does suggest that immune system overdrive may be responsible for more evil: slow recovery from surgery. At some point, it may be possible to predict recovery time from a preop blood test. This would be very helpful to know before surgery, and at some point may allow us to give drugs that blunt these processes and speed up surgical recovery.

Related post:

Reference: Clinical recovery from surgery correlates with single-cell immune signatures. Science Translational Medicine 6(255):255ra131 1-12, 2014.

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September Newsletter Released To Subscribers This Weekend!

The September Trauma MedEd Newsletter will be released to subscribers over the weekend. I’ll be covering chest trauma. Articles include:

  • Finger vs needle thoracostomy
  • Chest tube air leaks and how to manage them
  • Pneumothorax in children
  • And more!

Anyone on the subscriber list as of 8PM Saturday (CST) will receive it on Sunday, October 5. I’ll release it to everyone else next week via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

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Prone Positioning After Trauma 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.


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.

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Inline Stabilization vs Inline Traction of the Cervical Spine

Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.

When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!

Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!

Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.

Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.

Spine injury AO dissociation

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How Many Salt Tabs In A Liter Of Saline?

Seems like a simple, silly question, right? I dare you to figure it out without reading this post!

On occasion, our brain injured trauma patients have sodium issues. You know, cerebral salt wasting. Trying to maintain or regain the normal range, without making any sudden moves can be challenging. There are a lot of tools available to the trauma professional, including:

  • Saline
  • Hypertonic saline
  • Salt tablets
  • Fluid restriction
  • Some combination thereof

Fun times are had trying to figure out how much extra sodium we are giving with any of the first three items. This is important as you begin to transition from the big guns (hypertonic), to regular saline, and then to oral salt tabs.

Below is a quick and dirty conversion list. I won’t make your heads explode by trying to explain the math involved changing between meq, mg, moles, sodium and sodium chloride.

  • The “normal saline” bags we use are actually 0.9% saline (9 gm NaCl per liter)
  • Hypertonic saline can be 3% or 5% (30 gm or 50 gm per liter)
  • Salt tabs are usually 1 gm each (and yummy)

Therefore, a liter of 0.9% normal saline is the same as 9 salt tabs.

A liter of 3% hypertonic saline is the same as 30 salt tabs. The usual 500cc bag contains 15.

A liter of  5% hypertonic saline is the same as 50 salt tabs. The usual 500cc bag contains 30.

To figure out how many tablets you need to give to match their IV input, calculate the number of liters infused, then do the math! And have fun!

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