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Objective: The short-term safety of percutaneous dilatational tracheostomy has been widely demonstrated. However, less is known about their long-term complications. Through an illustrative case series, we present and define “corkscrew stenosis,” a type of tracheal stenosis uniquely associated with percutaneous dilatational tracheostomy. Methods: Patients treated at our institution for tracheal stenosis after percutaneous dilatational tracheostomy were reviewed. Demographic data including gender, age, history of presentation, lesion morphology, imaging, and management was collected and evaluated. The pathology of the stenosis and the strategies for prevention are presented. Results: From January, 2008 through December 2011, 11 patients had tracheal stenosis after percutaneous dilatational tracheostomy. The mean age was 54 ± 17 years and 55% were male. The stenotic lesions were characterized by a corkscrew morphology at the stoma site with a mean distance of 2.3 ± 0.8 cm from the vocal cords. Images of these lesions demonstrated disruption and fracture of the proximal tracheal cartilages and displacement of the anterior tracheal wall into the tracheal lumen. The majority of our patients required tracheal resection for definitive repair. Conclusions: We suggest that a unique form of tracheal stenosis can result from percutaneous dilatational tracheostomy. We observed corkscrew stenosis to be located proximally, associated with fractured tracheal rings, and morphologically appearing as interdigitation of these fractured rings. Recognizing corkscrew stenosis, its unique mechanism of formation, and technical means of prevention may be important in advancing the long-term safety of this procedure for critically ill patients who require prolonged ventilatory support. [ABSTRACT FROM AUTHOR]

Abstract: Background: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. Methods: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. Results: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. Conclusion: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention. [Copyright &y& Elsevier]

Abstract: Background: This report is the Presidential Address of the 59th Annual Meeting of the Southwestern Surgical Congress. Organ donation is discussed from the perspective of a trauma surgeon, a prospective live organ donor and a father of a transplant recipient. Current issues to increase organ donation in the United States are addressed. Methods: Recent publications of the Institute of Medicine (IOM) with respect to non–heart beating donation and efforts to increase organ donation were reviewed. Results: Data from the Scientific Registry of Transplant Recipients/Organ Procurement and Transplant Network were reviewed and cited in the report. Data also were obtained from the Donor Network of Arizona. Conclusions: The recommendations provided by the IOM and others should strengthen efforts to increase organ donation. It is hoped that collectively they will help to decrease the disparity between the number of solid organs available and the number of patients on the transplant recipient waiting list. The efforts of the participating organ procurement organization in the breakthrough collaborative are providing evidence that the IOM suggestions can be implemented with success. [Copyright &y& Elsevier]

The relative dietary efficacy of arginine α-ketoisocaproate (AKIC) and ornithine α-ketoisocaproate (OKIC) is evaluated in a rat (Sprague-Dawley) trauma (bilateral femur fracture) model. Both control and traumatized rats were starved for 2 d and then pair-fed for 2 or 4 d one of three liquid diets: diet 1 was a basic casein diet; diets 2 and 3 were the basic diet in which 10% of nitrogen was replaced by AKIC or OKIC nitrogen, respectively. Irrespective of the diet, the protein-efficiency ratio, defined as the gain in body weight per grams nitrogen consumed, was 27% less in traumatized rats than in control rats. More improvement in apparent nitrogen balance, particularly in traumatized rats, was seen with the AKIC supplement. Plasma amino acid patterns demonstrated stimulation of net protein synthesis with AKIC and not with OKIC. Dietary supplementation with AKIC may be beneficial to promote nitrogen economy in trauma victims. [ABSTRACT FROM AUTHOR]

Abstract: Background: The clinical pulmonary infection score (CPIS) and bronchoalveolar lavage (BAL) are 2 tools that have been validated to diagnose pneumonia in critically ill patients. However, the role of the CPIS in diagnosing trauma-associated pneumonia (TAP) remains in question. Methods: This prospective observational study included all trauma patients who were ventilated for longer than 48 hours from September 2008 to September 2009. The CPIS and quantitative culture results from the BAL were collected and used to define pneumonia. Results: A total of 162 patients were identified. In all, 58 (35.8%) and 104 (64.2%) had a CPIS greater than 5 and a CPIS of 5 or less, respectively. There were 95 (58.6%) patients who had a BAL completed regardless of CPIS. There were 65 patients who met the bacteriologic definition of pneumonia (≥104 colonies/mL), for an overall TAP incidence of 40.1%. Conclusions: The CPIS is unreliable as a clinical tool to predict a positive BAL at 104 or 105 or higher threshold. Therefore, BAL should be used for the diagnosis of TAP based on clinical rationale and not the CPIS. [Copyright &y& Elsevier]