Resistant CDiff
Schulz, John
pjschu at bpthosp.org
Sat Jan 5 01:42:45 GMT 2008
We are seeing this in Connecticut, prompting us to use third line agents such as rifaximin, which has been effective when I've had to resort to it. Over the last few years we have also been taking out an increasing number of colons for Cdiff.
J Schulz
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Today's Topics:
1. Re: RESISTANT Clostridium difficile (kmattox at aol.com)
2. ESBL (Matthew Schumacher)
3. Re: RESISTANT Clostridium difficile (William Bromberg)
4. Re: Alloderm (William Bromberg)
5. Re: RESISTANT Clostridium difficile (William Bromberg)
6. Alloderm (Pellegrini - MD, Joanmarie)
7. Re: Alloderm (Ronald Simon)
8. Re: RESISTANT Clostridium difficile (Ronald Simon)
9. Re: RESISTANT Clostridium difficile (Ronald Gross)
10. Re: RESISTANT Clostridium difficile (Joe Nold)
11. Re: RESISTANT Clostridium difficile (Ronald Gross)
12. RE: RESISTANT Clostridium difficile (Bjorn, Pret)
13. Re: RESISTANT Clostridium difficile (Krin135 at aol.com)
14. R: GSW to liver (Peter)
15. Re: R: GSW to liver (Ronald Gross)
16. Re: Alloderm (nappio at aol.com)
17. Re: RESISTANT Clostridium difficile (meredith mcbride)
18. medical director trauma coordinator (Milici, Justin J.)
19. Re: RESISTANT Clostridium difficile (Andrew J Bowman)
20. Re: medical director trauma coordinator (Ronald Gross)
21. Re: RESISTANT Clostridium difficile (Ronald Gross)
22. Re: medical director trauma coordinator (Janei D. Brockhausen)
----------------------------------------------------------------------
Message: 1
Date: Fri, 4 Jan 2008 11:59:17 +0000
From: kmattox at aol.com
Subject: Re: RESISTANT Clostridium difficile
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<1369478717-1199448217-cardhu_decombobulator_blackberry.rim.net-261448015- at bxe003.bisx.prod.on.blackberry>
Content-Type: text/plain; charset="Windows-1252"
A true resistance
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Eduardo Palencia" <palenciahccml at gmail.com>
Date: Fri, 4 Jan 2008 08:50:18
To:"Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Subject: Re: RESISTANT Clostridium difficile
K, do you refer to an aggresive course, or to a true microbiological resistance to antimicrobials?
Eduardo
2008/1/4, KMATTOX at aol.com <KMATTOX at aol.com>:
>
> In Houston, particular in the suburbs, cases of SEVERE RESISTANT C.
> Difficile are being seen. Resistant to both Flagyl
> and Vancomycin. WBCs as high
> as 80,000. Often in immunosuppressed patients, but not necessarily in
> HIV
> infected patients. Seems that the patients are on PPI drugs. I am
> aware of the CDC reports and a few of the recent case reports. From
> ONE
> hospital in Houston (not mine) I am aware of 6 cases. A couple have
> had
> operations because even after 8 weeks they were still very sick and
> at operation they had thickened large bowel.
>
> I am reporting this for two reasons:
>
> 1. Have you seen such severe resistance in C.difficile?
> 2. If this is a NEW phenomena, then we need to spread the word.
>
> k
>
>
>
> **************Start the year off right. Easy ways to stay in shape.
> http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
--
Eduardo Palencia Herrejón
Servicio de Medicina Intensiva
Hospital "Infanta Leonor", Vallecas, Madrid, Spain palenciahccml at gmail.com
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------------------------------
Message: 2
Date: Fri, 4 Jan 2008 07:36:03 -0500
From: Matthew Schumacher <cadeth66 at aol.com>
Subject: ESBL
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <c61.220672e6.34af823b at aol.com>
Content-Type: text/plain; charset="iso-8859-1"
Does anyone have info on the new ESBL strain?
-----Original Message-----
From: kmattox at aol.com
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: 1/4/2008 06:59
Subject: Re: RESISTANT Clostridium difficile
A true resistance
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Eduardo Palencia" <palenciahccml at gmail.com>
Date: Fri, 4 Jan 2008 08:50:18
To:"Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Subject: Re: RESISTANT Clostridium difficile
K, do you refer to an aggresive course, or to a true microbiological resistance [truncated by sender]
------------------------------
Message: 3
Date: Fri, 04 Jan 2008 08:54:38 -0500
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Subject: Re: RESISTANT Clostridium difficile
To: <trauma-list at trauma.org>
Message-ID: <477DF44D.85AB.003A.0 at memorialhealth.com>
Content-Type: text/plain; charset=US-ASCII
What's it sensitive too? What's the recommended regimen?
Bill
>>> <KMATTOX at aol.com> 1/3/2008 11:17 PM >>>
In Houston, particular in the suburbs, cases of SEVERE RESISTANT C.
Difficile are being seen. Resistant to both Flagyl and Vancomycin. WBCs as high
as 80,000. Often in immunosuppressed patients, but not necessarily in HIV
infected patients. Seems that the patients are on PPI drugs. I am
aware of the CDC reports and a few of the recent case reports. From ONE
hospital in Houston (not mine) I am aware of 6 cases. A couple have had
operations because even after 8 weeks they were still very sick and at operation
they had thickened large bowel.
I am reporting this for two reasons:
1. Have you seen such severe resistance in C.difficile?
2. If this is a NEW phenomena, then we need to spread the word.
k
**************Start the year off right. Easy ways to stay in shape.
http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/
------------------------------
Message: 4
Date: Fri, 04 Jan 2008 09:21:18 -0500
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Subject: Re: Alloderm
To: <trauma-list at trauma.org>
Message-ID: <477DFA8E.85AB.003A.0 at memorialhealth.com>
Content-Type: text/plain; charset=UTF-8
Marc,
There's two issues in my small experience — infection and early failure and late weakening and failure.
In the short term Alloderm, albeit more resistant to infection than plastic it is certainly not as resistant as natural tissue and when it gets infected, it melts away. Jose Diaz up at Vanderbilt says he has good luck in infected fields by treating the alloderm with sulfamylon slurry until it granulates and then VACing over it. I've tried it but haven't had good luck because every time I turn my back the residents (or, sadly, one of my partners changes the regimen so I don't think I ever gave it a real chance).
In terms of late weakening, I think it's very clear that Alloderm stretches over time, The abdominal contents don't push past the edges like a mesh failure but it essentially becomes a very expensive hernia sac at 1-3 years. I've seen it a couple of times but Todd Heniford (big hernia guy up at Carolinas Med) gave a grand rounds here last year and he reported that it's almost universal if you use Alloderm to bridge a gap rather than as a reinforcement.
I absolutely don't want to come off as if I'm putting myself out as some sort of expert, btw. I'm sure other people have more experience. This info is mostly second hand with oh, about 5-6 cases of massive hernia with infection or ostomy where I didn't feel comfortable putting in plastic. I tell the patients that we're probably going to have to do a "proper" repair in a couple of years. And who knows, either I or they may move out of town before that time!
Bill Bromberg
>>> "Marc Matthews - MedPro MMC X" <Marc_Matthews at medprodoctors.com>
1/3/2008 10:21 PM >>>
All,
Quick question . . . (As I just joined the website I am not sure if you have discussed this topic before.)
Is anyone having problems with Alloderm for abdominal wall reconstructions. We are having some recurrent hernias, infections, etc. I am wondering if anyone is finding that it is not being incorporated into the fascia and instead is just weakening over time. Patients are returning to clinic with complaints of recurrent hernias months to years out. I have placed it in several patients but stopped early on. I was concerned but had no data at that time.
What is everyone else seeing and what are people's feelings about this product and the porcine Surgisis product?
Thank you,
Marc R. Matthews, MD
Medical Director, Trauma Services, Maricopa Medical Center Medical Director, Respiratory Care Services, Maricopa Medical Center Associate Director, Arizona Burn Center, Maricopa Medical Center
CONFIDENTIALITY NOTICE: This message and any of the attached documents contain information from the Medical Professional Associates of Arizona, (MedPro), that may be confidential and/or privileged. If you are not the intended recipient, you may not read, copy, distribute, or use this information, and no privilege has been waived by your inadvertent receipt. If you received this transmission in error, please notify the sender by reply email and then delete this message. Thank you.
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------------------------------
Message: 5
Date: Fri, 04 Jan 2008 09:22:11 -0500
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Subject: Re: RESISTANT Clostridium difficile
To: <trauma-list at trauma.org>
Message-ID: <477DFAC3.85AB.003A.0 at memorialhealth.com>
Content-Type: text/plain; charset=UTF-8
TO dammit TO — ONE O. I hate that.
>>> "William Bromberg" <brombwi1 at memorialhealth.com> 1/4/2008 8:54 AM
>>>
What's it sensitive too? What's the recommended regimen?
Bill
>>> <KMATTOX at aol.com> 1/3/2008 11:17 PM >>>
In Houston, particular in the suburbs, cases of SEVERE RESISTANT C.
Difficile are being seen. Resistant to both Flagyl and Vancomycin.
WBCs as high
as 80,000. Often in immunosuppressed patients, but not necessarily
in HIV
infected patients. Seems that the patients are on PPI drugs. I
am
aware of the CDC reports and a few of the recent case reports. From
ONE
hospital in Houston (not mine) I am aware of 6 cases. A couple
have had
operations because even after 8 weeks they were still very sick and at operation
they had thickened large bowel.
I am reporting this for two reasons:
1. Have you seen such severe resistance in C.difficile?
2. If this is a NEW phenomena, then we need to spread the word.
k
**************Start the year off right. Easy ways to stay in shape.
http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
--
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To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/
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------------------------------
Message: 6
Date: Fri, 4 Jan 2008 09:46:26 -0500
From: "Pellegrini - MD, Joanmarie" <jpellegrini at emh.org>
Subject: Alloderm
To: <trauma-list at trauma.org>
Message-ID:
<86325BB1656A0F4BAC4611A956349E770E8CEA45 at VALIER.me.emh.org>
Content-Type: text/plain; charset="iso-8859-1"
I have used both Surgisis and Alloderm. I started with Surgisis a few years ago because I needed a biologic and it was significantly less expensive than Alloderm. I have since abandoned its use because of many problems with seromas, elevated white counts and fever with no other source, and too many cases of rapid dissolution of the product. I do still have some patients that are 3-5 years out with excellent results though. I have only been using Alloderm for 18 months. I switched to Alloderm because it has the most data and longest follow-ups. Unfortunately, it costs big bucks! However, I have one older gentleman that never incorporated the stuff. I think he is the problem rather than the product because he has failed every hernia operation no matter who does it or what material is used (no, he is not a smoker and has no medical issues). I now also have another recurrance in yet another very complicated patient who is 11 months out. I have not tried any of the other products such as Permacol or Collamend. I also have to admit that I use Alloderm only in the "problem" patients and so if you consider that, I think it is working as well as could be expected. Biologically, I think uncrosslinked is better but there is no head-to-head comparison of the products. It is becoming increasingly difficult for the surgeon to navigate this field because of all the "noise". There are so many products and there are very real differences. However, how to know which attributes are the most important? What I can say about Alloderm is that my patients seem to have a lot less pain than with synthetic meshes and Surgisis. Also, when it fails and you have to reoperate, there do not seem to be any issues with adhesions or other inflammatory messes. Since no company is going to fund a study of all the products, it sure would be nice if there was some type of registry we could enter our patients into for follow up and pooled results.
Joan Pellegrini, MD, FACS
Eastern Maine Medical Center
Director, Trauma Program
Co-Director, ICU
417 State Street
Webber West #340
Bangor, ME 04401
207-973-4949 office
207-973-4466 fax
207-356-9291 cell
________________________________
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------------------------------
Message: 7
Date: Fri, 04 Jan 2008 10:40:12 -0500
From: "Ronald Simon" <Traumamd at nyc.rr.com>
Subject: Re: Alloderm
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <477E535C.8020601 at nyc.rr.com>
Content-Type: text/plain; charset="iso-8859-1"
Had the same experience early on and then found out that yes it
stretches so when you sew it in, it has to be very tight. Much better
results since then.
ron simon
Marc Matthews - MedPro MMC X wrote:
> All,
>
> Quick question . . . (As I just joined the website I am not sure if
> you have discussed this topic before.)
>
> Is anyone having problems with Alloderm for abdominal wall
> reconstructions. We are having some recurrent hernias, infections,
> etc. I am wondering if anyone is finding that it is not being
> incorporated into the fascia and instead is just weakening over time.
> Patients are returning to clinic with complaints of recurrent hernias
> months to years out. I have placed it in several patients but stopped
> early on. I was concerned but had no data at that time.
>
> What is everyone else seeing and what are people's feelings about this
> product and the porcine Surgisis product?
>
> Thank you,
>
> Marc R. Matthews, MD
> Medical Director, Trauma Services, Maricopa Medical Center Medical
> Director, Respiratory Care Services, Maricopa Medical Center Associate
> Director, Arizona Burn Center, Maricopa Medical Center
>
> CONFIDENTIALITY NOTICE: This message and any of the attached documents
> contain information from the Medical Professional Associates of Arizona, (MedPro), that may be confidential and/or privileged. If you are not the intended recipient, you may not read, copy, distribute, or use this information, and no privilege has been waived by your inadvertent receipt. If you received this transmission in error, please notify the sender by reply email and then delete this message. Thank you.
> CONFIDENTIAL MATERIALS PROTECTED under ARS § 36-445, ARS § 36-2403 and Federal Patient Safety and Quality Improvement Act of 2005
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
-------------- next part --------------
begin:vcard
fn:Ronald Simon, MD
n:;Ronald Simon, MD
org:Bellevue Hospital Center
adr;dom:;;550 First Avenue NBV-15S5;New York;NY;10016 title:Director of Trauma and Surgical Critical Care tel;work:212-263-5751 version:2.1 end:vcard
------------------------------
Message: 8
Date: Fri, 04 Jan 2008 10:44:17 -0500
From: "Ronald Simon" <Traumamd at nyc.rr.com>
Subject: Re: RESISTANT Clostridium difficile
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Cc: ccm-l at ccm-l.com
Message-ID: <477E5451.60602 at nyc.rr.com>
Content-Type: text/plain; charset="iso-8859-1"
Seen it several times. Very low threshold for colectomy. As soon as they
go on pressors, they get their colon out. Seems to respond better to
vanco enemas but the data is very preliminary. Anytime now i see a WBC
above 30K i think about it.
ron simon
KMATTOX at aol.com wrote:
> In Houston, particular in the suburbs, cases of SEVERE RESISTANT C.
> Difficile are being seen. Resistant to both Flagyl and Vancomycin. WBCs as high
> as 80,000. Often in immunosuppressed patients, but not necessarily in HIV
> infected patients. Seems that the patients are on PPI drugs. I am
> aware of the CDC reports and a few of the recent case reports. From ONE
> hospital in Houston (not mine) I am aware of 6 cases. A couple have had
> operations because even after 8 weeks they were still very sick and at operation
> they had thickened large bowel.
>
> I am reporting this for two reasons:
>
> 1. Have you seen such severe resistance in C.difficile?
> 2. If this is a NEW phenomena, then we need to spread the word.
>
> k
>
>
>
> **************Start the year off right. Easy ways to stay in shape.
> http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
-------------- next part --------------
begin:vcard
fn:Ronald Simon, MD
n:;Ronald Simon, MD
org:Bellevue Hospital Center
adr;dom:;;550 First Avenue NBV-15S5;New York;NY;10016 title:Director of Trauma and Surgical Critical Care tel;work:212-263-5751 version:2.1 end:vcard
------------------------------
Message: 9
Date: Fri, 04 Jan 2008 12:10:24 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: RESISTANT Clostridium difficile
To: <ccm-l at ccm-l.com>, <trauma-list at trauma.org>
Message-ID: <477E2230.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII
Ken,
We have taken out 2 colons in the last 12 months for the exact circumstances you are describing. Patients were toxic, with temps >102, WBC >30K (31,500 and 38,000!!!) , on pressors and having profuse diarrhea. The second went to the OR without the final culture results - a pretty ballsie move, if you ask me. BUT - the cultures came back positive, the patient, who was close to death and on pressors, is alive and home, and he is very happy about that! Would I have done the same - I am still not sure I have the nerve, but I will let you all know what I do if I end up in the same situation....
Ron
>>> <KMATTOX at aol.com> 1/3/2008 11:17 PM >>>
In Houston, particular in the suburbs, cases of SEVERE RESISTANT C.
Difficile are being seen. Resistant to both Flagyl and Vancomycin. WBCs as high
as 80,000. Often in immunosuppressed patients, but not necessarily in HIV
infected patients. Seems that the patients are on PPI drugs. I am
aware of the CDC reports and a few of the recent case reports. From ONE
hospital in Houston (not mine) I am aware of 6 cases. A couple have had
operations because even after 8 weeks they were still very sick and at operation
they had thickened large bowel.
I am reporting this for two reasons:
1. Have you seen such severe resistance in C.difficile?
2. If this is a NEW phenomena, then we need to spread the word.
k
**************Start the year off right. Easy ways to stay in shape.
http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/
------------------------------
Message: 10
Date: Fri, 4 Jan 2008 09:20:26 -0800 (PST)
From: Joe Nold <jnoldscarmaker at yahoo.com>
Subject: Re: RESISTANT Clostridium difficile
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <54171.64259.qm at web52408.mail.re2.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Any talk of fecal enemas?
Have had some good results here.
---------------------------------
Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.
------------------------------
Message: 11
Date: Fri, 04 Jan 2008 12:29:17 -0500
From: "Ronald Gross" <Rgross at harthosp.org>
Subject: Re: RESISTANT Clostridium difficile
To: "Critical Care mailing list Trauma &" <trauma-list at trauma.org>
Message-ID: <477E269D.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII
Things that make you go Hmmmmmmm. I had suggested that in our shop, but couldn't find anyone to volunteer to administer them.......just kidding ;-)
Honestly, I know nothing about that. And no I wouldn't volunteer either!
>>> Joe Nold <jnoldscarmaker at yahoo.com> 1/4/2008 12:20 PM >>>
Any talk of fecal enemas?
Have had some good results here.
---------------------------------
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------------------------------
Message: 12
Date: Fri, 4 Jan 2008 12:31:00 -0500
From: "Bjorn, Pret" <pbjorn at emh.org>
Subject: RE: RESISTANT Clostridium difficile
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <9CCE32ECAAFDEB4DA01EC771B6AD951BFB2632 at VALIER.me.emh.org>
Content-Type: text/plain; charset="us-ascii"
How do you find donors who give a shit?
Pret
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Joe Nold
Sent: Friday, January 04, 2008 12:20 PM
To: Trauma &, Critical Care mailing list
Subject: Re: RESISTANT Clostridium difficile
Any talk of fecal enemas?
Have had some good results here.
---------------------------------
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------------------------------
Message: 13
Date: Fri, 4 Jan 2008 12:44:39 EST
From: Krin135 at aol.com
Subject: Re: RESISTANT Clostridium difficile
To: trauma-list at trauma.org
Message-ID: <d38.1be34424.34afca87 at aol.com>
Content-Type: text/plain; charset="US-ASCII"
In a message dated 04-Jan-08 11:30:10 Central Standard Time,
Rgross at harthosp.org writes:
Things that make you go Hmmmmmmm. I had suggested that in our shop, but
couldn't find anyone to volunteer to administer them.......just kidding ;-)
Honestly, I know nothing about that. And no I wouldn't volunteer either!
>>> Joe Nold <jnoldscarmaker at yahoo.com> 1/4/2008 12:20 PM >>>
Any talk of fecal enemas?
Have had some good results here.
Chuckle...I had to give some of those back in the late 1970s. "Old
Fashioned" treatment for severe, recalcitrant, antibiotic related diarrhea even then.
And the physician who ordered the offending antibiotics was usually the one
tapped to 'donate' for the mix.
I suspect that a live culture yoghourt enema might also work, and be a whole
lot more esthetically pleasing to give.
ck
Charles S. Krin, DO FAAFP
**************Start the year off right. Easy ways to stay in shape.
http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489
------------------------------
Message: 14
Date: Fri, 4 Jan 2008 18:57:45 +0100
From: "Peter" <taliente at tiscalinet.it>
Subject: R: GSW to liver
To: "'Trauma & Critical Care mailing list'"
<trauma-list at trauma.org>
Message-ID: <FBCMCL01B05OfIbalaw0014640d at FBCMCL01B05.fbc.local>
Content-Type: text/plain; charset="iso-8859-1"
Interesting discussion, but maybe we should look at the experience of liver surgery units and liver transplants. The biliary sutures are the ones most at risk, but there has been no proponents for papillary stents and now even placing stents or Kehr tubes is being discussed. The use of Octreotide is mainly for pancreatic fistulae and tends to increase the pressure in Vater's papilla, not the best solution if there is a bile leakage! But in medicine everything may seem to work, but the evidence? Just my reflections! Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Dr. Haim Paran
Inviato: mercoledì 2 gennaio 2008 18.54
A: 'Trauma & Critical Care mailing list'
Oggetto: RE: GSW to liver
I have a modest experience with 2 recent cases of penetrating injuries to the liver with continuous bile leak. One of them had a leak through the diaphragm into a chest tube and the other developed a bile leak after the laparotomy when a JP drain was left near a non bleeding laceration. In both cases an ERCP and stenting the papilla immediately decreased the output by 60% and the leak stopped spontaneously a week later. There were no complications from the procedure.
P.S. Octreotide usually decreases the bile output by 30%
Good luck,
Haim Paran
Kfar-Sava
Israel
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Errington Thompson
Sent: Wednesday, January 02, 2008 1:03 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: GSW to liver
Peter -
You might be right but as I'm looking at a patient who is post-injury day 32
(on going biliary drainage), I'm thinking a stent maybe helpful.
Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net
Everyone deserves to make an informed decision
- Errington Thompson, MD
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Peter
Sent: Tuesday, January 01, 2008 5:02 PM
To: 'Trauma & Critical Care mailing list'
Subject: R: GSW to liver
I think that the placement of a stent does nothing to improve drainage in
this case, but is an invasive procedure with a possibility of increasing the
risk of infection. The biliary output will decrease spontaneously.
Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Tchaka Shepherd
Inviato: lunedì 31 dicembre 2007 6.27
A: Trauma & Critical Care mailing list
Oggetto: RE: GSW to liver
If the patient remains stable. ERCP with stent placement should provide a
path of least resistance and significantly decrease your drain output.
Isolated liver injuries with hemodynamic stability infrequently need
operative intervention.
----------------------------------------
> From: jamac at pacific.net.ph
> To: trauma-list at trauma.org
> Date: Thu, 11 Dec 2003 18:17:25 +0800
> Subject: Re: GSW to liver
>
> Dr. Thompson,
> I will also take the patient to the OR. Seeing the extent of his
> injury, I
> will place a balloon tamponade and drain.
> Thanks.
> Joel U. Macalino, MD
> Philippines
> ----- Original Message -----
> From: Errington Thompson
> To: 'Trauma & Critical Care mailing list'
> Sent: Sunday, December 30, 2007 1:06 PM
> Subject: GSW to liver
>
>
> I have a couple of questions on a recent case. 30 yo male was too
> drunk
to
> have a gun but had one nonetheless. He shot himself in the right
> upper
> quadrant. He was stable, awake and talking in the ER. Entrance wound
> easily seen just under the ribs and just lateral to the mid-clavicular
line.
> The bullet was palpable just under the skin at about the 12th rib. No
SOB.
>
>
> 1) CT or not CT scan. IF you do scan the patient and see a thru and
> thru
> wound the liver, can you just watch him?
>
> I take the patient to the OR. He indeed has a thru and thru GSW to
> the
> liver. The wounds are not really bleeding. There is no bile oozing
> from
> either wound.
>
> 2) Drain or no drain?
>
> The patient develops an ileus and bile peritonitis. He is
> percutaneously
> drained. On day 5 with his drain output still over 300 cc per day the
> character of the drainage changes to a dark green. CT scan revealed
> an
> abscess posterior to the liver. Percutaneous drainage was performed.
> Enterococcus in the fluid. Antibiotics were started. Antiobiotics
stopped
> after 7 days.
>
> Thoughts?
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Mission Hospital
> Asheville, NC
> Author - A Letter to America
> www.whereistheoutrage.net
>
>
> Everyone deserves to make an informed decision
> - Errington Thompson, MD
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> --
> trauma-list : TRAUMA.ORG
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_________________________________________________________________
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------------------------------
Message: 15
Date: Fri, 04 Jan 2008 13:34:49 -0500
From: "Ronald Gross" <rgross at harthosp.org>
Subject: Re: R: GSW to liver
To: "'Trauma & Critical Care mailing list'"
<trauma-list at trauma.org>
Message-ID: <477E35F9020000B900017FD1 at gwmail6.harthosp.org>
Content-Type: text/plain; charset=UTF-8
You are comparing apples with oranges. Complications from liver transplants are a different animal than the case we have been discussing. We aren't talking about a suture line failure, but rather a rather large hole in the parenchyma of the liver with markedly disrupted intrahepatic ducts mixing with blood. A well placed stent will facilitate biliary drainage - of that I am 100% certain.
Ron
>>> "Peter" <taliente at tiscalinet.it> 01/04/08 12:57 PM >>>
Interesting discussion, but maybe we should look at the experience of liver surgery units and liver transplants. The biliary sutures are the ones most at risk, but there has been no proponents for papillary stents and now even placing stents or Kehr tubes is being discussed. The use of Octreotide is mainly for pancreatic fistulae and tends to increase the pressure in Vater's papilla, not the best solution if there is a bile leakage! But in medicine everything may seem to work, but the evidence? Just my reflections! Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Dr. Haim Paran
Inviato: mercoledì 2 gennaio 2008 18.54
A: 'Trauma & Critical Care mailing list'
Oggetto: RE: GSW to liver
I have a modest experience with 2 recent cases of penetrating injuries to the liver with continuous bile leak. One of them had a leak through the diaphragm into a chest tube and the other developed a bile leak after the laparotomy when a JP drain was left near a non bleeding laceration. In both cases an ERCP and stenting the papilla immediately decreased the output by 60% and the leak stopped spontaneously a week later. There were no complications from the procedure.
P.S. Octreotide usually decreases the bile output by 30%
Good luck,
Haim Paran
Kfar-Sava
Israel
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Errington Thompson
Sent: Wednesday, January 02, 2008 1:03 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: GSW to liver
Peter -
You might be right but as I'm looking at a patient who is post-injury day 32
(on going biliary drainage), I'm thinking a stent maybe helpful.
Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net
Everyone deserves to make an informed decision
- Errington Thompson, MD
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Peter
Sent: Tuesday, January 01, 2008 5:02 PM
To: 'Trauma & Critical Care mailing list'
Subject: R: GSW to liver
I think that the placement of a stent does nothing to improve drainage in
this case, but is an invasive procedure with a possibility of increasing the
risk of infection. The biliary output will decrease spontaneously.
Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Tchaka Shepherd
Inviato: lunedì 31 dicembre 2007 6.27
A: Trauma & Critical Care mailing list
Oggetto: RE: GSW to liver
If the patient remains stable. ERCP with stent placement should provide a
path of least resistance and significantly decrease your drain output.
Isolated liver injuries with hemodynamic stability infrequently need
operative intervention.
----------------------------------------
> From: jamac at pacific.net.ph
> To: trauma-list at trauma.org
> Date: Thu, 11 Dec 2003 18:17:25 +0800
> Subject: Re: GSW to liver
>
> Dr. Thompson,
> I will also take the patient to the OR. Seeing the extent of his
injury, I
> will place a balloon tamponade and drain.
> Thanks.
>
Joel U. Macalino, MD
> Philippines
> ----- Original Message -----
> From: Errington Thompson
> To: 'Trauma & Critical Care mailing list'
> Sent: Sunday, December 30, 2007 1:06 PM
> Subject: GSW to liver
>
>
> I have a couple of questions on a recent case. 30 yo male was too
drunk
to
> have a gun but had one nonetheless. He shot himself in the right
upper
> quadrant. He was stable, awake and talking in the ER. Entrance
wound
> easily seen just under the ribs and just lateral to the
mid-clavicular
line.
> The bullet was palpable just under the skin at about the 12th rib.
No
SOB.
>
>
> 1) CT or not CT scan. IF you do scan the patient and see a thru and
thru
> wound the liver, can you just watch him?
>
> I take the patient to the OR. He indeed has a thru and thru GSW to
the
> liver. The wounds are not really bleeding. There is no bile oozing
from
> either wound.
>
> 2) Drain or no drain?
>
> The patient develops an ileus and bile peritonitis. He is
percutaneously
> drained. On day 5 with his drain output still over 300 cc per day
the
> character of the drainage changes to a dark green. CT scan revealed
an
> abscess posterior to the liver. Percutaneous drainage was
performed.
> Enterococcus in the fluid. Antibiotics were started. Antiobiotics
stopped
> after 7 days.
>
> Thoughts?
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Mission Hospital
> Asheville, NC
> Author - A Letter to America
> www.whereistheoutrage.net
>
>
> Everyone deserves to make an informed decision
> - Errington Thompson, MD
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
_________________________________________________________________
Don't get caught with egg on your face. Play Chicktionary!
http://club.live.com/chicktionary.aspx?icid=chick_wlhmtextlink1_dec--
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------------------------------
Message: 16
Date: Fri, 4 Jan 2008 22:38:23 +0000
From: nappio at aol.com
Subject: Re: Alloderm
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<1107785487-1199486455-cardhu_decombobulator_blackberry.rim.net-166597659- at bxe015.bisx.prod.on.blackberry>
Content-Type: text/plain; charset="Windows-1252"
I have used it often and been to every meeting. Primary alloderm closure will always stretch, some to the extent of being a three thousand dollar hernia sac. For salvag closure it is ideal, but for definitive management I have only found it useful as a mesh underlay when combined with fascial component separation to provide definitive tissue closure of fascia on top of it. We have done this a number of times with excellent results. Your complaints are well known in hernia circles. DN
Sent from my Verizon Wireless BlackBerry
-----Original Message-----
From: "Marc Matthews - MedPro MMC X" <Marc_Matthews at medprodoctors.com>
Date: Thu, 3 Jan 2008 20:21:39
To:<trauma-list at trauma.org>
Subject: Alloderm
All,
Quick question . . . (As I just joined the website I am not sure if you have discussed this topic before.)
Is anyone having problems with Alloderm for abdominal wall reconstructions. We are having some recurrent hernias, infections, etc. I am wondering if anyone is finding that it is not being incorporated into the fascia and instead is just weakening over time. Patients are returning to clinic with complaints of recurrent hernias months to years out. I have placed it in several patients but stopped early on. I was concerned but had no data at that time.
What is everyone else seeing and what are people's feelings about this product and the porcine Surgisis product?
Thank you,
Marc R. Matthews, MD
Medical Director, Trauma Services, Maricopa Medical Center
Medical Director, Respiratory Care Services, Maricopa Medical Center
Associate Director, Arizona Burn Center, Maricopa Medical Center
CONFIDENTIALITY NOTICE: This message and any of the attached documents contain information from the Medical Professional Associates of Arizona, (MedPro), that may be confidential and/or privileged. If you are not the intended recipient, you may not read, copy, distribute, or use this information, and no privilege has been waived by your inadvertent receipt. If you received this transmission in error, please notify the sender by reply email and then delete this message. Thank you.
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------------------------------
Message: 17
Date: Fri, 4 Jan 2008 14:47:44 -0800 (PST)
From: meredith mcbride <mmcbridemd at yahoo.com>
Subject: Re: RESISTANT Clostridium difficile
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <169571.33920.qm at web33508.mail.mud.yahoo.com>
Content-Type: text/plain; charset=us-ascii
They usually enlist family member, preferably blood relatives. Apparently they stockpile several days worth of feces in the freezer, then mix up an enema solution with it. It re-establishes the normal colonic flora so that the c diff no longer has a favorable environment to flourish. I'm told that results are dramatic and seen within a day or two.
----- Original Message ----
From: "Bjorn, Pret" <pbjorn at emh.org>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, January 4, 2008 9:31:00 AM
Subject: RE: RESISTANT Clostridium difficile
How do you find donors who give a shit?
Pret
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Joe Nold
Sent: Friday, January 04, 2008 12:20 PM
To: Trauma &, Critical Care mailing list
Subject: Re: RESISTANT Clostridium difficile
Any talk of fecal enemas?
Have had some good results here.
---------------------------------
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------------------------------
Message: 18
Date: Fri, 4 Jan 2008 16:54:51 -0600
From: "Milici, Justin J." <JustinM at BaylorHealth.edu>
Subject: medical director trauma coordinator
To: "'traumanurses at listserve.com'" <traumanurses at listserve.com>,
"'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>,
"traumanurses at mailman.listserve.com"
<traumanurses at mailman.listserve.com>,
"'trauma-list-bounces at trauma.org'" <trauma-list-bounces at trauma.org>,
"'ena_trauma at neptune.serverside.net'"
<ena_trauma at neptune.serverside.net>
Message-ID:
<9EB5E1A9B3DCD34185BA7186B3A0310010A1BBE1F9 at BHDAEXVM32.bhcs.pvt>
Content-Type: text/plain; charset="us-ascii"
See below.... any input??
Justin Milici, RN, MSN, CCRN, CEN, CFRN, TNS
Trauma Education, Prevention/Outreach
Trauma Services - 11 Roberts
Baylor University Medical Center
3500 Gaston Ave.
Dallas, TX 75246
(214) 820-6818
(214) 820-1086 - Fax
(214) 344-3961 - Pager
E-mail: JustinM at baylorhealth.edu
________________________________
From: Loflin Kimberly [mailto:Kim.Loflin at LPNT.net]
Sent: Friday, January 04, 2008 10:03 AM
To: Milici, Justin J.
Subject: medical director trauma coordinator
Can anyone please help? I am in need of a Medical Director Trauma Coordinator job description? Thank you Kim Loflin
This e-mail, facsimile, or letter and any files or attachments transmitted with it contains information that is confidential and privileged. This information is intended only for the use of the individual(s) and entity(ies) to whom it is addressed. If you are the intended recipient, further disclosures are prohibited without proper authorization. If you are not the intended recipient, any disclosure, copying, printing, or use of this information is strictly prohibited and possibly a violation of federal or state law and regulations. If you have received this information in error, please notify Baylor Health Care System immediately at 1-866-402-1661 or via e-mail at privacy at baylorhealth.edu. Baylor Health Care System, its subsidiaries, and affiliates hereby claim all applicable privileges related to this information.
------------------------------
Message: 19
Date: Fri, 4 Jan 2008 17:55:38 -0500
From: "Andrew J Bowman" <andrewj.bowman at gmail.com>
Subject: Re: RESISTANT Clostridium difficile
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<dfe364720801041455x61cb82beta178cc94213f9eb at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
During my infectious disease rotation I saw this. It does work but man it's
gross.
Andrew
On 1/4/08, meredith mcbride <mmcbridemd at yahoo.com> wrote:
>
> They usually enlist family member, preferably blood relatives. Apparently
> they stockpile several days worth of feces in the freezer, then mix up an
> enema solution with it. It re-establishes the normal colonic flora so that
> the c diff no longer has a favorable environment to flourish. I'm told that
> results are dramatic and seen within a day or two.
>
>
> ----- Original Message ----
> From: "Bjorn, Pret" <pbjorn at emh.org>
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Friday, January 4, 2008 9:31:00 AM
> Subject: RE: RESISTANT Clostridium difficile
>
> How do you find donors who give a shit?
>
> Pret
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Joe Nold
> Sent: Friday, January 04, 2008 12:20 PM
> To: Trauma &, Critical Care mailing list
> Subject: Re: RESISTANT Clostridium difficile
>
>
> Any talk of fecal enemas?
> Have had some good results here.
>
>
>
>
> ---------------------------------
> Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try
> it now.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
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>
>
>
> ____________________________________________________________________________________
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> Find them fast with Yahoo! Search.
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>
------------------------------
Message: 20
Date: Fri, 04 Jan 2008 20:00:32 -0500
From: "Ronald Gross" <rgross at harthosp.org>
Subject: Re: medical director trauma coordinator
To: <trauma-list at trauma.org>
Message-ID: <477E9060020000B90001802B at gwmail6.harthosp.org>
Content-Type: text/plain; charset=US-ASCII
I am confused (OK you say, what else is new).....do they want a medical director or trauma coordinator?
>>> "Milici, Justin J." <JustinM at BaylorHealth.edu> 01/04/08 5:54 PM >>>
See below.... any input??
Justin Milici, RN, MSN, CCRN, CEN, CFRN, TNS
Trauma Education, Prevention/Outreach
Trauma Services - 11 Roberts
Baylor University Medical Center
3500 Gaston Ave.
Dallas, TX 75246
(214) 820-6818
(214) 820-1086 - Fax
(214) 344-3961 - Pager
E-mail: JustinM at baylorhealth.edu
________________________________
From: Loflin Kimberly [mailto:Kim.Loflin at LPNT.net]
Sent: Friday, January 04, 2008 10:03 AM
To: Milici, Justin J.
Subject: medical director trauma coordinator
Can anyone please help? I am in need of a Medical Director Trauma Coordinator job description? Thank you Kim Loflin
This e-mail, facsimile, or letter and any files or attachments transmitted with it contains information that is confidential and privileged. This information is intended only for the use of the individual(s) and entity(ies) to whom it is addressed. If you are the intended recipient, further disclosures are prohibited without proper authorization. If you are not the intended recipient, any disclosure, copying, printing, or use of this information is strictly prohibited and possibly a violation of federal or state law and regulations. If you have received this information in error, please notify Baylor Health Care System immediately at 1-866-402-1661 or via e-mail at privacy at baylorhealth.edu. Baylor Health Care System, its subsidiaries, and affiliates hereby claim all applicable privileges related to this information.
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------------------------------
Message: 21
Date: Fri, 04 Jan 2008 20:01:08 -0500
From: "Ronald Gross" <rgross at harthosp.org>
Subject: Re: RESISTANT Clostridium difficile
To: <trauma-list at trauma.org>
Message-ID: <477E9084020000B90001802F at gwmail6.harthosp.org>
Content-Type: text/plain; charset=US-ASCII
C'mon now Andrew, lets not get personal!
Ron GROSS
>>> "Andrew J Bowman" <andrewj.bowman at gmail.com> 01/04/08 5:55 PM >>>
During my infectious disease rotation I saw this. It does work but man it's
gross.
Andrew
On 1/4/08, meredith mcbride <mmcbridemd at yahoo.com> wrote:
>
> They usually enlist family member, preferably blood relatives. Apparently
> they stockpile several days worth of feces in the freezer, then mix up an
> enema solution with it. It re-establishes the normal colonic flora so that
> the c diff no longer has a favorable environment to flourish. I'm told that
> results are dramatic and seen within a day or two.
>
>
> ----- Original Message ----
> From: "Bjorn, Pret" <pbjorn at emh.org>
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Friday, January 4, 2008 9:31:00 AM
> Subject: RE: RESISTANT Clostridium difficile
>
> How do you find donors who give a shit?
>
> Pret
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Joe Nold
> Sent: Friday, January 04, 2008 12:20 PM
> To: Trauma &, Critical Care mailing list
> Subject: Re: RESISTANT Clostridium difficile
>
>
> Any talk of fecal enemas?
> Have had some good results here.
>
>
>
>
> ---------------------------------
> Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try
> it now.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> ____________________________________________________________________________________
> Looking for last minute shopping deals?
> Find them fast with Yahoo! Search.
> http://tools.search.yahoo.com/newsearch/category.php?category=shopping
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------------------------------
Message: 22
Date: Fri, 4 Jan 2008 18:27:27 -0700
From: "Janei D. Brockhausen" <jdbee01 at gmail.com>
Subject: Re: medical director trauma coordinator
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<c9cd47ba0801041727q3c58d74ane68a2170beb5fa43 at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
If you are loooking for the RN trauma coordinator position here is one I've
seen used a lot...
janei
*Job Description*
*Description*
*The trauma nurse coordinator (TNC) is a registered nurse with demonstrated
interest, education, and experience in trauma care and who, in partnership
with the trauma medical director and hospital administration, is responsible
for coordination of trauma care at Houston Northwest Medical Center. This
coordination should include active participation in the trauma performance
improvement program, the ability to positively impact care of trauma
patients in all areas of the hospital, and targeted prevention and education
activities for the public and health care professionals. The TNC will be
responsible for monitoring and coordinating all trauma services and system
elements to ensure an organized multi-disciplinary team approach to quality
care of the trauma patient. The TNC will be responsible for the overall
management and maintenance of the Trauma Registry, and statistical trauma
reports. The TNC will also assist the ED Nurse educator in assuring that
mandatory competencies are provided to staff and monitors compliance.*
On Jan 4, 2008 3:54 PM, Milici, Justin J. <JustinM at baylorhealth.edu> wrote:
>
> See below.... any input??
>
> Justin Milici, RN, MSN, CCRN, CEN, CFRN, TNS
> Trauma Education, Prevention/Outreach
> Trauma Services - 11 Roberts
> Baylor University Medical Center
> 3500 Gaston Ave.
> Dallas, TX 75246
> (214) 820-6818
> (214) 820-1086 - Fax
> (214) 344-3961 - Pager
> E-mail: JustinM at baylorhealth.edu
>
>
> ________________________________
> From: Loflin Kimberly [mailto:Kim.Loflin at LPNT.net]
> Sent: Friday, January 04, 2008 10:03 AM
> To: Milici, Justin J.
> Subject: medical director trauma coordinator
>
> Can anyone please help? I am in need of a Medical Director Trauma
> Coordinator job description? Thank you Kim Loflin
>
>
> This e-mail, facsimile, or letter and any files or attachments transmitted
> with it contains information that is confidential and privileged. This
> information is intended only for the use of the individual(s) and
> entity(ies) to whom it is addressed. If you are the intended recipient,
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End of trauma-list Digest, Vol 55, Issue 5
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