SV: extremity crunch- update

Tue, 18 Apr 2000 09:06:22 +0200

If he were a patient in our dept we would use hyperbaric oxygen, despite
lack of RCTs. He needs oxygen and this is a way of getting the tissue oxygen
pressure up to a level where angiogenesis and tissue repair can happen. We
would also have to go 20 min by ambulance, but with appropriate monitoring
this shouldn't be the biggest problem you are facing. 90 min at 2,4 ATA for
5-7 days and you should be able to see if something happens. We would also
give eneteral feeding, at least 100 kcal/d to avoid the complications of
TPN.
Good luck!

Guttorm Bratteboe MD 
Consultant 
Anaesthesia & Intensive Care / 
Hyperbaric Medicine Unit 
Haukeland University Hospital 
Bergen, Norway 

-----Opprinnelig melding-----
Fra: Caesar M. Ursic [mailto:cursic@email.msn.com]
Sendt: 17. april 2000 19:57
Til: trauma-list@trauma.org
Emne: extremity crunch- update

You all probably remember the case I posted six days ago describing a 39 yo
Jehovah's Witness requiring bilateral above knee amputations after
industrial-related crush injuries to the knees.  I thought you'd like to
know about his progress; I also have some questions for the group.

He remains intubated, mechanically ventilated on a morphine drip that
nevertheless allows him to communicate.  He remains cooperative.  Urine
output exceeds 0.5 ml/kg/hour and he has never required inotropic agents.
Hear rate 120-140/min, sinus rhythm after the initial Swan Ganz placed in
the OR was removed because of persistent ventricular ectopy.  We have
resuscitated him purely with crystalloid (Lact. Ringers, Plasmalyte)
although he did receive some hetastarch during his operative procedures.

We began giving him human recombinant erythropoeitin (Epogen) on day 1 (300
u/kg iv every Mon / Wed / Fri) as well as parenteral iron dextran (100 mg iv
daily), folate and vitamin B12.  We check labs every third day by drawing up
one ml of blood - this can be used by our lab to obtain serum electrolytes,
bun, creat and a CBC.His hematocrit/Hgb today are 5.9% and 2.0 g/dl.  His
WBC is 23,000 (was 10,000 three days ago). BUN/creat are normal.

Problem is: his amputations are not healing.  I have revised the right side
twice already and am getting ready to go again because despite trimming back
to what appears viable muscle grossly (very pale but contracts to cautery
and fluoresces under Woods lamp+fluorescein) the muscles invariably die by
the next dressing change.  I fear that the next step is a hip
disarticulation.  The femoral artery remains pulsatile within the wound.

questions:  anybody for hyperbaric oxygen?  My bias is no, because it would
involve a 30 min ambulance ride to the chamber and because I have found no
convincing evidence it would help this patient.  Some reports in the
literature of O2 therapy in Jehovah's Witnesses (McLoughlin, Cope, Harrison.
Hyperbaric oxygen therapy in the management of severe acute anemia in a
J'sW. Anaesthesia 54:891,1999 is the latest) but no level I or II data I can
find, obviously.

question: anybody for neuromuscular blockade?  Seems logical that limiting
muscular activity would diminish non-essential O2 consumption, although he
synchronizes beautifully with the vent (SIMV of 12/min, pressure support of
7 cm H20, no peep, Fi02 of .50).  He has no other indication for paralysis.

question: feed him enterally?  I have resisted the temptation to do this
based on my assumption that increasing O2 consumption in the splanchnic
circulation is not the thing to do in someone with such a marginal 02
delivery.  So he's on TPN instead, for now.

Thanks for the input

C.M.Ursic, MD
Dept. of Surgery
University of California Davis - East Bay
Oakland