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W. M. Stahl

Bio: W. M. Stahl is an academic researcher from Lincoln Hospital. The author has contributed to research in topics: Laparotomy & Abdominal trauma. The author has an hindex of 6, co-authored 9 publications receiving 474 citations.

Papers
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Journal ArticleDOI
TL;DR: Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of intra-abdominal hypertension and reduce these complications.
Abstract: Objective: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). Methods: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H 2 O) was treated by bedside or operating room laparotomy. Results: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11patients, eight patients (72.7%) had acidotic pHi (7.10± 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. Conclusions: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

323 citations

Journal ArticleDOI
TL;DR: The data suggest that Doppler indices should be an integral part of the physical examination and can screen patients with proximal injuries for further studies such as duplex sonography or arteriography.
Abstract: This prospective study assessed the role of Doppler pressure indices (Ankle-Brachial Index [ABI] or Brachial Brachial Index [BBI]) in the evaluation for occult arterial injury from penetrating proximity extremity trauma (PET). A total of 258 patients with 323 PETs were evaluated by physical examination and Doppler pressure (ABI/BBI) determination. An ABI/BBI of < 0.9 was considered abnormal. The findings were compared with those of arteriography in all patients. Eleven injuries (3.4%) found on arteriography were associated with normal indices. Five of these injuries were treated by repair (4 patients) or angiographic embolization of a bleeding vessel (1 patient), all in lesions proximal to the knee or elbow joints. The other six lesions were observed without intervention. All of the 29 injuries associated with abnormal indices had positive arteriographic findings. The 4 lesions that were treated operatively were proximal and the remaining 25, all with distal penetration, were observed without observation. As compared to angiography, Doppler indices yielded the following results: 283 true-negative, 11 false-negative, 29 true-positive, and 0 false-positive, for a sensitivity of 72.5%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 96%. These data suggest that Doppler indices should be an integral part of the physical examination and can screen patients with proximal injuries for further studies such as duplex sonography or arteriography.

56 citations

Journal ArticleDOI
TL;DR: The experience supports serial physical examination as a highly effective method of "selective conservatism" of anterior abdominal stab wounds and mandatory laparotomy for evisceration needs further clarification.
Abstract: An analysis of 186 consecutive patients with anterior abdominal stab wounds in a 2-year period was carried out to assess the efficacy of serial physical examination as the determining factor for the need for laparotomy. Of 106 patients managed by clinical evaluation, the incidence of negative laparotomy was 0.9% and three patients (2.7%) had an "unnecessary" celiotomy. There were no missed injuries or delayed detection of intraperitoneal visceral trauma. The incidence of negative laparotomy among patients subjected to wound exploration +/- peritoneal lavage (n = 41) was 2.4%, and 39 patients had mandatory laparotomy for evisceration, with a negative celiotomy rate of 20.5%. Our experience supports serial physical examination as a highly effective method of "selective conservatism" of anterior abdominal stab wounds. Mandatory laparotomy for evisceration needs further clarification.

34 citations

Journal ArticleDOI
TL;DR: Assessment of the ability of AgNF-coated PTFE grafts to sterilize perigraft tissue after mixed bacterial contamination and the relative retention of the drug on the graft after subjecting it to the biological environment for 3 weeks and antibacterial activity against coagulase-positive Staphylococcus aureus and Escherichia coli were determined determined.

26 citations

Journal ArticleDOI
TL;DR: Laroscopy is a useful modality in the evaluation of hemodynamically stable patients with abdominal missile wounds and was helpful in determining the need for laparotomy vs thoracotomy in lower chest wounds.
Abstract: The role of laparoscopy in the selective management of gunshot wounds (GSW) of the abdomen was prospectively investigated in 38 patients. All the patients were hemodynamically stable and had equivocal evidence of intraabdominal penetration. Laparoscopy was performed in the operating room under anesthesia. The site of penetration was in the thoracoabdominal area in 13, epigastrium in 7, and lower quadrants in 18. Twenty-three (60.5%) had nonpenetration on laparoscopy and a laparotomy was avoided. The remaining patients had injuries to the liver (4 patients), spleen (two patients), diaphragm (3 patients), hemoperitoneum or retroperitoneal hematoma (6 patients), and hollow viscus injuries (5 patients). Laparoscopy was also helpful in determining the need for laparotomy vs thoracotomy in lower chest wounds. The negative laparoscopy group (no penetration) had a significantly lower hospital stay compared to hemodynamically stable patients who had negative laparotomy without laparoscopy for nonpenetrating GSW. There were no complications related to laparoscopy. Laparoscopy is a useful modality in the evaluation of hemodynamically stable patients with abdominal missile wounds.

22 citations


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Journal ArticleDOI
TL;DR: These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.
Abstract: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.

1,352 citations

01 Jan 2006
TL;DR: State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion and recommended that these definitions be used for future clinical and basic science research.
Abstract: ObjectiveIntra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another.DesignAn international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes.MethodsPrior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS).ResultsIAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient.ConclusionsState-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.

1,192 citations

Journal ArticleDOI
TL;DR: These updated guideline recommendations reflect a consensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as being important to the relevant patient population.
Abstract: Keeping pace with the stream of new data and evolving evidence on which guideline recommendations are based is an ongoing challenge to timely development of clinical practice guidelines. In an effort to respond promptly to new evidence, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines (Task Force) has created a “focused update” process to revise the existing guideline recommendations that are affected by the evolving data or opinion. New evidence is reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence is reviewed at least twice a year, and updates are initiated on an as-needed basis and completed as quickly as possible while maintaining the rigorous methodology that the ACCF and AHA have developed during their partnership of >20 years. These updated guideline recommendations reflect a consensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as being important to the relevant patient population, as well …

741 citations

Journal ArticleDOI
TL;DR: The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabDominal hypertension during the intensive care unit stay was an independent outcome predictor.
Abstract: Objective: Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. Design: Multiple-center, prospective epidemiologic study. Setting: Fourteen intensive care units in six countries. Patients: A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period. Interventions: None. Measurements and Main Results: Intraabdominal pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and intraabdominal pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean intraabdominal pressure on admission than survivors: 11.4 4.8 vs. 9.5 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01‐1.06; p .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05‐1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24‐5.16; p .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06‐5.8; p .04). The occurrence of intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12‐3.06; p .01). Patients with intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without intraabdominal hypertension. Conclusions: Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor. (Crit Care Med 2005; 33:315‐322)

632 citations

Journal ArticleDOI
TL;DR: Although a quite high prevalence of intra-abdominal hypertension was found, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured.
Abstract: Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries None Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia We enrolled 97 patients, mean age 64±15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 65±40 Mean IAP was 98±47 mmHg The prevalence of IAH (defined as IAP 12 mmHg or more) was 505 and 82% had abdominal compartment syndrome (defined as IAP 20 mmHg or more) The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured

526 citations