RESUMEN
Aneurysmal degeneration following long-term access is an important problem associated with an arteriovenous fistula (AVF) and can result in rupture, thrombosis, or the need for ligation. We describe five patients receiving hemodialysis through large degenerative brachiocephalic AVFs who underwent successful revision and avoided the need for a temporary dialysis catheter. A hybrid approach using an open surgical technique with both endovascular and laparoscopic tools provides an opportunity to maintain patency and restore function by combining modern surgical tools.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/efectos adversos , Arteria Braquial/cirugía , Procedimientos Endovasculares , Oclusión de Injerto Vascular/cirugía , Laparoscopía , Diálisis Renal , Grapado Quirúrgico , Extremidad Superior/irrigación sanguínea , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Laparoscopía/efectos adversos , Laparoscopía/instrumentación , Engrapadoras Quirúrgicas , Grapado Quirúrgico/efectos adversos , Grapado Quirúrgico/instrumentación , Resultado del Tratamiento , Grado de Desobstrucción VascularAsunto(s)
Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/etiología , Arteria Femoral/lesiones , Vena Femoral/lesiones , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/cirugía , Fístula Arteriovenosa/cirugía , Angiografía por Tomografía Computarizada , Humanos , Masculino , Adulto JovenRESUMEN
BACKGROUND: A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. METHODS: In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage. RESULTS: During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival. CONCLUSIONS: PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion. LEVEL OF EVIDENCE: Therapeutic study, level IV.
Asunto(s)
Fracturas Óseas/complicaciones , Fracturas Óseas/mortalidad , Técnicas Hemostáticas , Huesos Pélvicos/lesiones , Choque Hemorrágico/mortalidad , Choque Hemorrágico/terapia , Adulto , Angiografía , Femenino , Fijación de Fractura/métodos , Fracturas Óseas/terapia , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Centros Traumatológicos , Resultado del TratamientoRESUMEN
Persistent pain is prevalent in the elderly population, although it is not an inevitable part of aging. It is important to understand how to manage pain effectively in old age, particularly because an increasing number of individuals are becoming older, or living longer. Several problems, less common in younger adults, may complicate the treatment of pain. An accurate pain assessment is required for the most efficient strategy of pain treatment. Challenges to an effective pain assessment include: pain underreporting by patients, atypical manifestations of pain in elderly, age-associated pharmacodynamic and pharmacokinetic changes to specific drugs, other general age-related changes, and misconceptions about tolerance or addiction to opioids. However, physicians are able to provide geriatric patients with appropriate analgesia by using comprehensive assessment involving a multidisciplinary approach, and the appropriate use of various treatment modalities.
Asunto(s)
Evaluación Geriátrica , Salud del Anciano , Dimensión del Dolor/tendencias , Quimioterapia , Geriatría , Umbral del Dolor , Farmacocinética , Técnicas PsicológicasRESUMEN
Persistent pain is prevalent in the elderly population, although it is not an inevitable part of aging. It is important to understand how to manage pain effectively in old age, particularly because an increasing number of individuals are becoming older, or living longer. Several problems, less common in younger adults, may complicate the treatment of pain. An accurate pain assessment is required for the most efficient strategy of pain treatment. Challenges to an effective pain assessment include: pain underreporting by patients, atypical manifestations of pain in elderly, age-associated pharmacodynamic and pharmacokinetic changes to specific drugs, other general age-related changes, and misconceptions about tolerance or addiction to opioids. However, physicians are able to provide geriatric patients with appropriate analgesia by using comprehensive assessment involving a multidisciplinary approach, and the appropriate use of various treatment modalities.(AU)