RESUMEN
A common complication of cardiopulmonary bypass (CPB) surgery is post-operative bleeding that may result in re-exploration. Bleeding is often due to the coagulopathy that follows the procedure, rather than the surgical technique. Etiology of this coagulopathy has been attributed to platelet dysfunction. We reviewed the medical records of 592 patients who had undergone CPB surgery between 1992 and 1994. Bleeding times (both pre and post operative) in treated (those who received platelets) and untreated patients were recorded where available. Both groups showed a rise in bleeding time (295 sec versus 192 sec, respectively, p<0.001). However, the treated group had a greater increase in the bleeding time compared to the un-treated (p<0.05). The result was the same when we compared 2 subgroups with similar pre-operative bleeding times. When the treated group was subdivided into those who received >10 units of platelets and those who received <10 units, there was no significant difference in the increase in their bleeding times (p>0.1). Administration of platelets did not improve bleeding time abnormalities induced by CPB. Both treated and untreated groups had a significant rise in their bleeding times, irrespective of the amount of platelets administered. The mean rise in the bleeding time in patients who bled significantly to require surgical re-exploration (but did not receive platelets) was not significantly different from those who received platelets. These observations suggest that the administration of platelets has no clinical benefit in improving bleeding time following CPB.
Asunto(s)
Puente Cardiopulmonar/efectos adversos , Transfusión de Plaquetas , Hemorragia Posoperatoria/terapia , Tiempo de Sangría , Puente de Arteria Coronaria , Interpretación Estadística de Datos , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective. METHODS: For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated. RESULTS: There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery. CONCLUSION: Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.
Asunto(s)
Anestesia Local/métodos , Colecistectomía Laparoscópica/economía , Colecistectomía Laparoscópica/métodos , Colelitiasis/cirugía , Dolor/prevención & control , Atención Perioperativa , Músculos Abdominales/cirugía , Bupivacaína/administración & dosificación , Bupivacaína/uso terapéutico , Colelitiasis/economía , Control de Costos , Costos de la Atención en Salud , Humanos , Meperidina/administración & dosificación , Meperidina/uso terapéutico , Dolor Postoperatorio/prevención & control , Prometazina/administración & dosificación , Prometazina/uso terapéutico , Instrumentos Quirúrgicos , Resultado del TratamientoRESUMEN
Reperfusion is known to cause tissue damage in ischemic pulmonary tissue. We investigated the time frame of this occurrence by examining electron microscopic changes in lung tissue. Isolated, perfused, and ventilated rabbit lungs (and heart) were placed en bloc in a 37 degrees C chamber and perfused through the pulmonary artery at 15 mm Hg pressure with oxygenated Krebs-Henseleit buffer, pH 7.4, 70 ml min(-1), for 20 min and the pulmonary pump and ventilator were stopped. The resultant ischemic state was maintained for 2 h, and reperfusion resumed with the same buffer. The lungs of four groups of rabbits (n = 5 per group) were each subjected to 30 min, 1, 2, and 4 h of reperfusion respectively. Upon completion, lungs were biopsied for scanning electron microscopy. Ischemic damage including the loss of lung architecture, and edema were seen. Reperfusion restored some of the tissue anatomy and the return to normalcy increased up to 1 h of reperfusion after which the damage increased with time. Results suggest that damage due to ischemia alone may be reversible. Initial recovery is due to the re-establishment of circulation. However, with time, the damage seen may be due to free radicals and with 4 h of reperfusion, cell death may have occurred.
Asunto(s)
Isquemia/patología , Pulmón/irrigación sanguínea , Pulmón/ultraestructura , Daño por Reperfusión/patología , Animales , Microscopía Electrónica de Rastreo , Conejos , ReperfusiónRESUMEN
OBJECTIVE: To investigate the relationship of mortality to early resuscitation using two levels of oxygen delivery (DO2) in critically ill surgical patients > or =50 yrs of age who were stratified into groups: age < or =75 yrs (age 50 to 75 yrs group); and age >75 yrs (age >75 yrs group). DESIGN: A prospective, randomized trial, continued from a previous project. SETTING: Surgical intensive care unit, university affiliated. PATIENTS: Consecutive patients, >50 yrs of age, unable to generate a DO2 of > or =600 mL/min/m2 with fluid resuscitation alone, with a diagnosis of systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, and/or acute respiratory distress syndrome. INTERVENTIONS: During the first 24 hrs of resuscitation, patients were randomized to receive fluids, blood transfusions, and vasoactive agents in order to achieve DO2 treatment goals of > or =600 mL/ min/m2 in the protocol group and 450 to 550 mL/min/m2 in the control group. MEASUREMENTS AND MAIN RESULTS: One hundred five patients completed the study. In patients aged 50 to 75 yrs, the mortality rate was 21% (9/43) in the protocol group and 52% (12/23) in the control group (p=.01, 95% confidence interval of -58% to -4%). In patients >75 yrs of age, the mortality rate was 57% (12/21) in the protocol group and 61% (11/18) in the control group. Oxygen extraction ratios (O2ER) and oxygen consumption values were significantly (p=.02) lower in the age >75 yrs group compared with the age 50 to 75 yrs group. CONCLUSIONS: Patients 50 to 75 yrs of age receiving a DO2 of > or =600 mL/min/m2 demonstrated a statistically significant (p=.01) improved survival rate over patients in the control group. Patients >75 yrs of age demonstrated no benefit from attempts to increase DO2 to >600 mL/min/m2, and they may have been overtreated as reflected by the lower O2ER values in this age group. Treating to an O2ER that reflects a balance between oxygen consumption and DO2 may be an alternative goal that allows individual titration.
Asunto(s)
Cuidados Críticos/métodos , Oxígeno/administración & dosificación , Síndrome de Dificultad Respiratoria/terapia , Sepsis/mortalidad , Sepsis/terapia , APACHE , Anciano , Anciano de 80 o más Años , Envejecimiento/metabolismo , Transfusión Sanguínea , Femenino , Fluidoterapia , Humanos , Masculino , Persona de Mediana Edad , Consumo de Oxígeno , Estudios Prospectivos , Resucitación/métodos , Sepsis/metabolismo , Tasa de SupervivenciaRESUMEN
OBJECTIVE: To compare pulmonary function and peripheral organ blood flow in septic pigs receiving high-volume fluid resuscitation or standard-volume fluid resuscitation with similar goals in oxygen delivery. DESIGN: A prospective study comparing 2 groups of septic pigs. SETTING: A university animal research laboratory. SUBJECTS: Eleven septic pigs. INTERVENTIONS: Basal oxygen delivery was increased from 450 to 550 mL/min to at least 600 mL/min by the sixth hour and maintained for 24 hours. From a baseline pulmonary artery occlusion pressure (PAOP) measurement of approximately 6 mm Hg, the high-volume group (n = 5) was treated until a PAOP measurement of 12 mm Hg was reached and the standard-volume group (n = 6) was treated until a PAOP measurement of 8 mm Hg was reached. Blood transfusions and inotropic agents were added as necessary to reach the oxygen delivery goal. RESULTS: The high-volume group had a significantly greater positive fluid balance, greater weight gain, and a higher PAOP but similar intrapulmonary shunt and extravascular lung water as compared with the standard-volume group. CONCLUSION: Resuscitation with large volumes of fluid in early sepsis with a physiological goal of a higher PAOP to augment oxygen delivery did not cause increased pulmonary edema and oxygenation deficit compared with maintenance of lower cardiac filling pressures.
Asunto(s)
Fluidoterapia/métodos , Pulmón/fisiopatología , Sepsis/terapia , Animales , Sepsis/fisiopatología , PorcinosRESUMEN
BACKGROUND: Because hemodynamic instability may have several causes in critically ill patients, adrenal insufficiency may not be readily diagnosed. Eosinophilia has been described in patients with chronic adrenal insufficiency but not in critically ill patients. The goal of this study was to determine whether eosinophilia could serve as a marker of adrenal insufficiency in critically ill patients. STUDY DESIGN: During a 1-year period, all surgical patients admitted to the surgical intensive care unit with an eosinophil count greater than 3 percent were prospectively studied. To diagnose adrenal insufficiency, the synthetic corticotropin (cosyntropin) stimulation test was used. RESULTS: Eosinophilia was diagnosed in 31 patients, 7 (23 percent) of whom had adrenal insufficiency. The mean time interval to diagnosis was 13.7 days (range, 4 to 39 days). In 82 percent of the patients treated with hydrocortisone, a response was evidenced within 24 hours of treatment by a decrease in the required inotropic support by more than 50 percent, an increase in the mean arterial blood pressure of more than 25 percent, or both. CONCLUSIONS: New-onset eosinophilia may be a useful marker for adrenal insufficiency. Prompt testing and diagnosis may avoid the occurrence of a treatable, life-threatening condition.
Asunto(s)
Insuficiencia Suprarrenal/diagnóstico , Eosinofilia/diagnóstico , Eosinófilos/patología , Pruebas de Función de la Corteza Suprarrenal , Insuficiencia Suprarrenal/sangre , Insuficiencia Suprarrenal/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Antiinflamatorios/uso terapéutico , Biomarcadores , Presión Sanguínea/efectos de los fármacos , Cuidados Críticos , Femenino , Humanos , Hidrocortisona/sangre , Hidrocortisona/uso terapéutico , Unidades de Cuidados Intensivos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
For direct laparoscopic entry using a sharp and dull trocar technique, the sharp trocar is inserted with a twisting motion under constant pressure, then replaced with a dull trocar when a slight loss of resistance is felt. A slow, gradual entry into the peritoneal cavity is accomplished by twisting the dull trocar under constant pressure. Previous major abdominal or pelvic surgery is not a contraindication to this procedure, and use of these trocars, which can be resterilized for every use, may reduce surgical costs by decreasing the need for disposable trocars. This technique has been used in 1655 patients without complication or failure.
Asunto(s)
Laparoscopía/métodos , Humanos , LaparoscopiosRESUMEN
STUDY OBJECTIVES: To determine the efficacy of an attachable subcutaneous silver-impregnated cuff in preventing local central venous catheter (CVC)-related infection and catheter-related sepsis in critically ill surgical patients. DESIGN: A prospective analysis of the use of an attachable subcutaneous silver-impregnated cuff compared with a control group in two consecutive time periods. SETTING: Two surgical ICUs at the Queen's Medical Center at the University of Hawaii Surgical Residency Program, Honolulu. PATIENTS: All surgical ICU patients requiring insertion of central catheters. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULT: Two hundred thirty-five CVCs in 154 patients were prospectively evaluated. Silver-impregnated cuffs were used in the first 100 catheters, but none were used in the remaining 135 catheters. The incidence of catheter-related infection in both groups was 15% and 20%, respectively, not statistically significant. Catheter-related sepsis was 3% in both groups. CONCLUSIONS: The use of an attachable subcutaneous silver-impregnated cuff failed to decrease the incidence of CVC-related infection and sepsis.
Asunto(s)
Infecciones Bacterianas/prevención & control , Cateterismo Venoso Central/instrumentación , Plata , APACHE , Adulto , Cateterismo Venoso Central/efectos adversos , Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/instrumentación , Cuidados Críticos , Enfermedad Crítica , Diseño de Equipo , Hawaii , Humanos , Incidencia , Persona de Mediana Edad , Estudios Prospectivos , Propiedades de Superficie , Procedimientos Quirúrgicos OperativosRESUMEN
BACKGROUND: Thirty-five patients with an intracardiac myxoma underwent excision of the tumor in Hawaii between 1974 and 1993. PATIENTS AND METHODS: There were 28 female and 7 male patients in the group. Their ages ranged from 11 to 79 years (mean 48) with the majority (71%) between 30 and 60 years old. The patients' medical records were reviewed and special attention was paid to clinical presentation, methods of diagnosis, operative findings, and postoperative course. RESULTS: No ethnic predisposition was found. Forty-six percent of the presenting symptoms were cardiac (congestive heart failure 26%, palpitations 14%, and syncope 6%) while arterial embolization accounted for 11%. Diagnosis was made by angiography, echocardiography, or gated cardiac blood pool imaging. All were reliable, but two-dimensional (2-D) echocardiography was used most often, with no false-positive or false-negative results. There were 32 left atrial, 2 right atrial, and 1 biatrial myxomas. Limited septectomy was performed in most cases, but 9 patients (26%) required Dacron patch repair of the atrial septum. There was 1 death from a cerebrovascular accident the day after the removal of a left-sided atrial myxoma. Other patients had few minor postoperative complications. One patient presented with a recurrence 8 years after resection at another institution; no further recurrences were found. CONCLUSIONS: We conclude that due to the non-specific presentation of atrial myxoma, a high index of suspicion is needed. The diagnostic method of choice is 2-D echocardiography. Limited septectomy is a safe procedure, but close follow-up for at least 10 years may be needed to rule out recurrence.
Asunto(s)
Neoplasias Cardíacas/cirugía , Mixoma/cirugía , Adolescente , Adulto , Anciano , Angiografía , Niño , Ecocardiografía , Electrocardiografía , Femenino , Estudios de Seguimiento , Imagen de Acumulación Sanguínea de Compuerta , Hawaii , Atrios Cardíacos , Neoplasias Cardíacas/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Mixoma/diagnóstico , Examen Físico , Complicaciones Posoperatorias , Valor Predictivo de las Pruebas , PronósticoRESUMEN
This is a case of a dissecting cusp of a mitral porcine xenograft causing severe hemolytic anemia in the absence of valvular dysfunction and regurgitation. Six months after valve replacement, the patient had no evidence of hemolytic anemia. A cuspal dissection between the atrial and ventricular membranes was found on histologic evaluation.