RESUMO
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.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Artéria Braquial/cirurgia , Procedimentos Endovasculares , Oclusão de Enxerto Vascular/cirurgia , Laparoscopia , Diálise Renal , Grampeamento Cirúrgico , Extremidade Superior/irrigação sanguínea , Artéria Braquial/diagnóstico por imagem , Artéria Braquial/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/instrumentação , Grampeadores Cirúrgicos , Grampeamento Cirúrgico/efeitos adversos , Grampeamento Cirúrgico/instrumentação , Resultado do Tratamento , Grau de Desobstrução VascularAssuntos
Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/etiologia , Artéria Femoral/lesões , Veia Femoral/lesões , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos por Arma de Fogo/cirurgia , Fístula Arteriovenosa/cirurgia , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Adulto JovemRESUMO
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.
Assuntos
Fraturas Ósseas/complicações , Fraturas Ósseas/mortalidade , Técnicas Hemostáticas , Ossos Pélvicos/lesões , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Adulto , Angiografia , Feminino , Fixação de Fratura/métodos , Fraturas Ósseas/terapia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Centros de Traumatologia , Resultado do TratamentoRESUMO
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.
Assuntos
Avaliação Geriátrica , Saúde do Idoso , Medição da Dor/tendências , Tratamento Farmacológico , Geriatria , Limiar da Dor , Farmacocinética , Técnicas PsicológicasRESUMO
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)