The Annals of thoracic surgery
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Thoracic surgeons have recently pursued innovative techniques that can help minimize postoperative pain. These have taken two basic directions. The first consists of a modification of the operative procedure itself, such that the surgical insult and hence the resulting pain are minimized. ⋯ Many authors have advocated the induction of spinal analgesia after thoracotomy, using either epidural opioids or local anesthesia, or both. Patient-controlled analgesia and multiple intercostal nerve blocks are other methods for managing postthoracotomy pain. The potential benefits conferred by aggressive pain control after thoracotomy are enormous for the patients, the surgeons, and the entire health-care system.
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Comparative Study
Absent diastolic cerebral blood flow velocity after circulatory arrest but not after low flow in infants.
It is controversial whether profound hypothermia (15 degrees C) provides adequate cerebral protection during a limited period of total circulatory arrest during pediatric cardiac surgery. In the present study, transcranial Doppler echography was used to monitor the blood flow velocity (BFV) pattern in the middle cerebral artery (MCA). The purpose of the study was to investigate the influence of a period of circulatory arrest on MCA BFV, as judged from the reperfusion flow velocity pattern. ⋯ Diastolic BFV normalized 54 to 328 minutes after the arrest in the arrest group. Circulatory arrest during profound hypothermia is followed by a period of low cerebral perfusion, whereby time-averaged MCA BFV is decreased and MCA BFV is absent during diastole. We speculate that this can be explained by an increase in intracranial pressure after brain edema.
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Described is an unusual injury, arising from a motorized vehicle accident, in which a detached fractured rib from a flail chest caused lung perforation and hemopericardium. The full diagnosis was only appreciated on computed tomography. Therefore, thoracotomy averted potential disaster.
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Case Reports
Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries.
Patients with penetrating pericardial trauma whose vital signs stabilize after fluid administration may present a therapeutic dilemma. Two-dimensional echocardiography has emerged as a diagnostic technique to help determine whether surgical intervention may be required. We present 5 patients with penetrating pericardial trauma whose vital signs stabilized after fluid administration and who had minimal clinical findings. ⋯ All 5 underwent surgical exploration and had major intrapericardial injuries. We conclude that a normal echocardiographic study does not rule out major intrapericardial injury in patients with penetrating chest trauma. Furthermore, small areas of effusion seen on echocardiography in these patients represent indications for surgical exploration.
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Carinoplasty was performed in 42 patients: 7 with wedge pneumonectomy, 15 with sleeve pneumonectomy, 14 with one-stoma-type carinal reconstruction, 5 with montage-type carinal reconstruction, and 1 other. Diagnoses in the 42 patients consisted of lung cancer in 31 (73.8%), tuberculous stenosis in 10 (23.8%), and tracheobronchial injury in 1 (2.4%). ⋯ Left wedge or sleeve pneumonectomy, without right thoracotomy, could be done by midline sternotomy and left thoracotomy but with limited tracheal resection. Left one-stoma-type carinoplasty was undertaken, sacrificing one lobe, as an alternative to pneumonectomy, where an approach drawing the carina down to an aortopulmonary window was considered to be preferable to the drawing-up approach.