American journal of surgery
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Since the role of a hiatal hernia in the pathophysiology of gastroesophageal reflux disease (GERD) has not been fully elucidated, we studied the effects of hiatal hernias on the function of the lower esophageal sphincter (LES) and esophageal acid clearance. ⋯ Among patients with proven GERD, those with a small hiatal hernia and those with no hiatal hernia had similar abnormalities of LES function and acid clearance. In patients with larger hiatal hernias, however, the LES was shorter and weaker, the amount of reflux was greater, and acid clearance was less efficient. Consequently, the degree of esophagitis was worse in the presence of a large hiatal hernia.
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Unplanned extubations are common, but can be life-threatening. ⋯ Our data support the use of water resistant tape to secure endotracheal tubes and the routine use of hand restraints.
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Late acute respiratory distress syndrome (ARDS), characterized by progressive pulmonary interstitial fibroproliferation, is associated with mortality > 80%. Although previous large prospective trials failed to show a benefit of steroids in early ARDS, recent small reports describe improved survival in patients with late ARDS. Recognizing the pathogenetic differences between early and late ARDS, we employed steroid therapy in patients with refractory late ARDS. ⋯ Steroid therapy appears to be effective in patients with refractory late ARDS. Prospective trials are needed to define the indications, timing of intervention, dose and duration, and precautions of steroid therapy.
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Medical practice guidelines have been promoted as a way to improve the cost-effectiveness of medical care. Algorithms for the transfusion of red blood cells, plasma, and platelets may be especially useful in the surgical setting if they incorporate point-of-care information that is both physiologic and patient-specific for transfusion decision making. Therefore, the goals of guidelines for surgical blood management should be twofold. They should (1) acknowledge patient-specific variability while addressing physician- and institution-dependent variables; and (2) improve blood component management by developing more physiologic clinical indicators of the need for allogeneic red blood cell transfusion.