American journal of surgery
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Clinical Trial
Stump pressure, electroencephalographic changes, and the contralateral carotid artery: another look at selective shunting.
Selective shunting during carotid endarterectomy is associated with the lowest operative stroke rate; therefore, patient selection for carotid shunting is critical. Electroencephalography (EEG) can detect ischemic brain cell dysfunction before irreversible injury. The carotid stump back pressure (CSP) has been inconsistent in determining the need for shunting, and contralateral carotid disease has had a variable impact. The purpose of this study was to evaluate CSP and operative EEG changes, and to determine the effect of contralateral carotid artery disease on determining the need for carotid shunting. ⋯ A CSP of < 50 mm Hg achieved a sensitivity of 89% in patients who developed ischemic EEG changes during carotid clamping, and a pressure > 50 mm Hg had a negative predictive value of 96%. However, a CSP of < 50 mm Hg had a positive predictive value of only 36%. Neither the addition of the status of the contralateral carotid artery or the calculation of the CSP/MAP improved the sensitivity of the CSP in determining the need for shunting. Operative EEG monitoring remains the most sensitive guide to carotid shunting in patients undergoing carotid endarterectomy under general anesthesia.
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Multicenter Study
A prospective multicenter evaluation of preoperative hemostatic screening tests. The French Associations for Surgical Research.
Several retrospective and four prospective reports have questioned the need for routine preoperative hemostatic screening tests (PHST) in general surgery. ⋯ Our results suggest that PHST should not be performed routinely, but only in patients with abnormal clinical data. Such a policy necessitates a thorough history--including answers to a specific questionnaire like those used in prospective studies--and a rigorous, well-conducted physical examination.
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Severe blunt trauma to the torso can result in diaphragmatic disruption. Prompt recognition of this potentially life-threatening injury is difficult when the initial chest roentgenogram is unrevealing and immediate thoracotomy or celiotomy is not performed. This retrospective study was undertaken to: (1) determine the incidence of missed diaphragmatic injuries on initial evaluation; (2) identify factors contributing to diagnostic delays; and (3) formulate a diagnostic approach that reliably detects diaphragmatic rupture following blunt trauma. ⋯ Blunt diaphragmatic injuries are easily missed in the absence of other indications for immediate surgery, since radiologic abnormalities of the diaphragm--particularly those involving the right hemidiaphragm--are often interpreted as thoracic trauma. In this setting, a high index of suspicion coupled with selective use of radionuclide scanning, ultrasound, and CT or magnetic resonance imaging is necessary for early detection of this uncommon injury.
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Comparative Study Clinical Trial
Short-stay carotid endarterectomy is safe and cost-effective.
Carotid endarterectomy (CEA) is conventionally performed following a contrast arteriogram, under general anesthesia, and with postoperative admission to an intensive care unit (ICU). We investigated whether any of these traditional adjuncts to CEA is necessary. ⋯ This pilot study suggests that CEA can be safely performed without routine preoperative carotid arteriography; that routine ICU admission is unnecessary for the majority of cases; and that elimination of routine arteriography and ICU admission can reduce hospital charges for CEA by nearly one half.
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The purpose of this study was to identify factors associated with unfavorable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from aggressive resuscitative efforts. ⋯ We recommend that all patients suspected of having cardiac stab wounds be fully resuscitated and undergo thoracotomy, as significant survival can be achieved and death is not always the outcome.