American journal of surgery
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Patients with sepsis often manifest disorientation, somnolence, asterixis and coma, symptoms also seen in portasystemic encephalopathy. Altered plasma concentrations of the neutral amino acids and in creased blood-brain transport of these acids may play a role in portasystemic encephalopathy. Plasma amino acids and blood-brain barrier transport of neutral amino acids were investigated in a rat model of abdominal sepsis, cecal ligation and puncture. ⋯ The brain uptake of several neutral amino acids was increased in the septic rats, while the uptake of lysine, a basic amino acid, was normal. In the brain capillaries isolated from septic rats, tyrosine and leucine transport was also greater than in sham-operated animals. Elevated neutral amino acids may play a role in the encephalopathy encountered in septic patients similar to its role in patients with portasystemic encephalopathy, as similar mechanisms appear to be operating.
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A 4 year experience with 245 patients with isolated lower thoracic or anterior abdominal gunshot wounds was reviewed. Twenty-three (16 percent) of the 144 abdominal injuries were clinically superficial and all were managed successfully nonoperatively. Of the remaining 121 patients, 115 were confirmed to have peritoneal violation at laparotomy and 111 (96 percent) of these had significant visceral injuries. ⋯ Twenty-six (17 percent) of the 156 patients with intraperitoneal trauma had unimpressive physical signs on admission. these findings support a policy of routine exploration for gunshot wounds violating the peritoneum. When depth of penetration is uncertain, diagnostic peritoneal lavage should be used. Only those patients with unequivocally superficial injuries warrant observation.
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The records of 84 patients in whom 98 Hickman-Broviac catheters were inserted were reviewed. The most common indication for catheter insertion was for administration of parenteral nutrition. Forty-four patients (52 percent) had catheters inserted for chemotherapy or combined chemotherapy and parenteranal nutrition. ⋯ The catheter-related sepsis rate was 8/6,308 catheter-days. These rates compare favorably with those reported by other investigators. Any patient with potential vascular access difficulty or obliterated or thrombosed veins who requires parenteral medication should be considered a candidate for insertion of a Hickman or Broviac catheter.
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A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. ⋯ The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.
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Randomized Controlled Trial Comparative Study Clinical Trial
Postoperative intermittent positive pressure breathing versus physiotherapy.
Seventeen patients admitted to the hospital to undergo elective upper abdominal surgery were randomly assigned to one of the two treatment groups: intermittent positive pressure breathing or physiotherapy. Postoperative pulmonary care in the two groups differed only with regard to administration of intermittent positive pressure breathing and chest physical therapy. Prospective evaluation included clinical examination, whole body plethysmography and determination of arterial blood gases preoperatively and on the 3rd postoperative day. ⋯ Although not statistically significant, the postoperative decrease in paitial arterial oxygen pressure was more pronounced in the physiotherapy group. Neither of the two therapeutic modalities is more effective than the other in preventing postoperative pulmonary complications. Considering the potential hazards, chest physical therapy is clearly the preferred treatment.