The American surgeon
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The American surgeon · May 2005
Comparative StudyInitial chest tube management after pulmonary resection.
Tube thoracostomy management with suction or water seal after anatomical pulmonary resection remains somewhat controversial. Initial chest tube management may influence the duration of pleural fluid drainage, duration of tube thoracostomy, and/or hospital length of stay following pulmonary resection. We hypothesized that initial chest tube management with water seal decreases time for chest tube removal and decreases time of hospital stay. ⋯ In the air leak group (n = 31), 7 (23%) patients were managed with water seal and 24 (77%) patients with suction. Both duration of chest tube (P = 0.001) and length of hospital stay (P < 0.05) were significantly lower in the water seal group. In patients without air leak, chest tubes should be managed with water seal following anatomical pulmonary resection, resulting in significantly shorter chest tube duration and hospital length of stay.
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Retroperitoneal bleeding is one of the most serious, potentially lethal complications of anticoagulation therapy. Although well documented in fully heparinized and coumadinized patients, there are only few reports of life-threatening hemorrhages in low-molecular-weight heparin (LMWH)-treated patients. We present a case of almost fatal spontaneous retroperitoneal bleeding in a 71-year-old woman with pneumonia and acute coronary syndrome. ⋯ It appears that those at highest risk receive doses approaching 1 mg/kg subcutaneously every 12 hours, have renal impairment, are of advanced age, and receive concomitant medications that can affect hemostasis. On average, a retroperitoneal hematoma occurs within 5 days of therapy with enoxaparin. In high-risk patients, enoxaparin activity (anti-factor Xa) should be carefully monitored.
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The American surgeon · May 2005
Assessment of nonoperative management of blunt spleen and liver trauma.
An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18-54), and 49 older adults (> or = 55). Nineteen patients who failed resuscitations died within 0-60 minutes of arrival and were excluded from treatment analysis. ⋯ Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.
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The American surgeon · May 2005
Case ReportsA Jehovah's Witness with complex abdominal trauma and coagulopathy: use of factor VII and a review of the literature.
Management of acute bleeding in patients who are Jehovah's Witnesses remains a challenge. Clearly, the most important concept is meticulous and early hemostasis to minimize ongoing blood loss. This is generally followed by supportive measures. ⋯ In this case, we believe the product was life-saving. Most importantly, there were no religious objections to its use. In appropriate patients, when surgical bleeding is controlled and there is still evidence of dilutional coagulopathy, factor VIIa may have a real role in patients, particularly those who are Jehovah's Witnesses.
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The American surgeon · Apr 2005
Case ReportsManagement of subclavian and axillary artery injuries: spanning the range of current therapy.
Injuries of the subclavian and proximal axillary arteries are potentially devastating but account for a minority of vascular injuries presenting to trauma centers in the United States. We have reviewed our recent experience with management of subclavian and axillary artery injuries in a state-designated level 1 academic trauma center and report four cases that illustrate the typical arterial injury patterns and the entire therapeutic armamentarium in its current iteration. Subclavian and proximal axillary artery injuries present as interesting surgical problems. ⋯ Consideration should always be given to the least invasive treatment options in stable patients. Awareness of multiple therapeutic modalities and indications for each should be an integral part of every surgeon's armamentarium. As with all vascular intervention, eventual failure is the rule rather than the exception; therefore, plans for longitudinal surveillance should be made independent of the technique used to treat the injury.