The American surgeon
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The American surgeon · Sep 1995
Case ReportsCentral venous catheterization via persistent left superior vena cava.
We describe the problems of clinical assessment of subclavian catheter placement whose course was noted to be along the left lateral border of the heart, suggesting malposition. After the catheter's position in a persistent left superior vena cava was confirmed by blood gas analysis, lateral chest X-ray film, and venography, the catheter was used to provide total parenteral nutrition without complications. The evaluation and workup of seeming malposition of central venous catheters and the embryologic development of a left-sided vena cava are discussed.
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The American surgeon · Sep 1995
Randomized Controlled Trial Clinical TrialThe influence of anesthetic method on infrainguinal bypass graft patency: a closer look.
Although several studies have demonstrated a reduced incidence of postoperative deep venous thrombosis among patients who receive regional anesthesia, the influence of anesthetic method on early arterial bypass graft patency has not been well studied. The records of 78 consecutive patients undergoing elective femoro-popliteal (FP) or femoro-tibial (FT) bypass grafts, and who were randomized to receive general anesthesia and postoperative patient-controlled intravenous narcotic analgesia (GEN, n = 41), or epidural anesthesia and postoperative continuous epidural analgesia (EPI, n = 37), were retrospectively reviewed. The two groups were evenly matched with respect to demographic characteristics, risk factors, and vascular variables. ⋯ Graft occlusion occurred in 11 (17.1%) of the 64 limb salvage cases, including nine (27.3%) GEN and two (6.5%) EPI cases (P < 0.05), and in seven (12.7%) of 55 greater saphenous vein grafts, including six (22.2%) GEN and 1 (3.6%) EPI cases (P < 0.05). By multivariate analysis, FT grafts, preoperative plasminogen activator inhibitor-1 (PAI-1) levels, and GEN were predictive of early graft occlusion (P < 0.05). Furthermore, the levels of circulating PAI-1 were higher 24 hours postoperatively among patients in the GEN group (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Nonoperative management of stab wounds of the abdomen is currently practiced in many trauma centers; this report examines the role of expectant management of gunshot wounds to the abdomen in a select patient population. Patients presenting to a single trauma service from 5/91 to 1/94 at Detroit Receiving Hospital with a gunshot wound (GSW) to the abdomen fulfilling the following criteria were observed: 1) single GSW to the right upper quadrant, 2) stable vital signs, 3) reliable examination with minimal abdominal tenderness and available team/operating room, and 4) minimal or no abdominal tenderness. ⋯ The role of expectant therapy of abdominal gunshot wounds is cautiously advanced. With appropriate criteria, this technique appears safe and efficacious.
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Poor outcomes following transcranial gunshot wounds (TC-GSW) and the perception of significant financial loss have led some institutions to adopt a fatalistic attitude towards these patients. This study was undertaken to define those factors predictive of mortality following TC-GSW as well as to determine the costs and benefits associated with providing care to these individuals. We reviewed the medical records of 57 TC-GSW patients seen at our Level I Trauma Center between January 1990 and December 1992. ⋯ Nonsurvivors who became organ donors were clinically and demographically indistinguishable from those in whom organs/tissues could not be retrieved. Despite the poor outcome following TC-GSW, vigorous resuscitation and stabilization is justified in all patients, in that nearly one half of nonsurvivors will become organ and/or tissue donors. Concerns regarding excessive monetary looses by treating facilities are unfounded.
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The American surgeon · Aug 1995
Central venous oxygen saturation, arterial base deficit, and lactate concentration in trauma patients.
Our object was to explore the usefulness of central venous oxygen saturation, arterial base deficit, and lactate concentration in the evaluation of trauma patients. In busy urban trauma centers, limited operating room availability may necessitate that certain hemodynamically stable patients experience some delay between diagnosis of injury and surgery. Because hemodynamic compromise may occur before operation is undertaken, some means of identifying those patients who have the most severe injuries or who are at greatest risk for hemodynamic instability would be useful. ⋯ ScvO2 did not significantly correlate with any of the parameters of blood loss and severity of injury examined. However, both base deficit and lactate concentration correlated with transfusion requirements; in addition, base deficit correlated with trauma score, and lactate correlated with peritoneal shed blood volume. Our data suggest that, after resuscitation, arterial base deficit and lactate concentration may be better indicators of blood loss than is ScvO2.