Journal of the American College of Surgeons
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Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk. ⋯ These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients.
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The assembly of the International Space Station in a low earth orbit will soon become a reality. The National Aeronautics and Space Administration envisions inhabited lunar bases and staffed missions to Mars in the future. Increasing numbers of astronauts, construction of high-mass structures, increased extra-vehicular activity, and prolonged if not prohibitive medical evacuation times to earth underscore the need to address requirements for trauma care in nonterrestrial environments. ⋯ With appropriate instrumentation and personnel, the majority of resuscitative and surgical interventions required to stabilize a severely injured astronaut are feasible in a microgravity environment. Onboard limitations in mass, volume, and power that are ever present in any spacecraft design will limit the realistic capabilities of the medical system. Standard proved and tested trauma and operative management protocols will constitute the basis for extra-terrestrial care. Surgeons should familiarize themselves with the microgravity environment and remain active in planning trauma care for the continued exploration of space.
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Juxtahepatic inferior vena cava injuries are often lethal. Various operative strategies have been used to improve outcome, but the mortality rate reported in the literature is 80 percent or more. The atriocaval shunt has been advocated for isolation of bleeding retrohepatic vena cava, but recent reports suggest that mortality might be even higher in patients selected for shunting, perhaps owing to ongoing hemorrhage because of indecision and delay prior to insertion, or to technical difficulty with insertion. A series of patients with juxtahepatic inferior vena cava injuries treated successfully with total vascular isolation and occlusion were studied. ⋯ Total vascular occlusion with selective use of aortic cross-clamping yielded 70 percent survival in an injury that historically has been associated with survival of 20 percent or less. Minimization of visceral ischemia is accomplished by occluding the aorta only after complete isolation of the inferior vena cava.
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Jehovah's Witnesses can create perplexing treatment problems by their refusal of blood transfusions. This dilemma is especially difficult for the trauma surgeon faced with critically low hemoglobin levels or life-threatening blood loss in an injured Jehovah's Witness. ⋯ Documentation of religious status and beliefs about blood transfusion, as well as knowledge of special treatment options available for anemic Jehovah's Witnesses, is necessary to provide quality care to this unique trauma population.
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Conventional imaging techniques do not routinely detect endocrine gastroenteropancreatic tumors preoperatively. The purpose of this study was to determine whether the new technique of somatostatin-receptor scintigraphy would improve the detection rate of these tumors before initial treatment. ⋯ In patients with insulinomas, somatostatin-receptor scintigraphy is not indicated because none of the six tumors was imaged. This holds true for nonfunctional pancreatic endocrine tumors and their metastases because no advantage for somatostatin-receptor scintigraphy was found over computed tomography and ultrasonography. In contrast, somatostatin-receptor scintigraphy is superior to computed tomography and ultrasonography for determining the extent of the disease in patients with gastrinomas or carcinoids. The problem of detecting primary tumors in these patients is not solved by somatostatin-receptor scintigraphy.