Annals of surgery
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The etiology of the Klippel-Trenaunay syndrome (KTS) remains obscure. Although venous hypertension secondary to deep venous obstruction has been suggested as a cause, recent studies have demonstrated that most patients have unimpeded venous drainage. Calf blood flows have been measured in 33 patients with KTS using venous occlusion plethysmography. ⋯ Biopsies of subcutaneous veins demonstrate the histological features of a response to chronically raised flow. The authors suggest that KTS is caused by mesodermal abnormality during fetal development, leading to the maintenance of microscopic arteriovenous communications in the limb bud, as a result of which the triad of nevus, hypertrophy, and superficial varices is produced. Deep venous abnormalities occur pari passu with the triad and are not responsible for its development.
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The management of impaired respiratory gas exchange in patients with nonuniform posttraumatic and septic adult respiratory distress syndrome (ARDS) contains its own therapeutic paradox, since the need for volume-controlled ventilation and PEEP in the lung with the most reduced compliance increases pulmonary barotrauma to the better lung. A computer-based system has been developed by which respiratory pressure-flow-volume relations and gas exchange characteristics can be obtained and respiratory dynamic and static compliance curves computed and displayed for each lung, as a means of evaluating the effectiveness of ventilation therapy in ARDS. Using these techniques, eight patients with asymmetrical posttraumatic or septic ARDS, or both, have been managed using simultaneous independent lung ventilation (SILV). ⋯ Also, there was x-ray evidence of ARDS improvement in the poorer lung. While the ultimate outcome was largely dependent on the patient's injury and the adequacy of the septic host defense, by utilizing the SILV technique to match the quantitative aspects of respiratory dysfunction in each lung at specific times in the clinical course, it was possible to optimize gas exchange, to reduce barotrauma, and often to reverse apparently fixed ARDS changes. In some instances, this type of physiologically directed ventilatory therapy appeared to contribute to a successful recovery.
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The efficacy of supplemental fresh frozen plasma (FFP) therapy after massive packed red cell (PRBC) replacement for hemorrhagic shock was studied in 22 conditioned dogs. Ten dogs were randomized to received FFP, balanced electrolyte solution (BES), and PRBC, while 12 dogs received BES and PRBC. Coagulation factor activity for Factors I, II, V, VII and VIII, as well as antithrombin III (AT III), prothrombin time, partial thromboplastin time, and thrombin time, were measured at preshock, postshock, postresuscitation, and postshock day two. ⋯ The changes in factor activity from postresuscitation until day two reflected factor half life and molecular weight, independent of FFP therapy. These data show that prophylactic FFP therapy does not efficiently restore coagulation activity. Consequently, routine FFP therapy for its procoagulant effects after hemorrhagic shock should be abandoned pending controlled studies in man.
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Comparative Study
Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.
Fifty-six blunt multiple trauma patients (HTI-ISS 22-57) were studied for the effects of immediate versus delayed internal fixation of a femur or acetabular fracture on the pulmonary failure septic state. The pulmonary failure septic state may be defined as an alveolar arterial oxygen tension difference greater than 100, plus fever and leukocytosis. These patients were divided into four groups. ⋯ Thirty days of femur traction increased the duration of the pulmonary failure septic state relative to Group I by a factor of 3 to 5 for all criteria at a statistically significant level, while increasing fracture complications by a factor of 17, positive blood cultures by a factor of 74, and the use of narcotics by a factor of 2. Group IV, which had four out of seven immediate internal fixations, behaved similarly to Group II. Femoral shaft traction should be avoided in the blunt multiple trauma patients because it greatly increases the cost of care and the risk of multiple systems organ failure.(ABSTRACT TRUNCATED AT 400 WORDS)
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Sequential changes in circulating total protein and albumin masses after abdominal vascular surgery.
Sequential changes in total circulating protein (TCP) and total circulating albumin (TCA) masses after different blood replacement regimens were investigated in a prospective study involving 40 patients undergoing reconstructive abdominal aortic surgery. Group I (13 patients) had 80 gm of albumin during operation and 60 gm of albumin during the following 3 days. Blood loss was replaced milliliter for milliliter by whole blood. ⋯ In groups II and III, a significant decrease in TCP was followed by complete recovery of TCP. This also entailed a decrease in the TCA/TCP ratio, indicating an enhanced synthesis of acute-phase proteins. Based on these findings, a depression of globulin synthesis by supplemental albumin administration is proposed.