Arch Surg Chicago
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To define cerebral perfusion pressure during carotid clamping, carotid back and jugular venous pressures were measured in 100 consecutive carotid endarterectomies in 92 patients. The mean +/- 1 SD was 40.5 +/- 16.0 mm Hg for carotid back pressure, 11.8 +/- 4.8 mm Hg for jugular venous pressure, and 28.7 15.4 mm Hg for cerebral perfusion pressure. A number of variables affect jugular venous pressure, including jugular vein compression, patient position, and the anesthetic type. ⋯ The jugular venous pressure must also be measured, and the cerebral perfusion pressure must be calculated. Based on established safe levels of cerebral blood flow, it is probable that patients who undergo a carotid endarterectomy with a cerebral perfusion pressure of less than 18 mm Hg have cerebral ischemia and may require a shunt. Selective shunting, based on the cerebral perfusion pressure, gave a 1% mortality and 2% permanent neurologic deficit in this series.
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At least three myopathies have been associated with malignant hyperthemia (MH). The clinical manifestations of MH are variable and depend on the nature of the underlying myopathy and the anesthetic agents administered. Unless muscle relaxants are used, fever and muscle rigidity may be delayed at onset. ⋯ A hyperthermic reaction developed in an 8-year-old boy with a family history of Duchenne's muscular dystrophy one hour after induction of anesthesia. Temperature elevation and muscle rigidity were minor components of the condition. Determination of arterial blood gas concentrations and the serum potassium level established the diagnosis and enabled the start of lifesaving therapy.
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Congenital right posterolateral (Bochdalek's) diaphragmatic hernia usually has clinical manifestations different from those of left Bochdalek's hernia; it often masquerades as a pleural effusion, an asymptomatic intrathoracic mass, or an intestinal obstruction. The primary reason for the difference in symptoms is the presence of the liver on the right, which occludes the diaphragmatic defect and permits normal development of the ipsilateral lung. We recommend a transabdominal approach for surgical repair.