Arch Surg Chicago
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The recent development of laparoscopic cholecystectomy has introduced the technique of laparoscopy to the general surgical community. As increasing numbers of laparoscopic cholecystectomies are performed, increasing numbers of complications directly related to laparoscopy will result. A case of subcutaneous emphysema and hypercarbia without pneumothorax is reported in a patient undergoing laparoscopic cholecystectomy. Etiology, evaluation, and therapy for subcutaneous emphysema associated with laparoscopy are reviewed.
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Randomized Controlled Trial Comparative Study Clinical Trial
7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport.
To evaluate the use of hypertonic saline/dextran solutions in the prehospital resuscitation of severely injured patients, we administered 250 mL of either 7.5% sodium chloride/dextran 70 (HSD) (n = 83) or lactated Ringer's solution (n = 83), followed by conventional isotonic fluids, to 166 trauma patients with systolic blood pressures less than or equal to 100 mm Hg, in a prospective, randomized, double-blinded clinical trial. Patients in the sodium chloride/dextran 70 group required less fluid before hospitalization and arrived in the emergency department with higher systolic blood pressures than patients in the lactated Ringer's solution group. The rate of survival to hospital discharge for the entire cohort was 64% for patients in the sodium chloride/dextran 70 group vs 59% for patients in the lactated Ringer's solution group. ⋯ Actuarial survival for patients with severe head injuries in the sodium chloride/dextran 70 group compared with patients with severe head injuries in the lactated Ringer's solution group did not quite reach statistical significance. There were no adverse side effects associated with sodium chloride/dextran 70 administration. Administration of small volumes of sodium chloride/dextran 70 before hospitalization increased the blood pressure of severely injured patients more effectively than did lactated Ringer's solution and showed tendencies toward improving survival in the patients with severe head injuries.
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Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, patient arterial carbon dioxide levels may be adversely altered. Patients were selected for laparoscopic cholecystectomy using the same criteria as for open cholecystectomy. ⋯ Patients with preoperative cardiopulmonary disease demonstrated significant increases in arterial carbon dioxide levels and decreases in pH during carbon dioxide insufflation compared with patients without underlying disease. Results of concurrent noninvasive methods of assessing changes in partial arterial pressures of carbon dioxide (end-tidal carbon dioxide measured with mass spectrographic techniques) may be misleading and misinterpreted because changes in partial arterial pressures of carbon dioxide are typically much smaller than changes in arterial blood levels and, unlike arterial gas measurements, do not indicate the true level of arterial hypercarbia. During laparoscopic cholecystectomy, patients with chronic cardiopulmonary disease may require careful intraoperative arterial blood gas monitoring of absorbed carbon dioxide.
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Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. ⋯ Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.
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Timing of invasive procedures during chest tube therapy in spontaneous pneumothorax is undefined. Evaluation of 115 patients with primary and secondary spontaneous pneumothorax treated with tube thoracostomy revealed nearly maximal healing rates after 48 hours without a relevant increase if drainage was maintained for up to 10 days. In secondary spontaneous pneumothorax, a significantly lower healing rate was observed after 48 hours compared with primary spontaneous pneumothorax (60% vs 82%). ⋯ Hospital stay averaged 6 days in primary and 15 days in secondary spontaneous pneumothorax. Considering their efficacy and the low incidence of complications, the early use of invasive procedures such as surgical pleurectomy, after 48 hours of persistent gas leaking, seems justified. Shorter in-patient care and lower recurrence rates may result.