Arch Surg Chicago
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During a five-year period, 104 patients underwent a pericardial window procedure to diagnose possible cardiac injury. Eighty-eight procedures were performed by a subxiphoid approach, and 16 were transdiaphragmatic in combination with an exploratory laparotomy. There were 51 patients with stab wounds, 45 with gunshot wounds, and eight with blunt trauma. ⋯ Cardiac wounds repaired included the right ventricle (eight), left ventricle (three), right atrium (five), and cardiac vein or pericardial wounds (three). Complications were negligible and consisted of minor wound infections (two) and postpericardiotomy syndromes (two). The pericardial window provides a rapid and safe means of diagnosing cardiac injuries in patients with equivocal signs of heart injury while sparing the patient without a heart wound a major operation.
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Comparative Study
The use of infrared photoplethysmography in identifying early intestinal ischemia.
Acute intestinal ischemia and infarction remain serious clinical problems despite early operative intervention. An accurate and reproducible method of assessing ischemic tissue is critical to determine the precise limits of resection. The purpose of this study was to compare the utility of infrared photoplethysmography, intravenous fluorescein, and Doppler ultrasound in assessing intestinal ischemia in an operative canine model. ⋯ Infrared photoplethysmography proved to be 100% sensitive for ischemia when its waveform amplitudes were 50% or greater of matched reference waveforms, whereas both intravenous fluorescein and Doppler ultrasound were 88% sensitive. All were comparably specific. We conclude that infrared photoplethysmography is comparable to intravenous fluorescein and Doppler ultrasound in the assessment of ischemic intestinal segments.
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The apparent volume of distribution (Vd) of aminoglycosides was found to be increased in 100 patients in a surgical intensive care unit who had gram-negative pneumonia or intraabdominal sepsis and acute physiologic scores greater than 12. Following loading or maintenance doses, carefully timed blood samples were collected for measurements of serum concentrations by fluorescence polarization immunoassay. ⋯ Since there is a predictable increase in aminoglycoside Vd in the septic surgical patient, a proportionately larger aminoglycoside dosage is required initially to achieve desirable peak serum levels. Close monitoring of blood levels during maintenance dosing is suggested since dynamic changes in renal function and aminoglycoside Vd occur in the critically ill.
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To determine the microvascular site of vasodilation during hyperdynamic sepsis, we measured arteriolar and venular responses to live Escherichia coli bacteremia in the rat cremaster muscle by direct in vivo videomicroscopy. Our data indicate that cardiac output (by thermodilution) increased, systemic vascular resistance decreased, and a differential arteriolar response occurred, with constriction of large arterioles and dilation of small terminal arterioles. ⋯ Alternatively, small-arteriole dilation may be an inappropriate response and secondary to release of vasoactive inflammatory mediators. If the latter is true, there is a potential therapeutic role for selective manipulation of the tone of small terminal arterioles in hyperdynamic sepsis.
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During a seven-year period, 15 patients admitted to an intensive care unit with a metabolic alkalosis resistant to saline and potassium chloride infusions and with an arterial pH of greater than 7.44 and arterial carbon dioxide pressure (PaCO2) of greater than 50 mm Hg, while breathing spontaneously, were given hydrochloric acid at 200 mmol/24 h through a central venous line until the arterial pH had decreased to less than 7.36 or PaCO2 had decreased to less than 40 mm Hg. Five patients without respiratory failure had a significant decrease in PaCO2, pH, bicarbonate Ion (HCO3-), and base excess (BE). Four patients with acute respiratory failure had a significant decrease in PaCO2, HCO3-, and BE and an increase in arterial oxygen pressure, indicating that in both of these patient groups alveolar ventilation had improved. Six patients with chronic respiratory failure had a significant decrease in pH, HCO3-, and BE, although there was no significant change in PaCO2, indicating that in this patient group alveolar ventilation could not be consistently increased in response to a reduction in arterial pH.