Surgery, gynecology & obstetrics
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Surg Gynecol Obstet · Feb 1990
Comparative StudyTreatment of uncontrolled hemorrhagic shock with hypertonic saline solution.
Hypertonic saline solution (HTS) treatment of uncontrolled hemorrhagic shock (UCHS) induced by incision of three major branches of the ileocolic artery, leading to free intra-abdominal bleeding, was studied in rats. The rats were divided into two groups. In group 1, the abdominal wall was closed immediately after induction of hemorrhage and the rats were divided into six subgroups--1a, five untreated; 1b, 14 treated with 5 milliliters per kilogram of sodium chloride 7.5 per cent (HTS) after five minutes; 1c, eight had HTS infused after 15 minutes; 1d, nine had HTS infused after 30 minutes; 1e, nine had HTS infused after 60 minutes, and 1f, nine had HTS infused after 120 minutes. ⋯ In group 2, the hemodynamic response to intra-abdominal vessel injury in untreated rats was similar to that of those in group 1 and the amount of sponges used to absorb shed blood was 2.4. After five, 60 and 120 minutes of HTS treatment, the hemodynamic response was similar to that in group 1. Five and one-half (p less than 0.01), 3.5 and 3.0 sponges, respectively, were used to absorb shed blood.(ABSTRACT TRUNCATED AT 400 WORDS)
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Two patients with massive ovarian tumors, one with a 51 kilogram Stage IC mucinous cystadenocarcinoma and the other with a 34 kilogram mucinous cystadenoma, are presented. Problems associated with resection of massive ovarian tumors, including respiratory failure, intraoperative fluid shifts, adequate exposure, orthostatic hypotension and adynamic intestine, are identified. Guidelines for avoiding these pitfalls by the use of appropriate monitoring, controlled drainage of the cyst and transverse elliptic incision with abdominoplasty are suggested.
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The two prior hypotheses of the study were that, among a high risk population of patients who were hypertensive, who had diabetes and who underwent elective general surgical treatment, the duration of intraoperative hypotension and hypertension (greater than 20 millimeters of mercury above or below the preoperative base line) and intraoperative administration of less than 300 milliliters per hour of saline solution containing fluids would identify patients at higher risk for postoperative renal dysfunction. Among those who had an intraoperative mean arterial pressure (MAP) that fell more than 20 millimeters of mercury below the base line, 15 per cent of those with fall of MAP lasting for greater than or equal to 60 minutes had postoperative renal dysfunction, whereas those with drops in pressure lasting for less than 60 minutes did not sustain increased postoperative renal dysfunction. Patients who had intraoperative MAP rise to greater than 20 millimeters of mercury above the preoperative base line value for greater than 30 minutes also had twice the rate of postoperative renal dysfunction. ⋯ Two intraoperative events also significantly increased postoperative renal dysfunction rates: cardiac arrest and the drainage of massive ascites. Patients with decompensated congestive heart failure at admission to the hospital had significantly increased postoperative renal dysfunction; these patients and probably should not undergo an operation unless it is an emergency. All of the patients, regardless of the magnitude of the operation and of its projected length or type of anesthesia, should be given greater than 300 milliliters per hour of isotonic saline-like solutions.
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Although individual reports have indicated that a fracture of the first or second rib is predictive of injury to the thoracic aorta and its major branches, the results of a careful review of the literature do not support this contention. In patients suffering blunt trauma, the risk of disruption of the aorta is not greater in patients with fracture of the upper two ribs, compared with victims of trauma with fracture of other ribs or those without fracture of ribs. Clinical manifestations are often absent in patients with disruption of the aorta or the innominate artery, but evidence of mediastinal hemorrhage is almost always present on roentgenograms of the chest. ⋯ Repeat examinations must be performed and serial roentgenograms of the chest must be obtained for several days after injury to assess the possibility of unrecognized vascular trauma. If clinical or roentgenographic evidence of vascular injury is revealed, arteriography is mandatory. Thoracic CT scanning in patients with evidence of mediastinal hemorrhage on plain film may be of value in selecting patients for angiography, but additional experience must be obtained before such a protocol becomes an established policy.