Surgery
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Comparative Study
Betablockers compared with antithyroid drugs as preoperative treatment in hyperthyroidism: drug tolerance, complications, and postoperative thyroid function.
Subtotal thyroid resection or hemithyroidectomy was performed for hyperthyroidism on two groups of patients: 84 treated before surgery with antithyroid drugs and thyroxin and 111 given only beta-blocking agents before surgery. These two patient groups were compared with reference to preoperative medication, operation, immediate postoperative course, and late results, with follow-up for 3 to 7 years. The advantages of beta-blockers compared with conventional antithyroid medication were lack of adverse reactions, rapid effect of treatment, considerably shortened preoperative treatment time, and fewer outpatient visits, with consequent financial benefit. ⋯ Signs of hypofunction, necessitating thyroxin supplementation, were observed in 28.6% of patients in the antithyroid drug/thyroxin group and in 25.7% in the beta-blocker group. Toxic recurrence occurred in 1.8% of the group that received beta-blockers and in 1.2% of the other patients. The study demonstrated that beta-adrenoceptor blockade is a safe method for preoperative treatment in hyperthyroidism, with advantages for patients and regarding costs.
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Chylous ascites is an unusual postoperative complication that can lead to significant mechanical, nutritional, and immunologic consequences. We present the report of a patient with chylous ascites after abdominal aortic aneurysm repair. Paracentesis is essential for diagnosis and is often useful in the initial management of the patient with mechanical respiratory distress. ⋯ Elemental diet supplementation or total parenteral nutrition may be necessary to minimize lymph flow. The sequestration of lymphocytes into the ascitic fluid may result in a profound decrease in absolute lymphocyte count. With appropriate nutritional support the prognosis of postoperative chylous ascites is excellent and reoperation rarely necessary.
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The role of pulmonary innervation in the genesis of hemodynamic responses to hypertonic salt solutions was assessed in an animal model of total lung denervation by total division of the pulmonary hilum followed by reimplantation of the organ. This was performed in 10 mongrel dogs (weighing 12 to 20 kg) randomly assigned to two groups: group I (five dogs) was comprised of animals with catheters placed in the pulmonary artery of the denervated lung; group II (five dogs) was comprised of animals with catheters placed in the pulmonary artery of the intact lung; a control group (group III) (five dogs) was submitted to a sham thoracotomy with catheters inserted in either pulmonary artery. On the seventh postoperative day the mean arterial pressure (MAP) was monitored and severe hemorrhagic shock (MAP = 40 mm Hg) was produced in all animals. ⋯ A significant rise of MAP was uniformly observed in animals of groups II and III. In group I low elevations of MAP were observed during the infusion period, followed by a return to shock levels on discontinuation of the infusion. The results suggest that selective lung denervation abolished the beneficial cardiovascular effects of hypertonic NaCl infusion during resuscitation from severe hemorrhagic shock without affecting the plasma osmolality pattern.
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Primary hemostasis was studied in 22 injured patients in the operating room (OR) after a minimum of 10 transfusions, 6 and 15 hours after surgery, on postoperative days 2 and 4 and during convalescence (mean 25 days after surgery). The platelet count was low in the OR and continued to fall after surgery through the second postoperative day; it began to rise by day 4 and was above normal at convalescence. Most patients had prolonged bleeding time through day 4. ⋯ A secondary rise in these proteins occurred at convalescence. Despite severe alterations in both the number and function of platelets after massive transfusion for injury, no patient had clinical oozing. Therefore the routine administration of platelets in comparable patients without "medical bleeding" is unwarranted.
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Randomized Controlled Trial Clinical Trial
Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study.
We performed a prospective, randomized, double-blind study of continuous epidural analgesia for 72 hours after major abdominal procedures. Patients were randomly assigned to one of five treatment groups: epidural morphine, epidural bupivacaine, a combination of morphine and bupivacaine, epidural saline solution, and no epidural catheter. All patients received supplemental morphine sulfate or meperidine hydrochloride, intramuscularly or intravenously, as needed. ⋯ The group that received the combination of morphine and bupivacaine did best on all measures; in most instances the difference between the results seen with the combination regimen and those seen with saline solution or no catheter were significant at the 0.05 level. With the exception of pruritus, complications were evenly distributed among all treatment groups, including noncatheterized controls. We conclude that epidural analgesia with the combination of morphine and bupivacaine is safe, is easily managed, and gives pain relief superior to that provided by traditional, systemic administration of narcotics.