Surgery
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Because of the rarity of child donors, in cases of adult donors room requirement for the liver graft is a major technical obstacle to liver transplantation in children. To overcome this difficulty in a child, the authors performed an orthotopic transplantation with an adult liver that had been reduced to the left lobe. The absence of technically-related complications suggests that this procedure might facilitate the performance of liver transplantation in children.
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Portacaval or mesocaval shunts may relieve ascites that is caused by chronic forms of primary Budd-Chiari syndrome. When inferior vena cava stenosis is severe or is the site of thrombosis, another procedure has to be used. Portoatrial or cavoatrial shunting has been suggested, and a few reports have been made after only a short follow-up period. ⋯ Cavoatrial bypass performed with the use of a long Dacron graft was successful as noted at a 4 1/2-year postoperative follow-up, and there was angiographic proof of patency. Budd-Chiari syndrome with stenosis or thrombosis of the inferior vena cava may be cured by prosthetic bypasses to the right atrium. Combined mesocaval and cavoatrial shunt should be encouraged in this specific situation.
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Comparative Study Clinical Trial Controlled Clinical Trial
Effect of end-expiratory pressure on total oxygen dynamics.
The role of altered end-expiratory pressure on total oxygen dynamics was studied prospectively in 18 patients with injuries and sepsis. Eight patients received high tidal volumes (12 to 18 ml/kg), continuous positive airway pressure, and intermittent mandatory ventilation (CPAP/IMV); 10 patients received low tidal volumes (8 to 10 ml/kg) with zero end-expiratory pressure and assist control mode of ventilation (ZEEP/A-CM). CPAP/IMV patients had better oxygen tension, reduced physiologic shunting in the lung (24% versus 18%), and an improved arterial tension: inspired oxygen concentration ratio. ⋯ Consequently, the total oxygen delivery was reduced for all 3 days following insult and for the cumulative data for all 3 days (266 versus 306 ml/min) in the CPAP/IMV patients. Oxygen consumption was also reduced in the CPAP/IMV patients; this reduction was not significant for each of the first 3 days but was significant when the data for the 3 days were added to the analysis (306 versus 272 ml/min). Future prospective randomized studies are needed to determine the most effective use of ventilatory support on total oxygen dynamics including oxygen delivery and oxygen consumption.
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The clinical course and final outcome were determined for 63 trauma victims who underwent resuscitative thoracotomy (RT) for hypovolemic cardiac arrest in the Department of Emergency Medicine during a 24-month period. The objectives of the study were to determine the efficacy of and indications for RT and to define the prognostic signs for survival. Of 63 patients, six were successfully resuscitated (9.5%), and five of these were discharged from the hospital (7.9%). ⋯ In our experience, RT is most beneficial for victims of penetrating thoracic trauma, especially those with cardiac injuries. However, routine use of this high cost/low benefit procedure cannot be recommended for patients who have cardiac arrest secondary to blunt trauma or severe head injuries. Also, it is not recommended for patients whose pupillary reflexes and respiratory movements are absent.
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Comparative Study
Peripheral postcapillary venous pressure: a new, more sensitive monitor of effective blood volume during hemorrhagic shock and resuscitation.
Peripheral postcapillary venous pressure (PCVP) and mixed venous oxygen saturation (SvO2 or PASO2) have been shown to be sensitive indicators of volume status and appear to reflect the adequacy of peripheral perfusion during controlled bleeding. This study demonstrates that in an open-chest dog model with controlled venous return, PCVP is closely and linearly (r2 = 0.6) correlated with cardiac output (CO). Furthermore, oxygen saturation as measured in the central venous system (CVSO2) and peripheral vein PVSO2) were found to be closely and linearly related to PASO2 (r = 0.72 to 0.99 and 0.91 to 0.98, respectively). ⋯ During resuscitation after controlled hemorrhage, the PCVP and PVSO2 accurately reflected the restoration of blood volume and were as good as CO and central saturations. Central venous and pulmonary wedge pressures both poorly reflected the return to full volume repletion (P less than 0.01). Thus, PCVP and PVSO2 seem to be reliable indices of volume status and perfusion and do not require invasive, central monitoring.