Cardiovascular surgery (London, England)
-
The initial treatment of uncontrolled hemorrhage shock from an abdominal source is controversial. The hemodynamic effects of transfemoral diaphragmatic aortic occlusion with a balloon followed by a single bolus of hypertonic saline solutions have been evaluated in 28 dogs. The animals were submitted to pressure-driven hemorrhage for 90 min, according to mean arterial pressure in the abdominal aorta and randomized into four groups, according to the treatment employed at 34 min after hemorrhage. ⋯ The recovery of mean arterial pressure in aortic-occluded dogs given isotonic NaCl was associated with a marked increase in systemic vascular resistance index, without improvements in cardiac index, systolic index and cardiac filling pressures. In occluded dogs given hypertonic NaCl and NaAc the mean arterial pressure recovery lasted longer, with lower increases in systemic vascular resistance index, while the cardiac index, systolic index and cardiac filling pressures showed a marked albeit transient increase. Injection of hypertonic saline following aortic occlusion produced significantly better hemodynamic profiles and should be seriously considered for the first treatment in severe uncontrolled hemorrhagic shock from an abdominal vascular source.
-
From 1967 to 1993, 21 patients underwent surgical repair of aortic left ventricular discontinuity as a result of acute bacterial endocarditis. Repair of the defect between the aorta and left ventricle was usually with interposition of a patch (prosthetic patch or autologous pericardium), using a continuous monofilament suture. Interrupted pledgetted stitches were used when the ventricular tissue appeared friable. ⋯ Of 11 long-term survivors (5 to 61 months (mean 21 months) after operation), nine have had event-free courses. Two cases of recurrent subacute bacterial endocarditis occurred 3 and 52 months after surgery in patients who were intravenous drug abusers, both of whom were managed medically. It is concluded that while aortic left ventricular discontinuity remains a potentially lethal complication of acute bacterial endocarditis, débridement of infected necrotic tissue, patch repair of the defect, and prosthetic valve replacement offer satisfactory immediate and late results.
-
Comparative Study
Reperfusion injury in skeletal muscle: controlled limb reperfusion reduces local and systemic complications after prolonged ischaemia.
Previous studies in isolated limbs using crystalloid perfusion solutions have shown that control of the initial reperfusion reduces postischaemic complications. However, no experimental study has been undertaken to evaluate the concept of controlled limb reperfusion experimentally in an in vivo blood-perfused model and to assess the local as well as systemic effects of normal blood reperfusion and controlled limb reperfusion. Of 20 pigs undergoing preparation of the infrarenal aorta and iliac arteries, six were observed for 7.5 h and served as controls; 14 others underwent 6 h of complete infrarenal occlusion. ⋯ Furthermore, controlled limb reperfusion resulted in higher total adenine nucleotides content, less tissue acidosis, markedly reduced creatine kinase release, and potassium release as compared with that of normal blood reperfusion. This study shows that 6 h of acute infrarenal aortic occlusion will result in severe reperfusion injury (postischaemic syndrome) if normal blood at systemic pressure is given in the initial reperfusion phase. In contrast, initial treatment of the ischaemic skeletal muscle by controlled limb reperfusion reduces the metabolic, functional and biochemical alterations.
-
Two patients are reported who presented with intestinal ischaemia caused by a subadventitial rupture of the origin of the coeliac trunk and superior and inferior mesenteric arteries after blunt trauma from deceleration injury. In both cases the initial clinical examination revealed a painful abdomen without any 'peritonism'. Abdominal ultrasonographic examination showed no abnormality. ⋯ In the first, the diagnosis was made by laparatomy but only after 2 days. In the second, diagnosis was made by aortography performed because of the early appearance of gastric dilatation. Both patients died as a result of extensive associated injuries and delay in diagnosis.