The effect of the halovest and body position on pulmonary function in quadriplegia

Pulmonary function (vital capacity) was measured in ten quadriplegics and ten normal subjects in the following situations: supine, sitting, supine with a halovest, and sitting with a halovest. When changing from the supine to sitting positions, vital capacity decreased in the quadriplegics and increased in normal subjects. The halovest significantly reduced the vital capacity in normal subjects, but had much less of a detrimental effect in quadriplegics. As a result of this prospective, controlled study, we conclude the following: (a) the compromised state of pulmonary function in quadriplegics is not a contraindication for the use of a halovest, (b) the halovest causes a significant (p less than 0.01) restriction in vital capacity in able bodied subjects, and (c) when tenuous pulmonary function exists in a quadriplegic, pulmonary mechanics are better in the supine position.     

Zero‐order asymptotic solution of a class of singularly perturbed linear‐quadratic problems with weak controls in a critical case

We consider a linear‐quadratic optimal control problem where the second power of a small parameter stands in front of the derivative and a control in a state equation and in front of a quadratic form with respect to control in a performance index; moreover, in the state equation, the nonhomogeneity has the first order of the power of a small parameter, and a matrix in front of the state variable is singular if the small parameter is equal to zero. Using immediate substituting a postulated asymptotic expansion of a solution, containing a regular series and four boundary layer functions series, into the problem condition, we obtain problems for finding asymptotic terms of the zero order for the optimal control and the first order for the optimal trajectory. An illustrative example is given.     

Failure of autoregulation after closed head injury: an experimental model

Cats were subjected to a 3.5-atm fluid percussion impact administered to the cerebral cortex. Near-infrared spectrophotometry (NIRS) was used to measure the quantity of oxyhemoglobin and total hemoglobin in the illuminated tissue as well as the cytochrome a, a3 redox state. Corroborative data were obtained by freezing brains with liquid nitrogen and measuring cortical concentrations of ATP, creatine phosphate (CP), and lactate. Immediately postimpact there was a rise in mean arterial pressure with a 38% increase of highly oxygenated blood and a shift toward oxidation in the cytochrome a, a3 redox state. By 4 hours postimpact, cytochrome a, a3 was becoming progressively reduced despite the persistence of hyperemia. This was associated with a significant (p less than 0.01) decrease in ATP and CP concentration. Additional studies in which a 0.5-sec, 100-v electrical seizure was induced before and after fluid percussion demonstrated significant differences in seizure response, indicating a failure of autoregulation.     

Congenital disseminated malignant rhabdoid tumor and cerebellar tumor mimicking medulloblastoma in monozygotic twins: pathologic and molecular diagnosis.

Malignant rhabdoid tumors are highly aggressive childhood tumors. Recently, all of the malignant rhabdoid tumors, whatever their location, have been related to the inactivation of the hSNF5/INI1 gene. A subset of cerebral tumors, associated with malignant rhabdoid tumors or isolated ones arising in siblings, showed similar molecular alterations. We report for the first time in monozygotic twins a congenital disseminated malignant rhabdoid tumor in one twin and a cerebellar tumor mimicking a medulloblastoma in the other. Molecular analysis revealed similar alterations for both tumors: a deletion of exon 7 of the hSNF5/INI1 gene in one allele, and a point mutation in the same exon in the other, suggesting a common genetic pathway. Analysis of constitutional DNA revealed a germline mutation. These findings are in favor of a common etiology for rhabdoid tumor and a subset of brain tumors developing in infancy.     

Cystodefecoperitoneography in Patients with Genital Prolapse

The aim of the study was to prospectively evaluate pre- and postoperative findings of cystodefecoperitoneography (CDP) and to correlate the findings to the clinical examination in patients with genital prolapse. Twenty-five female patients were investigated both pre- and postoperatively with a standardized questionnaire, clinical examination and CDP, including contrast medium in the rectum, vagina, bladder, small bowel and peritoneal cavity. At preoperative clinical examination a rectocele was diagnosed in 24 patients, a cystocele in 7 and an enterocele in 2. At the preoperative CDP a rectocele was diagnosed in 21 patients, a cystocele in 22 patients and a peritoneocele in 9, of which six contained small bowel (i.e. an enterocele). Surgery was performed according to the clinical findings. At the postoperative clinical examination no rectocele was diagnosed, a cystocele was diagnosed in 3 patients and an enterocele in 1. Postoperative CDP showed a rectocele in 4 patients, a cystocele in 24 and a peritoneocele in 7 patients, of which three contained small bowel (i.e. an enterocele). CDP may complement the clinical assessment of patients with genital prolapse, in particular to confirm or detect defects involving the posterior compartment. The radiologic definition of cystocele needs further evaluation.     

E-learning as educational tool in emergency and disaster medicine teaching

E-learning is a new project for education based on the adoption of new computerised, multimedia and telematic technologies. Its application has deeply changed the concept of a teacher-based teaching to a student-centred educational project. It offers a great flexibility in the educational methodology, in the administration of contents, in the synchronous and/or asynchronous interaction between teachers and students, in the organisation and in the structure of the course, in the educational plans, in the support, the tracking and the evaluation of the student. E-learning could represent a great resource and a possible revolution in the concept of education and in the field of medical education as well. In some specific fields of application, as Emergency and Disaster Medicine, where the interaction between the student, the teacher and the patient, even if of great importance, are difficult to obtain in a quiet setting and have a lot of organizing, technical and economic troubles, e-learning approach could find a fertile field of application. In this paper we present a new program of educational activities we started in the field of Emergency and Disaster Medicine together with a review of the history of the instructional design and related technologies, ranging from the development of computer aided instruction to modern e-learning applications as teaching methodologies, and their impact on pedagogic and operative aspects.     

EMIGRANT ETHERIST: THE MEDICAL AND SCIENTIFIC INFLUENCE OF JOHN HENRY HILL LEWELLIN (1818–86), PIONEER ANAESTHETIST AND SURGEON AND PATRON OF BOTANY IN AUSTRALIA

The pioneer anaesthetists in Australia came from varying professional backgrounds. To the influence of Belisario in Sydney, Pugh in Launceston and Buchanan in Stroud, can be added the role of John Henry Hill Lewellin (1818–86). Lewellin immigrated from Scotland to become a pioneer Melbourne etherist and surgeon from 1852. Born in India, he studied surgery at Bart's Hospital in London (1842) and as a Member of the Royal College of Surgeons from that year, practised as a surgeon and dentist in Glasgow. On 19 December 1846 he was the first to use the newly discovered ether in anaesthetic practice in Glasgow, and one of the first to do so in the United Kingdom. He emigrated to Melbourne in 1852, where he achieved considerable success in the management of tetanus with ether. He was an active member of the Medical Society of Victoria and a vigorous participant in its clinical discussions. As a surgeon, Lewellin pursued a significant community role in the broader Melbourne society of the day. He served as a Magistrate, became Vaccination Officer in Victoria and, as an active doctor-soldier, served with sequential promotions finally to the rank of Surgeon-Major in the Volunteer Force (Rifles) of the Colony. He became a patron of science and a supporter of the Melbourne botanist, Ferdinand von Mueller. Of all his prodigious scientific writing, von Mueller dedicated Volume 8 of his Fragmenta to his surgical colleague, as one 'who is a most skilful physician' and later as 'a most generous promoter of my investigations'. Lewellin's legacy, in his pioneering contributions as an early anaesthetist in two continents, lives on in the scientific names of two floral species which perpetuate his name.     

Substernal goiter. Report of 212 cases

AIM OF THE STUDY: The aim of this retrospective study was to report the results of the surgical treatment in a series of 210 patients operated on for substernal goiters. PATIENTS AND METHOD: From 1982 to 1996, 210 patients with substernal goiters, including 80% of women, were operated on via a cervical approach in 208 cases, via a sternotomy in two cases. Two patients with operative contra-indications were not operated on. Twenty-five were operated on for a substernal recurrence of a goiter. In 160 cases, extraction of the substernal portion was easy. In 48 cases, removal of the substernal portion was facilitated by the discovery of the recurrent nerve at its entering into the larynx and a downward dissection of the tracheal attachments of the lobe. The complete dissection of the cervical portion made easier the ascension of the substernal portion even in very large substernal components. RESULTS: Three papillary carcinomas were diagnosed. A transient laryngeal nerve palsy occurred in 7.2% of the patients and a transient hypoparathyroidism in 13.4%, A definitive laryngeal nerve palsy occurred in 1.2% of the patients, and a persistent hypoparathyroidism in 2.1%. Of the 25 patients who underwent surgery for recurrence of a goiter, three (12%) developed a transient laryngeal nerve palsy, one (4%) a permanent nerve palsy, four (20%) a transient hypoparathyroidism and one (4%) a persistent hypocalcemia. CONCLUSION: CT scan and MRI are the best explorations to evaluate intrathoracic extension of substernal goiters. Thyroidectomy was performed via a cervical incision in 208 patients and via a sternotomy in two patients only. The complete dissection of the cervical portion with discovery of the recurrent nerve at its entering into the larynx, facilitates the ascension of the substernal portion even in very large substernal goiters.     

Possible origin of suprasellar arachnoid cysts: neuroimaging and neurosurgical observations in nine cases

OBJECT: In this study the authors identify and investigate two new classifications of suprasellar arachnoid cysts. METHODS: The authors used computerized tomography cisternography, magnetic resonance (MR) imaging, and neuroendoscopy to investigate nine cases of suprasellar arachnoid cysts. A communicating cyst with early filling and early clearance of a radioopaque tracer was found in seven of nine cases; a communicating cyst with delayed filling and delayed clearance of the tracer was observed in one case; and a noncommunicating cyst was observed in the other. The MR findings indicated a variation in the position of the basilar artery (BA) bifurcation in relation to the ventral surface of the midbrain. A distance existed between the BA bifurcation and the ventral surface of the midbrain in a communicating cyst with early filling, whereas the BA bifurcation was posteriorly displaced in a communicating cyst with delayed filling and also in a noncommunicating cyst, leaving little space between the bifurcation and the ventral surface of the midbrain. Endoscopic observation revealed, in the case of communicating cysts with early filling and early clearance of tracer, that the BA bifurcation is located inside the cyst with no overlying membrane, whereas in a noncommunicating cyst, the BA and its branches can be observed through the transparent membrane of the lesion. CONCLUSIONS: The authors postulate two different types of suprasellar arachnoid cysts: a noncommunicating intraarachnoid cyst of the diencephalic membrane of Liliequist and a communicating cyst that is a cystic dilation of the interpeduncular cistern.     

A parathyroid cyst and an adenoma associated with primary hyperparathyroidism: report of a case

A case of a parathyroid cyst associated with an adenoma in a different gland is reported. A 55-year-old female was explored with preoperative diagnosis of primary hyperparathyroidism after endoscopic removal of a right ureteral stone. The operation revealed a cyst, 20 x 10 mm in size at the left lower gland, and a solid tumor, 32 x 12 x 7 mm in size and 1,300 mg in weight in the left upper gland. Histological examination disclosed a parathyroid cyst and an oxyphilic and chief cell adenoma, respectively. Postoperative course was uneventful including normalized serum Ca level. To our knowledge, 59 cases of parathyroid cysts have been reported in the Japanese literature, of which 31 were in the hyperparathyroid status. The most common causes were cystic degeneration of the adenomas. A parathyroid cyst with a concomitant adenoma in a different gland like our case is very rare. This is the first reported case in Japan and the sixth reported case in the world literature.     

Genetic profiling of a distant second glioblastoma multiforme after radiotherapy: Recurrence or second primary tumor?

OBJECT: In nearly all patients with glioblastoma multiforme (GBM) a local recurrence develops within a short period of time. In this paper the authors describe two patients in whom a second GBM developed after a relatively long time interval at a site remote from the primary tumor. The genetic profiles of the tumors were compared to discriminate between distant recurrence and a second primary tumor. METHODS: Both patients harboring a supratentorial GBM were treated with surgery and local high-dose radiotherapy. Local control of the disease at the primary tumor site was achieved. Within 2 years, a second GBM developed in both patients, not only outside the previously irradiated target areas but infratentorially in one patient and in the opposite hemisphere in the other. The tumors were examined for the presence of several genetic alterations that are frequently found in GBMs--a loss of heterozygosity at chromosome regions 1p36, 10pl5, 19q13, and 22q13, and at the CDKN2A, PTEN, DMBT1, and TP53 gene regions; a TP53 mutation; and EGFR amplification. In the first patient, genetic profiling revealed that the primary tumor had an allelic imbalance for markers in several chromosome regions for which the second tumor displayed a complete loss. In the second patient, genetic profiling demonstrated the presence of genetic changes in the second tumor that were identical with and additional to those found in the primary tumor. CONCLUSIONS: Based on the similarities between the genetic profiles of the primary and the second tumors in these patients, the authors decided that in each case the second distant GBM was a distant recurrence rather than a second independent primary tumor.     

Failure of stabilization of the spine with methylmethacrylate. A retrospective analysis of twenty-four cases

Twenty-four patients who had a major complication after attempted stabilization of the spine with methylmethacrylate were referred for treatment. The initial instability that necessitated stabilization was caused by a traumatic condition in fifteen of these patients and by a metastatic tumor in nine. The average length of time before failure of fixation was 208.3 days for the patients who had a traumatic condition and 193.7 days for those who had a neoplasm. In eleven patients a progressive neural deficit developed postoperatively, and in six others the recovery of neural function was possibly hindered by the cement. A deep wound infection developed in six patients, and in five of them treatment by removal of the methylmethacrylate and metal, followed by a prolonged period of cervical traction, was required. Loosening and failure of fixation was the most common complication--it occurred in twelve of the fifteen patients who had a traumatic lesion and in eight of the nine who had a neoplasm. Salvage operations that included removal of the cement and conventional bone-grafting procedures were performed in eleven of the twelve patients who had loosening associated with a traumatic lesion and in six of the eight who had loosening and a tumor. Stability was restored in every patient. Improved long-term results can be achieved by using grafts of iliac bone and triple-wire stabilization methods (a midline wiring between the spinous processes and two iliac-crest grafts, one on each side, wired to the posterior elements) instead of methacrylate in the primary treatment of traumatic injuries. The treatment of choice for instability caused by neoplastic destruction of two or more vertebral bodies includes a construct of methylmethacrylate anteriorly. However, if cement is used, early augmentation with posterior fusion of the spine and stabilization should be considered. As a rule, combined anterior and posterior stabilization is recommended for the reconstruction of a spine that is unstable due to neoplastic destruction. In general, whenever methylmethacrylate is used for spinal stabilization, it should be augmented with grafts of iliac bone to provide long-term stability.     

Six years follow-up of a penis replantation in a child

Total amputation of the penis is very rare in a child. This article presents a case of a traumatic penile amputation at the base of the perineum, with scissors, in a 4-year-old child. Six hours after the aggression, the penis was replanted. Three weeks after the intervention, except for skin necrosis, the results were excellent. Six years afterward, this child has done very well from pediatric, psychological, urological, and plastic surgery points of view. Sensibility and erections are present and normal. Longer follow-ups particularly during puberty are necessary. Total amputation of the penis is a very rare accident in a child. Partial lesions are more common, particularly during circumcision. As in adult cases, replantation of the penis in a child needs a clean section by scissors or a knife, a correct conservation of the penis (in ice but without direct contact), and a short period between the lesion and the surgical procedure. All these conditions explain that very few cases are reported in the literature. We present a case of amputation of the penis in a 4-year-old child, with good results 6 years afterward.     

Peripheral arteriovenous anastomosis: an alternative technique in a free flap transfer.

Prevention of thrombosis in the inflow and outflow vessels of a free flap is a problem of current interest. The method of creating a peripheral arteriovenous anastomosis within a free flap was validated in an experimental study and substantiated in a clinical case. No thrombotic complications were observed in 16 transfers of saphenous fasciocutaneous flaps in a dog model, as well as in an elderly patient with free radial forearm flap transfer to an irradiated foot. Scanning electron microscopy of the venous anastomosis proximal to the arteriovenous fistula revealed the difference of pathologic changes as early as 4 hr following surgery. It is the conclusion of the authors, that performing a distal arteriovenous fistula in a free flap, is an effective procedure for prevention of early occlusion in a proximally anastomosed artery and vein.     

Impact of genetic versus environmental factors on the control of muscle glycogen synthase activation in twins

Storage of glucose as glycogen accounts for the largest proportion of muscle glucose metabolism during insulin infusion in normal and insulin-resistant subjects. Studies in first-degree relatives have indicated a genetic origin of the defective insulin activation of muscle glycogen synthase (GS) in type 2 diabetes. The aim of this study was to evaluate the relative impact of genetic versus nongenetic factors on muscle GS activation and regulation in young and elderly twins examined with a 2-h euglycemic-hyperinsulinemic (40 mU x m(-2) x min(-1)) clamp combined with indirect calorimetry and excision of muscle biopsies. The etiological components were determined using structural equation modeling. Fractional GS activity; GS phosphorylation at sites 2, 2 + 2a, and 3a + 3b corrected for total GS protein; and GS kinase 3 (GSK3) activity were similar in both age groups, whereas total GS activity and protein were lower in elderly compared with younger twins. GS fractional activity increased significantly during insulin stimulation in both young and elderly twins. Conversely, there was a significant decrease in GS phosphorylation at site 3a + 3b and GSK3 activity during insulin stimulation in both age groups, whereas GS phosphorylation at site 2 and 2 + 2a only decreased on insulin stimulation in the younger twins. The increment in whole-body glucose disposal (Rd) and nonoxidative glucose metabolism (insulin - basal) correlated significantly with the increment in GS fractional activity. Fractional GS activity had a major environmental component in both age groups. GSK3 activity exhibited a genetic component in young (basal: a2 = 0.42; insulin: a2 = 0.58) and elderly (insulin: a2 = 0.56) twins. Furthermore, GS phosphorylation at site 2 (insulin: a2 = 0.69) in the elderly and at site 3a + 3b (insulin: a2 = 0.50) in the young twins had a genetic component. In conclusion, GSK3 activity and GS phosphorylation, particularly at sites 2 and 3a + 3b, had major genetic components. Total and fractional GS activities per se were, on the other hand, predominantly controlled by environmental factors. Moreover, GS activity was intact with increasing age, despite a significant reduction in nonoxidative glucose metabolism.     

Ileal occlusion caused by enterolith migrated from Meckel's diverticulum

The authors present a case report of an intestinal obstruction due to a relatively big coprolite migrated from a large Meckel's diverticulum to the distal Ileum. The patients apparently healthy and a vegetarian, complained on admission of the absence of emission of faeces and gas since four days before with noticeable abdominal distension. In the physical examination he presented intestinal meteorism, a hard abdomen, painful on deep palpation in the median quadrants, especially in the epigastric and mesogastric ones. The abdominal X-RAY in the standing position confirms: an occlusive state with numerous liquid levels in the Ileum. Because of a worsening of the symptomatology and the appearance of generalized comprimission, two days later an exploratory laparotomy was performed. The intervention showed the presence of a Meckel's diverticulum with approximately 10 cm in length, with an ample neck, the distal Ileum for approximately 15 cm in dilation returned rapidly to a normal calibre, after a pastous endoluminal formation borne in the Meckel's diverticulum (Meckel resection presented actually a large niche at the fundus level with a eroded wall) and migrated in the distal Ileum where it could cause the obstruction. In the present case it is probably useful to perform a preoperative CT scan in order to get a precise etiology and perform an ascending Colonscopy, so avoiding a surgical procedure. According to the authors a CT scan is indicated in all cases of intestinal occlusion of unknown case, in order to have a more precise definition of the physiopathology of the occlusion.     

Comparative studies on intracellular calcium and nadh fluorescence of the rabbit corpus cavernosum

Erectile function (erection and detumescence) involves the complex interaction of direct neuronal stimulation of corporal smooth muscle, neurohumoral release of specific endothelial contractile and relaxant factors, and secondary modulation by a variety of putative neuropeptides and vasoactive modulators. Using surface spectrofluorometry, we have correlated spontaneous contractile activity and the contractile response to field and pharmacological agents with intracellular calcium and NADH metabolism. The results demonstrate that the corpus cavernosal tissue has very unusual properties. Spontaneous contractile activity is correlated with a phasic increase in intracellular calcium. However, spontaneous contractile activity is most often correlated with a bi-phasic effect on the ratio of NADH/NAD. At the start of the spontaneous contraction, there is a sharp phasic increase in NADH/NAD; peak contractile force occurs simultaneous with a phasic decrease in this ratio showing that at peak force generation, there is a decrease in the level of intracellular energy. Phenylephrine stimulation results in an increase in intracellular calcium in proportion to the increase in tension; however, phenylephrine stimulation at low concentrations results in a net increase in the NADH/NAD ratio whereas high concentrations of phenylephrine result in a net decrease in the NADH/NAD ratio. In general, field stimulation results in a decrease in tension at low frequencies, a biphasic response at midfrequencies, and a contraction at high frequencies. These contractile responses are directly related to alterations in the intracellular concentration of calcium. That is, a decrease in tension is preceded by a decrease in intracellular calcium while an increase in tension is preceded by an increase in intracellular free calcium. Field stimulation results in a rapid and phasic alteration in the NADH/NAD ratio; however, the NADH/NAD response can be either an increase, decrease, or biphasic response. There does not appear to be a consistent relationship between the contractile/relaxant response to field stimulation and altered NADH/NAD ratio. Finally, ATP, bethanechol, and nitroprusside induce a decrease in the basal tension of the corpus cavernosal strips which corresponds with a decrease in the NADH/NAD ratio. However, whereas nitroprusside relaxation is correlated with a decreased intracellular calcium level, both ATP and bethanechol stimulate an increase in intracellular free calcium. These studies indicate that the response of the corpus cavernosal tissue to both field stimulation and pharmacological agents is complex and may involve both direct and indirect actions of a variety of cellular mediators on the corporal smooth muscle. © 1994 Wiley-Liss, Inc.     

A study on complement activation in cardiopulmonary bypass--experimental and clinical evaluations

Complement activation in patients undergoing cardiopulmonary bypass (CPB) was studied, with particular reference to anaphylatoxins. Complement levels were compared between a bubble oxygenator group (BOG) and a membrane oxygenator group (MOG). The influence of primed homologous blood on complement activation was also evaluated. C4a levels gradually increased during CPB in the BOG, whereas in the MOG they changed little. There was a marked initial rise of C4a levels in the BOG of high H/A (primed homologous vs. circulating autologous blood volume ratio). C3a levels increased more steeply in the BOG than in the MOG. In general C5a levels remained low in both groups, but were slightly higher in the BOG than in the MOG. Complement levels were determined in monkeys (Macaca fascicularis) undergoing continuous intraaortic infusion of 1) autologous blood extracorporeally bubbled with O2, 2) blood contacted with nylon, or 3) O2 microbubbles. The results indicated 1) elevation of C4a and C3a in the bubbled blood group, 2) elevation of C3a alone in the nylon group, and 3) no elevation of either anaphylatoxin. It was thus inferred that 1) during CPB, the complement might be rather dominantly activated via the classical pathway in the BOG, and via the alternative pathway in the MOG, 2) higher anaphylatoxin levels in the BOG than in the MOG might be related to mode and grade of blood trauma including plasma denaturation, and 3) the H/A ratio might be a factor able to modify complement activation.     

Lipoprotein(a) levels in relation to albumin concentration in childhood nephrotic syndrome.

BACKGROUND: Lipoprotein(a) [Lp(a)] is a lipoprotein consisting of a low-density lipoprotein (LDL) particle linked to a polymorphic glycoprotein, apoprotein(a) [apo(a)]. Prior studies have reported high Lp(a) levels in the nephrotic syndrome, but it is still controversial whether this is due to the degree of hypoalbuminemia or proteinuria. METHODS: To investigate a model of nephrotic syndrome in the absence of renal failure, we studied a group of 84 children in different clinical stages of the disease for a period of five years. We evaluated the direct relationships between lipoproteins, including Lp(a), and/or plasma albumin and proteinuria. RESULTS: Lp(a) levels were significantly higher in the subjects with the active disease compared with patients in remission, and were also significantly different when subjects were ranked by albumin quartiles. Multiple regression analysis revealed that Lp(a) levels were inversely correlated with apo(a) isoform size and plasma albumin levels but not with the proteinuria/creatinine clearance ratio. Among subjects in complete remission, Lp(a) levels were different in patients with albumin levels below or above the fifth percentile. After the improvement of the clinical stage of the disease, the Delta% variation of albumin levels was related to the Delta% of apoB and LDL cholesterol (LDL-C), but not with the Delta% variation of Lp(a), whereas the Delta% variation of LDL-C was, in turn, related to the Delta% of Lp(a) levels. CONCLUSIONS: These results suggest that in the childhood nephrotic syndrome, the increased Lp(a) levels are mainly related to hypoalbuminemia, probably through a mechanism involving apoB overproduction, which leads to an increased number of LDL particles to be converted into Lp(a).     

Negative fluid balance in patients with abdominal compartment syndrome--case reports

Abdominal compartment syndrome (ACS) is defined as a sustained increase of intra-abdominal pressure (IAP) above 20 mmHg followed by the development of organ dysfunction. Treatment of ACS is still a question to be discussed and surgical decompression is usually preferred. According to recent data, massive crystalloid resuscitation of shock plays a key role in the development of secondary ACS in trauma patients. As mentioned previously, a high volume of infused crystalloids and a positive fluid balance were associated with ACS development in trauma patients as well as in septic patients. Moreover, we observed that a treatment strategy based on the achievement of a negative fluid balance resulted in a dramatic decrease in IAP and an improvement in haemodynamics and ventilation. This approach has been indicated as an interesting option for non-surgical treatment, with a caution that such intervention may exacerbate gut hypoperfusion. In this report we present two patients with secondary ACS development following abdominal surgery in which the achievement of a negative fluid balance showed a similar effect. Moreover, the fluid removal procedure also seemed to be associated with an improvement in splanchnic perfusion, as measured by gastric tonometry.