Acute Pancreatitis: A Review

A series of 68 patients with acute pancreatitis admitted to the Royal North Shore Hospital of Sydney in a three-year period is discussed. An ætiological diagnosis was made in 68% of these. There were three cases associated with a parathyroid adenoma and a 10% incidence of hæmorrhagic pancreatitis, and pseudocysts occurred in 6%. There was no mortality in the 22 patients who underwent laparotomy. The ætiological mechanisms, diagnosis and treatment of acute pancreatitis are reviewed.     

Estimating allowable blood loss with correction for variations in blood volume

All the theoretical relationships between blood loss and change in haematocrit used for calculating the allowable pre-transfusion blood loss assume a strictly normovolaemic situation. In this study a formula was derived in which account was taken of the variation in blood volume. The formula was based on clinical data. Measurements of the blood loss, the blood haemoglobin concentration and the haematocrit (HCT) were performed on 230 occasions in the course of 35 transurethral prostatic resections. The change in blood volume was estimated by the haemoglobin dilution method and the value so obtained was compared to both the measured haematocrit and the theoretical value that would presumably have been recorded if there had been no change in blood volume. The relationship established from these comparisons was: blood loss = preoperative blood volume x [In preop HCT - In postop HCT (1 + 0.15 x blood volume change)].     

Hæmodilution in Clinical Extracorporeal Circulation: Some Effects of Human Serum Albumin

Two groups of seven patients with uncomplicated septal defects or pulmonary valve stenosis were perfused by the use of “Travenol” bag oxygenators and a heat-exchanger for open heart surgery. A dilute perfusate was used, to which human serum albumin was added in one group for comparison with the other group. No clinical differences were found between the two groups, but hæmatocrit values suggested that the albumin prolonged the duration of hæmodilution into the postoperative period. The probable advantages of maintaining hæmodilution in this way are discussed.     

Effect of renal replacement therapy on viscosity in end-stage renal disease patients.

Viscosity, an important determinant of microcirculatory hemodynamics, is related to hematocrit (HCT), and may be altered by renal failure or its treatment. To assess these factors, we studied the effect of dialysis on the viscosity of whole blood, plasma, and reconstituted 70% HCT blood of eight continuous ambulatory peritoneal dialysis (CAPD) and nine hemodialysis (HD) patients under steady shear flow conditions at different shear rates, before and after dialysis, compared with nine normal subjects. The density of the red blood cells (RBCs), a marker of cell hydration, was measured in HD patients by a nonaqueous differential floatation technique. Whole blood viscosity was higher in controls than patients, and correlated with HCT before treatment (P less than 0.05) at shear rates of 11.5 to 230 s-1) in HD patients, and 23 to 230 s-1 in all end-stage renal disease (ESRD) patients. In contrast, whole blood viscosity correlated with HCT in CAPD patients only at the lowest shear rates (2.3 and 5.75 s-1, P less than 0.05). Plasma viscosity was higher in CAPD patients than both HD patients before treatment and controls (P less than 0.05, analysis of variance [ANOVA]), despite lower plasma total protein, albumin, and similar fibrinogen concentration compared with HD patients. When all samples were reconstituted to 70% HCT, CAPD patients had higher whole blood viscosity than control subjects'. The high HCT blood viscosity of the ESRD patients was higher than control subjects' at capillary shear rates, suggesting increased RBC aggregation and decreased RBC deformability in patients with renal disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of blood group type on prognosis of transitional cell carcinoma of the urinary bladder

The correlation of blood group to grade, stage and tumor markers at diagnosis and to the subsequent clinical course was investigated in a consecutive retrospective series of 230 patients with primary transitional cell carcinoma of the urinary bladder. The follow-up period was 5-9 years. There were no significant differences in grade, stage or DNA ploidy between patients of blood groups A and O. However, the deletion of ABH blood group isoantigen was found more frequently in tumors from patients of blood group O. Concerning progression of superficial bladder tumors, this was found earlier among patients of blood group O, and in a multivariate analysis this emerged as an independent prognostic factor. The crude and corrected mortality was not significantly higher among patients of group O than among those of other blood groups.     

Development of a magnetic fluid shaft seal for an axial-flow blood pump

A rotating impeller in a rotary blood pump requires a supporting system in blood, such as a pivot bearing or magnetic suspension. To solve potential problems such as abrasive wear and complexity of a supporting system, a magnetic fluid seal was developed for use in an axial-flow blood pump. Sealing pressures at motor speeds of up to 8,000 rpm were measured with the seal immersed in water or bovine blood. The sealing pressure was about 200 mm Hg in water and blood. The calculated theoretical sealing pressure was about 230 mm Hg. The seal remained perfect for 743 days in a static condition and for 180+ days (ongoing test) at a motor speed of 7,000 rpm. Results of measurement of cell growth activity indicated that the magnetic fluid has no negative cytological effects. The specially designed magnetic fluid shaft seal is useful for an axial-flow blood pump.     

Transfusions in patients undergoing cardiac surgery with autologous blood

PURPOSE: Determinants of allogeneic blood use in cardiac surgery include preoperative factors such as female sex, age, body weight, hematocrit and red cell volume. We verified if these variables also predicted the need for allogeneic transfusions when autologous blood is predonated. METHODS: Demographic and intraoperative variables, hemoglobin concentrations and transfusion requirements in patients undergoing cardiopulmonary bypass with autologous blood predonation were reviewed. Multivariate logistic regression and RECPAM tree-growing analyses were applied to identify the preoperative predictors of allogeneic transfusion in these patients. RESULTS: Data from 230 patients included in our autologous blood program between 1995 and 1998 were analysed. Patients undergoing complex/reoperative surgical procedures and patients over age 64yr with a low red cell volume (<2070ml) undergoing simple procedures were more likely to require allogeneic red cells. Younger patients with a low red cell volume undergoing simple procedures carried an intermediate risk. Allogeneic transfusion was avoided in 95% of patients undergoing simple procedures when red cell volume > or = 2070ml. CONCLUSIONS: In our institution, complex/reoperative surgery, low red cell volume and increased age are the main factors associated with the need for allogeneic red cell transfusion despite autologous blood predonation. Knowledge of the factors that limit the effectiveness of predonation with respect to allogeneic blood exposure should help clinicians decide which cardiac surgical patients should be included in autologous blood programs.     

Measurement of limb blood flow by electrical impedance plethysmography.

Limb blood flow has been measured in 72 individuals by the noninvasive technique of electrical impedance plethysmography. Venous occlusion was not used. Blood flow was measured in 230 limbs in which 195 limbs were either in normal individuals or the clinically normal limbs of patients (normal limbs). Thirty-five limbs were clinically abnormal. Measurements on limbs with clinical abnormalities showed that blood flow values often fell within the limits of the normal range. However 3 cases of known vascular injury and 2 cases studied after hand surgery under tourniquet showed lowered blood flow values by comparison with the unaffected limb. A simultaneously recorded range of cardiac output and stroke volume measurements gave similar results to those obtained in a previous, unconnected study.     

Effectiveness of autologous fibrin tissue adhesive in reducing postoperative blood loss during total hip arthroplasty: a prospective randomised study of 100 cases

PURPOSE: To evaluate the effectiveness of autologous fibrin tissue adhesive (auto-FTA) in reducing blood loss during cementless total hip arthroplasty (THA). METHODS: From September 2000 to August 2001, 100 patients who predonated 400 ml of autologous blood were randomised to undergo either standard treatment with auto-FTA (auto-FTA group) or standard treatment alone (control group). The volume of postoperative blood loss and the decrease in haemoglobin level were measured. All patients were followed up for 3 years to evaluate the rate of bone ingrowth and heterotopic ossification. RESULTS: The mean postoperative blood loss was 580 ml (standard deviation [SD], 240 ml) in the auto-FTA group and 810 ml (SD, 341 ml) in the control group; the difference was significant (230 ml, p<0.001). The decrease in haemoglobin concentration was 17 g/l (SD, 11 g/l) in the auto-FTA group and 22 g/l (SD, 12 g/l) in the control group. The difference was significant (5 g/l, p=0.03). The percentage of total blood loss of >1200 ml in any single patient was significantly lower in the auto-FTA group (4%) than in the control group (20%) [p=0.01]. CONCLUSION: Auto-FTA is a safe and effective means of reducing perioperative blood loss in THA.     

A case of heart surgery without homologous transfusion for complete atrioventricular septal defect associated with tetralogy of Fallot

We performed intracardiac repair in an 11-month-old infant, weighing 5.1 kg, with complete atrioventricular septal defect and tetralogy of Fallot, who had been on a respirator, preoperatively, because of congestive heart failure due to severe common atrioventricular valve regurtitation. The preoperative angiogram revealed a very narrow and hypoplastic left pulmonary artery. Autologous blood donation after induction of anesthesia and minimalization of the cardiopulmonary bypass circuit (priming volume: 230 ml) made it possible to perform open-heart surgery without homologous blood transfusion in this case. The perioperative hemodynamics and respiratory status were satisfactory. An angiogram taken 1 year after surgery showed a well-developed left pulmonary artery.     

Retrospective and consecutive analysis of the long-term outcomes of the SBG stem: a 15-year follow-up study

Background  

In 1991, 230 cementless total hip arthroplasties (THAs) with anatomical Stolzalpe-Buchner-Graf (SBG) stems were implanted in 230 patients at our hospital. Patients were examined retrospectively and consecutively 15 years after the operations.     

Intraoperative blood salvage during liver resection: a randomized controlled trial

OBJECTIVE: A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss. BACKGROUND: Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established. METHODS: Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed. RESULTS: Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11-0.85, P = 0.025). CONCLUSION: Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.     

An Assessment of the Xenon- 133 Method of Measuring Muscle Blood Flow1

The ¹¹³Xe method for measuring muscle blood flow is discussed, and has been evaluated in both normal and ischæmic limbs, a standard amount of ischæmic exercise being employed as the stimulus to hyperæmia. This is considered to be a reliable technique with a high degree of reproducibility, which may be applied to advantage in the clinical assessment of patients with peripheral vascular disease.     

THE ROLE OF BRADYKININ IN ENDOTOXIC SHOCK OF INTESTINAL ORIGIN

A relationship was looked for between blood levels of bradykinin and endotoxæmia produced by superior mesenteric artery occlusion in the rabbit. The levels of bradykinin were unrelated to and unaltered by the degree of endotoxæmia observed in the systemic and portal circulations. These findings suggest that bradykinin is not responsible for the release of endotoxin from the gut, or for the circulatory collapse which follows.     

The management of accidental dural puncture and postdural puncture headache: a North American survey

Study Objective

To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America.

Design

Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP).

Setting

University hospital.

Measurements

In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up.

Main Results

Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset.

Conclusions

Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.     

Anæmia and Surgery: A Retrospective Clinical Study

A study has been made comparing the surgical performances of 145 anæmic patients who had hæmoglobin levels below 10 gm/100 ml of blood with the surgical performances of 412 routine surgical cases. While there appeared to be an apparent increase in cardiac arrests or deaths during surgery or in the early postoperative period in the anæmic cases, it is doubtful whether this is significant. Other surgical or postoperative complications did not appear to occur more frequently in the anæmic cases than in the controls, nor did the complications in the anæmic patients require treatment not given to patients in the control series.     

Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax

Background

A prospective, randomized study was carried out on patients with primary spontaneous pneumothorax, with the aim of determining if video-assisted thoracoscopy is superior to axillary thoracotomy in the surgical treatment of this condition.

Methods

Patients were randomly assigned to two groups; video-assisted thoracoscopy (group A; n = 46) and axillary thoracotomy (group B; n = 44). All fit the established criteria for surgical indication (relapse or persistent air leakage after pleural drainage). In all cases the treatment consisted of apical segmentectomy of the blebs or dystrophic complex and pleural mechanical abrasion. The study evaluated the following factors: postoperative blood loss, respiratory function (maximum inspiratory and expiratory pressures, forced expiratory volume in the first second and forced vital capacity), postoperative pain (analog visual scale), supplementary doses of analgesics, postoperative complications, hospital stay, and resumption of normal activity. Relapses were evaluated for the minimum period of time of two years.

Results

No significant differences were found in any of the factors studied in either group.

Conclusions

Video-assisted thoracoscopy and axillary thoracotomy offer similar results in the surgical treatment of primary spontaneous pneumothorax. The rate of complication is low and the level of pain is acceptable without long-term sequelae.     

Correlating the blood alcohol concentration with outcome after traumatic brain injury: too much is not a bad thing

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (≥230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.     

Spontaneous Intramural Hæmatoma in the Sigmoid Colon of a Hæmophiliac

This paper describes a case of intramural hamatoma of the colon occurring spontancously in a patient with hæmophilia so mild that the diagnosis was unsuspected before operation. Successful resection was achieved with a minimun of blood loss. During subsequent surgery, it was necessary to control bleeding with repeated infusions of cryoprecipitate.