Splenic hamartoma associated with thrombocytopenia: A case report

IntroductionHamartomas are rare, benign tumors of the spleen. Few cases of splenic hamartomas associated with thrombocytopenia have been reported.Presentation of caseAn asymptomatic 64-year-old man with myelodysplastic syndrome was found to have a splenic tumor. Laboratory tests were significant for thrombocytopenia, with a platelet count of 7.8 × 10⁴/μL. Ultrasonography showed splenomegaly (10.8 × 6.6 cm), and a hypoechoic splenic mass (8.0 × 7.0 cm). Color doppler ultrasound revealed blood flow within the mass, and the mass density was homogeneous on abdominal computed tomography (CT). Contrast-enhanced CT showed heterogeneous enhancement of the splenic mass during the arterial phase. Positron emission tomography (PET)-CT showed no significant fludeoxyglucose (FDG) accumulation within the mass. The differential diagnosis included splenic hamartoma, splenic hemangioma, splenomegaly associated with extramedullary hematopoiesis, and malignant tumor, including solitary splenic metastasis. A laparoscopic splenectomy was performed due to the possibility of malignancy, the presence of thrombocytopenia, and the risk of splenic rupture. The resected specimen showed a localized, well-demarcated, 8.0 × 7.0 cm splenic mass. Histological examination revealed abnormal red pulp proliferation and the absence of normal splenic structures. The patient’s post-operative course was uneventful. His platelet count improved on post-operative day 1 and he was discharged on post-operative day 9. He remained in good health with a normal platelet count one month after surgery.DiscussionMaking definitive preoperative diagnosis is difficult in splenic hamartomas. Surgery is necessary for diagnosis when malignancy cannot be ruled out.ConclusionsSurgery may also improve symptoms of hypersplenism, including thrombocytopenia.     

Risk factors and outcomes of pancreatitis after open heart surgery

BACKGROUND: We sought to analyze the risk factors and natural history associated with post-cardiac surgery acute pancreatitis. METHODS: Retrospective analysis of all patients having undergone cardiac surgery at our hospital between January 1, 1992, and October 1, 2001. RESULTS: A total of 10,249 cardiac operations were performed. Thirty-nine (0.4%) patients developed postoperative pancreatitis. There was a higher incidence during the period spanning 1992 through 1996 than 1997 through 2001 (0.6% versus 0.2%, P< .05). Patients with pancreatitis had longer postoperative length of stay (51+/-5 days versus 10+/-1 days, P<.05) and a greater in-hospital mortality rate (28% versus 4%, P<.05) than patients who did not develop pancreatitis. A history of alcohol abuse, cardiac surgery performed during 1992 to 1996, increased cardiopulmonary bypass time, and increased cross-clamp time were independent risk factors for the development of pancreatitis. Multiple-organ failure was an independent predictor for death among patients with pancreatitis. CONCLUSIONS: Although the frequency of post-cardiac surgery pancreatitis is diminishing, it is still associated with significant mortality.     

体外循环开心术后并发颅内出血

8例心脏病患者体外循环开心术后并发颅内出血或血肿，发生率为0．28％。其中硬膜下血肿4例，脑内血肿3例，蛛网膜下腔出血1例。6例死亡，2例存活，随访半年情况良好。对于体外循环心脏手术患者，应警惕颅内血肿发生并及时首选头部CT检查，正确把握开颅手术适应证。     

Subsequent intracranial haemorrhage following open heart surgery

Intracranial haemorrhage (ICH) is an uncommon but lethal complication of open heart surgery. The aim of the present paper is to analyse studies of ICH subsequent to open heart surgery and further to discuss the risk factors and strategies. Articles were obtained from Index Medicus/MEDLINE database of the National Library of Medicine USA from 1966 to present, and the Chinese Biomedical Literature Database (CBMDISC) of the Institute of Medical Information of Chinese Academy of Medical Sciences from January 1982 to December 2000. Search terms included cardiopulmonary bypass, cardioplegia, neurosurgery, craniotomy, sphenotresia, ICH, intracranial haematoma, haemorrhagic stroke/infarct and craniocerebral injury. Information obtained from the cited literature helped complete the collection of the documents. In total 35 reports covering 179 cases are reviewed. Of the 182 ICHs of 179 patients after open heart surgery, intracerebral haemorrhage was the most frequent (41.21%), subdural haematoma was the second (22.53%) and epidural haematoma was the third (12.64%). Of the 77 sites of ICHs that can be traced, the frontal region was involved the most (23.34%) and the parietal, occipital and temporoparietal regions second (each was 12.99%). It occurred most often on the right (55.84%), more often on the left (31.77%), and the least often on bilateral (12.99%) sides of the brain. Haemorrhage in intracerebral was most common (40.66%), sudural the second (22.53%), then epidural (12.64%) and subarachnoid (3.85%) and the least common in multiple sites. Sixty‐eight (37.36%) of the patients were treated by craniotomy for haematoma evacuation, 30 (16.48%) by conservative treatment, 27 (14.84%) were not treated in time and died, and the other 57 (31.32%) treatment methods are unknown. Forty‐two patients (23.08%) survived, one of whom (0.55%) was in a vegatative state, 103 (56.59%) died and 37 (20.33%) have unknown outcomes. ICH following open heart surgery is rare but risky and always life threatening. Any factors leading to cerebrovascular injury or fluid shifts with fluctuations in cerebral volume during pre‐, intra‐ or postoperation of open heart surgery may cause ICH. Computed tomography scan optimizes the detection of ICH. Miscellaneous prophylactic approaches are mandatory for patients vulnerable to ICH following open heart surgery. Therapeutic approaches as either antibiotics or early operations should be determined on a substantial basis of prosthetic endocarditis patients with ICHs.     

A case of open heart surgery associated with liver cirrhosis and pancytopenia

A 58-year-old female was diagnosed as mitral regurgitation and tricuspid regurgitation, combined with liver cirrhosis (T. Bil 2.3 mg/dl, ICG-R 37%) and pancytopenia (Hb 9.4 g/dl, WBC 3,000, Plt 56,000). She underwent mitral and tricuspid annular plications. After extracorporeal circulation, the postoperative platelet count was maintained higher than preoperative one by transfusion of platelet-rich plasma. Administration of FOY was begun during operation. Levels of T. Bil. and BUN were highest at 15th postoperative day and decreased gradually. Postoperative pleural effusion was treated by administration of 25% albumin solution keeping the level of Alb. up 3.5 mg/dl.     

心脏不停跳心内直视手术的临床研究（附1106例报告）

目的　探讨心脏不停跳心内直视手术的方法和意义。方法　总结 110 6例施行心脏不停跳心内直视手术病例。并行循环者 ,阻断上、下腔静脉而不阻断升主动脉 ,不使用心脏停搏液 ;逆行灌注者 ,阻断升主动脉后经冠状静脉窦逆行持续灌注机器氧合血 ,鼻咽温维持在 (33± 1)℃ ,均在心脏空跳条件下完成心内直视手术。结果　心脏手术完毕即可停机 ,术后血流动力学平稳 ,多巴胺用量很少。低心输出量综合征发生率 0 .45 % ,无严重心律失常 ,血尿发生率 1.90 %～ 3.41%。血液生化、心肌超微结构检查结果均显示较传统方法好。无 1例发生空气栓塞。早期死亡率 1.90 % (2 1/ 110 6例 )。结论　心脏不停跳法是一种较接近生理状态的心肌保护方法 ,能最大程度地减少心肌缺血缺氧损伤 ,避免再灌注损伤 ,而获得较理想的心肌保护效果     

心内直视手术后出血二次开胸止血

目的:总结17例心内直视手术后出血二次开胸止血病人的出血原因及处理得失。方法:17例病人因心内直视手术后大出血行二次开胸止血术,其中男12例,女1例,年龄7～66岁,平均(27.7±16.3)岁,体重16～64kg,平均(43.37±18.5)kg。心内直视手术毕常规置纵隔、心包引流管,胸膜腔敞开者置胸腔引流管。术后保持引流管通畅并监测引流量、心率、血压、中心静脉压。记录心内直视术后至二次开胸止血观察时间,输血量及二次术中探查所见。结果:心内直视术后引流量400～2520ml,平均(1449±622)ml。心内直视术后至二次开胸止血观察时间1～27h,平均(7.1±6.7)h,心脏术后4h以内两次开胸止血7例(41.2％),8h以内二次开胸止血12例(70.1％)。二次开胸术中发现活动性出血1.1例(64.7％),渗血5例(38.5％)。输库血400～3200ml,平均(1820±919)ml。17例病人中切口感染5例(29.4％),死亡3例(17.6％)。结论:心内直视手术后出血是一凶险并发症。一旦出现,尤其术后8h以内,有二次开胸止血指征,应尽速开胸止血。心内直视手术后出血大部分是由于止血或结扎不严密造成的,重在预防。     

心脏直视手术中参附注射液的心肌保护作用

目的观察参附注射液对体外循环下心内直视手术患者心肌损伤标志物的影响。方法30例择期心脏手术患者随机分成参附组和对照组,每组15例。两组麻醉诱导方式相同,参附组在麻醉诱导前静脉输入参附注射液2 ml/kg。分别在术前、心脏再灌注5、10、30、60及120 min测定肌酸磷酸激酶同功酶(LDH)、乳酸脱氢酶(CK-MB)、心肌钙蛋白(cTnI),并进行组间比较。结果两组患者所测心肌损伤标志物在开放升主动脉后显著升高,但参附组明显低于对照组。结论参附注射液能减轻体外循环期间心肌缺血-再灌注损伤,对心肌有一定保护作用。     

Effects of temperature on somatosensory evoked potentials during open heart surgery

Somatosensory evoked potentials (SEPs) have been found to be useful for early detection of brain ischemia during hypothermic cardiopulmonary bypass in cardiac surgery. However, the relationship between temperature and latency period remains unclear. We prospectively analyzed SEPs obtained during hypothermic cardiopulmonary bypass in 20 patients who had valvular replacement.
We concluded that i) a linear correlation was found between temperature and latency period during cooling and rewarming, ii) no hysteresis effect existed in cooling and rewarming, iii) there was a greater hypothermic effect on the synaptic transmission than on the conduction velocity, and, iv) age had also more profound effect on relationship between temperature and latency of SEPs.     

Erector Spinae Block a safe,simple and effective analgesic technique for major hepatobiliary surgery with thrombocytopenia

Hepatobiliary surgeries are associated with severe pain, and coagulopathy. Adequate pain control is vital and difficult to achieve for these patients. Epidural analgesia is considered the routine standard technique for the management of both somatic and visceral pain from major abdominal surgeries until now. However, it is invasive, blind and carries the risk of dural or vascular puncture. Coagulopathy found in patients posted for hepatobiliary surgery further increases the concerns. We found ultrasound guided erector spinae plane block as a safe, simple yet an effective alternative to epidural analgesia for postoperative pain management of hepatobiliary surgeries.     

Severe thrombocytopenia associated with phenytoin and cimetidine therapy

A 67-year-old man developed a sudden onset of severe isolated thrombocytopenia (platelet count, 1000/mm3) after 10 days of phenytoin administration as a prophylactic measure prior to craniotomy. The patient had also been taking cimetidine for 2 months prior to admission. No other hematological complications were noted, and an extensive hematologic investigation was otherwise unremarkable. Rapid resolution of the thrombocytopenia upon discontinuation of phenytoin and cimetidine strongly suggests a drug-induced adverse reaction.     

心脏空搏下心内直视手术在先天性心脏病中的应用

目的 探讨浅低温体外循环心脏空搏下心内直视手术在先天性心脏病中应用的可行性。方法 在181例常见的先天性心脏病中,采用这一手术方法,观察该方法对心肌保护的效果,总结气栓防、术野显露及体外循环相关的经验。结果 181例手术顺利,术野显露达到要求,无气栓发生,术后死亡1例。结论 浅低温体外循环心脏空搏下心内直视手术在常见的先心病中具有实用价值,但对体外循环提出了新的要求。     

A case of bilateral phrenic nerve paralysis following open heart surgery]

Coronary artery bypass surgery was performed on a 58-year-old female under cold cardioplegia with topical ice slush cooling. Bilateral phrenic paralysis was observed postoperatively, in spite of prevention with a mat during aortic cross clamp, cold injury owing to ice slush was thought to be causative. Mechanical ventilatory support continued for more than two months until her complete recovery of diaphragmatic function. She complained of sleeplessness besides respiratory symptoms, and felt uneasy. Although cold injury is mostly reversible, it is stressed that we must deliberately wean from mechanical ventilatory support, turning our attention to symptoms and blood gas analysis with as much mental assistance as possible.     

Protein C deficiency associated with massive cerebral thrombosis following open heart surgery

We describe a case of massive cerebral venous thrombosis following open heart surgery in a patient with a reduced level of Protein C (40% of mean level). Protein C deficiency is an inherited disorder which in the homozygous form may result in massive fatal venous thrombosis in the newborn. A Protein C level below 55% is highly suggestive of heterozygous deficiency and has been associated with a tendency to venous thrombosis although its clinical penetrance is variable. This is the first reported case of massive venous thrombosis in a patient following open heart surgery associated with Protein C deficiency.     

静脉滴注银杏叶提取物对心脏直视手术心肌保护作用

目的研究静脉滴注银杏叶提取物（EGb）对心脏直视手术的心肌保护效应。方法30例择期行二尖瓣置换术患者,随机分为抑肽酶组（Ⅰ组）、EGb组（Ⅱ组）和对照组（Ⅲ组）,每组10例。三组的麻醉方法均相同,分别在术前、主动脉开放即刻、开放后1、6、24h测定肌酸激酶同工酶（CK-MB）、超氧化物歧化酶（SOD）、丙二醛（MDA）及内皮素（ET）的浓度,同时分别记录各组的复跳时间、心内电击除颤次数、复跳后24h多巴胺的平均用量、心肺转流（CPB）时间、主动脉阻断时间、手术时间。结果三组患者在术后各时点CK-MB、SOD、MDA、ET浓度与术前相比差异有统计学意义（P〈0．01）,但Ⅱ组变化与Ⅰ组、Ⅲ组相比明显偏小;Ⅱ组的复跳时间、除颤次数及复跳后24h多巴胺的平均用量与Ⅰ组、Ⅲ组相比差异有统计学意义（P〈0．05）。结论静脉注射EGb能够减轻心脏直视手术的心肌缺血一再灌注损伤,具有明显的心肌保护作用。     

Deep sternal wound infections following open heart surgery in Iceland. A population-based study

Objective. The aim of this nationwide case-control study was to study the epidemiology and identify risk factors of deep sternal wound infections (DSWI) in Iceland. Patients and methods. Between 1997–2004, 1 650 adults underwent open cardiac surgery in Iceland. For every infected patient four control subjects were chosen (n =163), matched for time of operation. The groups were compared by multivariable logistic regression analysis. Results. Forty one patients (2.5%) developed DSWI, most often following CABG (76%). The most common pathogens were Staphylococcus aureus (39%) and coagulase-negative staphylococci (24%). All except two patients underwent debridement and rewiring of the sternum. Length of hospital stay was significantly longer in the DSWI group with a trend for increased hospital mortality and significantly greater 1-year mortality (17% vs. 5%, p =0.02). History of stroke (OR 5.12), peripheral arterial disease (OR 5), corticosteroid use (OR 4.25), smoking (OR 3.66) and re-operation for bleeding (OR 4.66) were the strongest independent predictors for DSWI. Conclusion. Incidence of DSWI in Iceland (2.5%) is comparable to other recently published studies, with similar risk factors and significantly reduced survival at one year following the infection.     

Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery

Aim: To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery. Background: The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population. Methods/Materials: Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation. Results: Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg·kg^?1 vs 0.2 mg·kg^?1, P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes. Conclusions: A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg·kg^?1·h^?1, a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.     

Ventilatory support following open heart surgery

One thousand consecutive patients undergoing open heart surgical procedures were evaluated for the need for ventilation in the postoperative period. All cases of mitral valve replacement (237) and double valve replacement (85) were electively ventilated. Fifty-two other patients required ventilation for various reasons which included low cardiac output with inotropic support, ventricular arrhythmias, left atrial pressure above 18 mm Hg, bleeding, hypo or hyperthermia, unsatisfactory blood gases, neurological problems, overdosage of narcotics, incomplete reversal of relexants and flooded lungs at the end of operation. Twenty patients needed ventilation beyond 4 days. Prolonged ventilatory support was maintained with nasotracheal tube and only 3 patients required tracheostomy after 12 days for cerebral and pulmonary complications. The pulmonary complications encountered during postoperative ventilation were stiff lungs, copious secretions and bleeding in 20 patients.