Intravenous adenosine for surgical management of penetrating heart wounds

Accurate suturing of penetrating cardiac injuries is difficult. Heart motion, ongoing blood loss, arrhythmias due to heart manipulation, and the near-death condition of the patient can all affect the outcome. Rapid intravenous injection of adenosine induces temporary asystole that enables placement of sutures in a motionless surgical field. Use of this technique improves surgical conditions, and it is faster than other methods. Herein, we describe our experience with the use of intravenous adenosine to successfully treat 3 patients who had penetrating heart wounds.     

Low-Velocity Nail-Gun Injuries to the Interventricular Septum: Report of Two Cases,One in a Child

Nail-gun injury to the heart is rare. Nail-gun injury to the interventricular septum is rarer: we could find only 5 reported cases, and none involving a child. We report 2 additional cases, in which nails penetrated the interventricular septum without causing acute pericardial tamponade, heart block, or shunt across the septum. Transesophageal echocardiography provides a dynamic way to evaluate the patient preoperatively, intraoperatively, and postoperatively.In the cases reported here, both the adult with multiple interventricular nails and the child with a single nail underwent foreign-object removal via median sternotomy. The child needed cardiopulmonary bypass for removal of the nail. There were no short-term or long-term sequelae from these interventricular septal injuries.     

Administration of adenosine for termination of atrioventricular nodal reentry tachycardia: induction of atrial fibrillation with rapid conduction over an accessory pathway and unmasking of concomitant Wolff-Parkinson-White syndrome

The antiarrhythmic properties of adenosine, its ultra-short half-life and the absence of frequent serious side effects make it a front-line agent in arrhythmia management, especially in the treatment of atrioventricular nodal reentrant tachycardia. Due to a shortening of atrial refractoriness, adenosine can facilitate the induction of atrial fibrillation. Life threatening tachycardias may result from a potential rapid conduction of atrial fibrillation over an accessory pathway especially if the latter one has a short antegrade refractory period. We report a case of a 59 year old female patient in which intravenous administration of adenosine during typical atrioventricular nodal reentrant tachycardia was followed by atrial fibrillation with rapid conduction over a hitherto unknown accessory pathway. After intravenous administration of adenosine the tachycardia was terminated successfully within 38 s. After a short period of asystole, spontaneous atrial fibrillation developed unmasking an antegrade preexcitation with subsequent rapid ventricular response (210 b/min). The three-lead ECG showed a narrow QRS complex tachycardia. Because of spontaneous conversion to sinus rhythm and the absence of hemodynamic compromise there was no need for external cardioversion. During electrophysiological study an antidromic atrioventricular reentrant tachycardia was recorded over a left posteroseptal accessory pathway including antegrade conduction properties only. Because of its ultrashort half-life, serious side effects after adenosine administration are rare. The possibility of life threatening proarrhythmias after intravenous adenosine administration should be taken into consideration if the etiology of a paroxysmal supraventricular tachycardia is not clear and a concomitant Wolff-Parkinson-White syndrome cannot be excluded. As with application of all intravenous antiarrhythmic agents, the administration of adenosine should only be performed if continuous ECG monitoring and cardioversion facilities are available and possible.     

Adenosine induced transient cardiac standstill in catheter interventional procedures for congenital heart disease

Objective—To describe the use of intravenous adenosine to create transient cardiac standstill during balloon dilatation procedures for congenital heart defects.
Setting—A tertiary paediatric cardiac centre.
Design and patients—This was a prospective pilot study. Thirteen patients born with congenital heart disease and who had stenotic lesions requiring relief were considered for the technique. All were suitable for balloon dilatation. Their ages ranged from 2 months to 30 years, mean (SD) 9.9 (9.8) years. The dose of adenosine varied from 0.125 mg/kg to 0.555 mg/kg, mean 0.33 (0.127).
Results—Two patients only developed sinus bradycardia in response to adenosine, which may have been related to the technique of administration. The other 11 experienced a period of asystole, which ranged from 2.4 to 10.8 seconds, mean 4.99 (2.27), and a total atrioventricular block period of 5.0 to 21.2 seconds, mean 9.47 (4.64). The interval between adenosine injection and the onset of asystole varied from 2.4 to 15.8 seconds, mean 8.05 (3.6), depending on cannula size, site of administration, and cardiac output. The peak gradient across the stenotic lesions fell from 52.3 (23.7) to 17.8 (11.9) mm Hg (p < 0.001). Apart from one short episode of atrial fibrillation there were no complications.
Conclusions—Intravenous adenosine is a safe and effective agent for creating transient cardiac standstill during balloon dilatation procedures for congenital heart disease. This achieves stability which is likely to improve results and reduce complications. It may have applications in other fields of cardiac intervention where an immobile heart is desirable during the critical phase of a procedure.

Keywords: adenosine;  asystole;  balloon dilatation;  congenital heart disease     

头皮动静脉瘘五例并文献复习

目的 探讨头皮动静脉瘘的诊断方法及治疗特点.方法 回顾性分析新疆医科大学第一附属医院神经外科2015年4月至2021年8月连续收治的5例头皮动静脉瘘患者的病历资料,对其临床特点、治疗方式、预后等进行评价.采用临床症状结合影像学检查结果进行疗效评估.术后即刻行头颈部CT血管成像或DSA检查,并术后3个月经门诊或电话随访,...     

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.     

516例胸部创伤的救治体会

为了进一步探讨胸部创伤的临床表现特征 ,总结救治中的体会 ,回顾性分析我院 10年间胸部创伤516例临床资料 ,重点分析血气胸、心脏穿透伤、气管支气管破裂、胸腹联合伤及合并多发伤救治中存在的问题。全组治愈 511例 ,死亡 5例 ,死亡率 1 0 %。血气胸的治疗强调及早胸腔闭式引流 ,心脏穿透伤和气管支气管破裂强调尽早开胸手术修补 ,对胸腹联合伤应果断采取抢救性手术 ,对合并多发伤者则应加强多学科协作以提高救治成功率     

Perfusion of isolated organs and the first heart-lung machine

In 1885, Max von Frey (1852-1932), while working in Carl Ludwig's Physiological Institute in Leipzig, Germany, designed an apparatus that had criteria characteristic of a heart-lung machine. With this device, he perfused the entire lower extremity of dogs, and took measurements of oxygen consumption, and carbon dioxide and lactate production. In 1935, another type of perfusion apparatus was constructed by Charles A Lindbergh (1902-1973). This device was the result of cooperation with Alexis Carrel (1873-1944) who was a pioneer of experimental organ transplantation. Using Lindbergh's pulsating device, organs such as thyroid, ovary, suprarenal gland, spleen, heart and kidney from fowls and cats were perfused with an oxygenated medium, and were maintained under sterile conditions. Beginning in 1934, John H Gibbon (1903-1973) developed and tested a heart-lung machine to institute cardiopulmonary bypass in cats during experimental occlusion of the pulmonary artery. In 1953, he performed the first successful open-heart operation in a patient using a heart-lung machine. This included elements that were similar to those used by von Frey - ie, the oxygenator and the pumps for continuous circulation of blood. A comparison of the three experimental devices revealed the following: the application for experimental purposes preceded clinical use; the development shifted from Europe to the United States, and was achieved by people who were not specialists; and the intention to build such a device was first purely scientific interest, but later shifted to the care for and treatment of patients with heart and circulatory defects by open-heart surgery.     

新生儿心脏手术132例麻醉处理

目的 探讨新生儿心脏手术的麻醉处理。方法 行心脏手术患儿132例，年龄9h～31d，体重1.12～4.15kg，经气管插管行静脉复合全身麻醉。结果 主动脉阻断时间84～200min，体外循环时间135～600min，术中死亡8例，其余124例心脏自动复搏;术后渗血16例;肺部感染8例;无麻醉并发症。结论 平稳的复合麻醉，术中早期纠正凝血功能，早期使用血管活性药物，加强肺保护，有利于新生儿心脏手术的成功。     

Prevention of gallstones by ursodeoxycholic acid after cardiac surgery

Background One of the problems in prosthetic-valve recipients is the development of gallstones. We suggested that the use of a heart-lung machine may be closely related to gallstone formation. The objective of this study was to clarify the efficacy of ursodeoxycholic acid (UDCA) in the prevention of gallstone formation after open cardiac surgery.Methods One hundred and six patients without gallstones who underwent cardiac surgery in which a heart-lung machine was used were randomly divided into two groups: group A, comprising 54 patients who did not receive UDCA, and group B, comprising 52 patients who received UDCA (600mg daily for 6 months from 1 week before surgery). Both groups were followed by ultrasonography for 60 months. Blood markers of hemolysis (hemoglobin, reticulocyte count, haptoglobin, total bilirubin, and lactate dehydrogenase) were evaluated before, immediately after, and at 3 weeks and 3, 6, 12, 24, and 60 months after surgery.Results In groups A and B, cumulative incidence rates for gallstone formation were 15.1% and 0% at 3 months, 23.0% and 0% at 6 months, 29.2% and 2.0% at 12 months, 29.2% and 8.4% at 24 months, and 29.2% and 8.4% at 60 months, respectively. In regard to the composition of the gallstones, they were considered to be mainly black pigment stones.Conclusions The prophylactic administration of UDCA resulted in a significant decrease in the incidence of gallstones after open cardiac surgery.     

Role of endogenous adenosine in atrial fibrillation after coronary artery bypass graft

BACKGROUND: Atrial fibrillation (AF) is the most common complication following coronary artery bypass graft (CABG). The mechanism of AF after CABG is not well defined; however, it is suggested that endogenous adenosine, released in response to tissue hypoxia, may play a mechanistic role in these arrhythmias. HYPOTHESIS: The purpose of this study was to examine whether intravenous theophylline, via adenosine A1 receptor antagonism, would correct or modify new-onset early (<48 h post CABG) atrial fibrillation in patients post CABG, and thereby implicate endogenous adenosine as an inciting agent. METHODS: A prospective double-blind, placebo-controlled study design was applied to 385 consecutive patients with coronary artery disease who had undergone CABG. Any patient who developed AF within 48 h of the operative procedure was randomly assigned to receive 5 mg/kg of intravenous theophylline (Group A) or matched intravenous placebo (Group B). The patients who converted to sinus rhythm within 15 min of drug administration were accepted as showing positive responses. RESULTS: Thirty patients comprised the study group. In Group A, 8 of the 15 patients (53%) converted from AF to sinus rhythm within 15 min of theophylline administration. One patient who converted to sinus rhythm 20 min after theophylline administration was accepted as showing a negative response. In the placebo-treated group, no patient converted to sinus rhythm within 15 min (p<0.007 compared with Group A). CONCLUSIONS: The mechanism of AF after CABG is not well defined and is probably multifactorial. However, this study demonstrated that antagonism of the adenosine A1 receptor can promptly convert many of these patients back to sinus rhythm, and thereby implicates endogenously released adenosine in a mechanistic role for inciting early (<48 h) post-CABG AF.     

Echocardiographic evaluation after blunt trauma of the chest

We studied by cross-sectional echocardiography 27 consecutive subjects with severe blunt trauma of the chest. Inadequate studies were obtained in 6 subjects (22%). Abnormal, unexpected findings were noted in 6 of the remaining 21 subjects (29%): moderate size pericardial effusion in 3 and focal ventricular dysfunction in 4. No patient with echocardiographic abnormality was suspected clinically of having heart damage. One of the 6 subjects with abnormal echocardiographic findings died from sudden asystole 6 days later. The remaining 5 patients had normal echocardiographic findings when studied 1 week after trauma. This study shows that, following blunt chest trauma, cross-sectional echocardiography can detect unsuspected myocardial and pericardial damage in an appreciable number of patients. Ultrasonic examination of the heart complements other investigations in establishing the diagnosis of heart damage and may help improve the care of patients with heart trauma.     

Primary Prevention of Sudden Cardiac Death in Adults with Transposition of the Great Arteries: A Review of Implantable Cardioverter-Defibrillator Placement

Transposition of the great arteries encompasses a set of structural congenital cardiac lesions that has in common ventriculoarterial discordance. Primarily because of advances in medical and surgical care, an increasing number of children born with this anomaly are surviving into adulthood. Depending upon the subtype of lesion or the particular corrective surgery that the patient might have undergone, this group of adult congenital heart disease patients constitutes a relatively new population with unique medical sequelae. Among the more common and difficult to manage are cardiac arrhythmias and other sequelae that can lead to sudden cardiac death. To date, the question of whether implantable cardioverter-defibrillators should be placed in this cohort as a preventive measure to abort sudden death has largely gone unanswered. Therefore, we review the available literature surrounding this issue.     

Clostridial septic arthritis: case report and review of the literature

We describe a patient who had septic arthritis caused by Clostridium perfringens. Clostridial organisms are very uncommon causes of septic arthritis. Only 13 cases have been reported previously. The diagnosis should be suspected in patients with a history of penetrating joint trauma and in immunocompromised patients. Successful treatment has usually consisted of surgical synovectomy in combination with high-dose intravenous penicillin therapy. Multiple aspirations of affected joints as a definitive treatment should be used with caution and only in patients who are not candidates for surgery.     

钝性外伤后结肠损伤的外科诊治分析

目的总结钝性外伤后结肠损伤的临床特点,探讨结肠损伤的诊断和治疗方法。方法回顾性评估62例钝性腹部外伤后结肠损伤患者的临床表现、检查、诊断方法、相关损伤以及手术方法等临床资料。结果62例中41例急诊剖腹探查明确诊断,Ⅰ期肠修补或切除吻合术47例,Ⅱ期肠造瘘术或肠外置术15例,发生肠瘘2例,死亡6例。结论早期诊断、及早手术是结肠损伤治疗的关键。结肠损伤Ⅰ期手术安全可靠,但须掌握其适应证。     

颈和颈根部血管开放性损伤的救治(附12例报告)

目的 :总结颈和颈根部大血管开放性损伤的临床特点 ,提高急救水平。方法 :回顾性分析我院 1999年 5月至 2 0 0 2年 5月年收治的 12例颈和颈根部血管开放性损伤的临床表现、急救和手术处理 ,讨论急救与手术处理要点。结果 :所有病例简单止血后急诊手术。 4例颈外静脉和 1例颈内动脉直接结扎止血 ;2例颈外动脉、1例颈内静脉缝合修补 ;1例颈内静脉用自体大隐静脉行重建血管 ,1例锁骨下动脉远端Fogarty导管取栓后端端吻合 ,1例锁骨下动脉Gore Tex人造血管重建 ;1例锁骨下动、静脉联合损伤分别用自体大隐静脉和头静脉重建 ,术后 3d因肾衰死亡 ,11例痊愈 (91 7% )。结论 :颈和颈根部血管开放性损伤应尽快压迫止血急救 ,及时手术探查 ,除颈外静脉可直接结扎外 ,尽可能修补或重建血管     

Effect of local lidocaine anesthesia on ventricular escape intervals during permanent pacemaker implantation in patients with complete heart block

Transient asystole is often noted during the course of permanent pacemaker implantation in patients with complete heart block. Since subcutaneous lidocaine is frequently used as the local anesthetic agent for permanent pacemaker implantation, the effect of this drug on ventricular escape intervals was studied. Ventricular escape intervals after transient cessation of pacing were studied in 9 patients with complete heart block before and 10, 30, and 45 minutes after subcutaneous lidocaine administration for permanent pacemaker implantation. The total lidocaine dose ranged from 170 to 400 mg (1.9 to 9.5 mg/kg of body weight). Therapeutic blood levels were achieved in 7 patients. The mean ventricular escape interval before lidocaine was 1.83 +/- 0.32 seconds, which increased to 2.58 +/- 1.35, 2.96 +/- 1.06, and 2.68 +/- 1.27 seconds at 10, 30, and 45 minutes after lidocaine (p less than 0.02). The mean maximal escape interval before lidocaine was 2.06 +/- 0.30 seconds, which increased to 3.80 +/- 1.44 seconds (p less than 0.01), a mean increase of 84%. The percent increase in maximal escape interval was related directly to the peak lidocaine level achieved. After lidocaine administration, 5 patients had asystole greater than 4 seconds and 1 required resumption of pacing. Thus, subcutaneous lidocaine contributes to the occurrence of asystole seen during permanent pacemaker implantation. It is advisable to limit the amount of lidocaine administered during permanent pacemaker implantation to the minimum necessary to achieve adequate local anesthesia. Strong consideration should be given to the use of a temporary pacemaker in patients with complete heart block during permanent pacemaker implantation even in the absence of previous asystole.     

右美托咪定对小儿先天性心脏病外科手术麻醉血流动力学的影响

目的探讨右美托咪定对小儿先天性心脏病外科手术麻醉过程中血流动力学的影响。方法将68例在体外循环下行心脏手术的先天性心脏病患儿按随机数字法随机分为咪达唑仑组(n=34)和右美托咪定组(n=34)。麻醉诱导:两组均给予咪达唑仑0.2 mg/kg、芬太尼10μg/kg、维库溴铵0.2 mg/kg行麻醉诱导。麻醉诱导后,行气管内插管,机械通气。麻醉维持:咪达唑仑组输注咪达唑仑0.2 mg.kg-1.h-1和芬太尼10μg.kg-1.h-1,1 h后分别以0.1μg.kg-1.h-1和5μg.kg-1.h-1维持;右美托咪定组输注右美托咪定1μg.kg-1.h-1和芬太尼10μg.kg-1.h-1,1 h后分别以0.5μg.kg-1.h-1和5μg.kg-1.h-1维持。必要时以0.4%～1.0%异氟醚吸入维持麻醉。监测并记录记录麻醉诱导前、麻醉后1 h、切皮前、切皮后即刻、手术结束即刻、手术结束后10 min的血压和心率。结果两组患儿在输注麻醉药物1 h后,收缩压和心率均显著降低,差异有统计学意义(均P<0.05);在切皮时,咪达唑仑组收缩压、舒张压和心率较切皮前明显增高,且明显高于右美托咪定组,差异有统计学意义(均P<0.05);右美托咪定组较少患儿需加用异氟醚,与咪达唑仑组比较,差异有统计学意义[35.3%(12/34)vs.85.3%(29/34),χ2=17.752,P=0.000]。结论与咪达唑仑比较,右美托咪定可更有效的维持小儿先天性心脏病外科手术麻醉过程中的血流动力学稳定。     

Subarachnoid pleural fistula due to penetrating trauma: case report and review of the literature

We describe a case of a 30-year-old man who developed a recurrent pleural effusion after sustaining a gunshot wound to the left side of his chest with subsequent complete paralysis at the T2 level. Subarachnoid-pleural fistulas have rarely been reported as complications of penetrating and blunt trauma, thoracic surgery, as well as spinal surgery. Concomitant injuries may overshadow or complicate the diagnosis of subarachnoid-pleural fistulas. The diagnosis should be considered in any patient with a pleural effusion that is associated with severe neurologic injury, as the fistula rarely heals without surgical intervention and may lead to CNS infection or pneumocephalus.     

Side effects of amrinone therapy.

We gave intravenous amrinone to 40 patients in heart failure, and oral amrinone to 18 patients. Acute intravenous administration caused a significant reduction in mean blood pressure and this was severe enough to require correction by plasma infusion in five patients. Oral amrinone was accompanied by thrombocytopenia in 10 patients but no complications were associated with the low platelet count. Other potentially serious adverse effects were: abdominal pain (two patients), nausea and vomiting (three patients), jaundice (one patient), myositis (one patient), pulmonary infiltrates (two patients), and polyserositis (one patient). Less serious adverse effects observed were: splenomegaly, eosinophilia, fever, headache, reduced tear secretion, dry skin, and nail discoloration. The potentially severe adverse reactions with amrinone need to be weighed carefully against its benefits in the treatment of heart failure.