Radiographic pulmonary abnormalities after pediatric cardiac surgery.
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Bronchi↗
Biomedical subjects
A Bach
Publications and source records attributed to A Bach.
Safety of a guidewire technique for replacement of pulmonary artery catheters.
The purpose of this study was to determine if a guidewire change from a pulmonary artery catheter (PAC) to a central venous catheter (CVC) poses a significant infection risk. A total of 128 consecutive cardiac surgical patients with PACs inserted in the operating room were entered into this study. Postoperatively, patients were randomly allocated to receive a double-lumen CVC, either at the initial introducer insertion site over a guidewire, or at a new site with de novo catheterization. The tips of all introducers, PACs, and CVCs were cut off, cultured, and semi-quantitatively analyzed. The results show that insertion of CVCs over a guidewire within 48 hours after initial venapuncture is no more likely to be associated with catheter colonization than is de novo percutaneous insertion at a different site. From 48 hours up to 72 hours following initial insertion of the PAC, an incidence of catheter-related infection of 35.3% was observed in the guidewire group, as opposed to 12.5% in the de novo group. It is recommended that the use of a guidewire technique for catheter replacement (PAC to CVC) is a safe alternative to de novo insertion of a CVC within 48 hours after initial insertion of the PAC. In order to minimize the potential risk of catheter-related infection and bacteremia in cardiac surgical patients, de novo catheterization beyond 48 hours after initial venapuncture is suggested.
Bacteremia↗
Nosocomial sinusitis in ventilated patients. Nasotracheal versus orotracheal intubation.
A total of 68 postoperative patients whose lungs were ventilated for more than 4 days were studied prospectively during a one-year study period to investigate the effect of the mode of intubation on the paranasal sinuses. After an initial X ray of the skull showing no pathological findings, patients were assigned randomly to one of the study groups; the lungs of patients in group A were ventilated via an orotracheal tube (n = 32), and patients in group B via a nasotracheal tube (n = 36). X ray examinations of the sinuses were performed at regular intervals. Diagnosis of sinusitis was confirmed by transantral needle puncture and culture of fluids obtained. Antibiotic regimens were altered according to laboratory testing. Two patients in group A developed signs of sinusitis in comparison to 15 patients in group B (p less than 0.01). However, there were significantly more airway complications in the orotracheal group, particularly during the period of weaning from ventilation. We conclude that orotracheal intubation should be preferred as the routine route of intubation.
Aged↗
Infectious risk of replacing venous catheters by the guide-wire technique.
During the perioperative period cardiac surgical patients are often monitored by pulmonary artery (PA) catheters. This catheter, which is floated through the right heart into the pulmonary artery, enables the intensivist to measure and calculate indices of myocardial performance. After a variable period of time this invasive monitoring can often be abandoned following cardiovascular stabilization in these patients, but patients usually still require a central venous (CV) access for diagnostic and therapeutic purposes. To place this CV catheter either a de novo puncture at a new site or a guide-wire change at the existing exit site through the PA catheter in place can be performed. Each de novo puncture is associated with a risk of traumatising internal vessels or organs. In contrast, guide-wire change avoids this risk but inherits a potential risk of transferring bacteria by manipulation of contaminated lines. Our study included 159 consecutive cardiac surgical patients in whom PA monitoring was established preoperatively and terminated within a period of up to 72 hours postoperatively. At random the PA catheter was replaced by a CV line either by de novo puncture or by guide-wire change. All CV lines were left in place for 7 days according to standard practice in our intensive care unit (ICU). After removal of CV catheters all catheter tips were cultured semiquantitatively by rollplate technique according to Maki (26) and subsequent immersion broth culture. A positive culture was defined as growth of one up to 15 colonies on the agar-plate or any microbial growth in the broth. A significant colonization was assumed in catheters yielding more than 15 colony forming units (cfu) on the blood agar plate (26). Our results show a significant risk of colonization and catheter-related infection associated with the guide-wire technique as opposed to the de novo puncture. The figures for relevant colonization were 33.3% in the guide-wire group as opposed to 10.5% in the de novo group. However, this difference was noted only in the subgroup in which replacement of PA catheters by CV catheters was performed beyond 48 h after initial insertion of PA catheters. Within the time intervals of 24 and 25 to 48 h, respectively, we could not detect any significant difference between groups.
Aged↗
[Surfactant administration in acute respiratory failure].
We report the case of a 21-year-old man who developed adult respiratory distress syndrome (ARDS) after severe lung contusion due to a car accident. At the scene of the accident the patient was awake and oriented, but there were signs of hypoxaemia (SaO2 by pulse oximetry: 86%). The trachea was intubated in the emergency room and, after diagnosis of multiple rib fractures on the right side (the patient nos. 4-11) and emergency treatment, was extubated 16 h later. During spontaneous breathing there was no improvement of pulmonary function, and the patient was transferred to the intensive care unit 5 days later and reintubated because of acute respiratory failure. He then developed the signs of severe ARDS. No improvement occurred during conventional ventilatory treatment including inversed-ratio ventilation, high-frequency ventilation, and ventilation via a double-lumen tube. On day 15 a bovine surfactant preparation (38 mg/kg body wt.) was instilled into both lungs. Initially there was deterioration of the pulmonary function, probably due to crusts in the bronchial mucous membrane. After aspiration of the crusts at bronchoscopy, there was progressive respiratory improvement. The inspired oxygen concentration and PEEP level could be reduced, and the ventilatory ratio normalised within 14 days. This therapeutic intervention improved pulmonary function and probably led to the successful outcome after 36 days of ventilatory support.
Accidents, Traffic↗
[Osteomyelitis around a knee prosthesis due to Streptococcus anginosus].
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Aged↗
[Cognitive and psychomotor performance following isoflurane, midazolam/alfentanil and propofol anesthesia. A comparative study].
Mental and psychomotor abilities are impaired to varying degrees after general anaesthesia. This has important implications for the time over which patients are monitored in the recovery room and for the discharge of outpatients after day surgery. The present study was undertaken to compare recovery and mental and psychomotor skills in the first 60 min following general anaesthesia with isoflurane, midazolam/alfentanil and propofol. METHODS. A total of 45 patients undergoing microsurgical lumbar nucleotomy were randomized to three study groups. Group 1 (n = 15): anaesthesia was induced with thiopentone and maintained with isoflurane; group 2 (n = 15): anaesthesia was induced with midazolam and maintained with alfentanil; group 3 (n = 15): anaesthesia was induced and maintained with propofol. Vecuronium was used for muscle relaxation and the lungs were ventilated with a mixture of 66% nitrous oxide in oxygen. The following were checked 15, 30, 45, and 60 min after extubation: choice reaction times and critical flicker fusion for psychomotor testing; the maze test and a modification of the ball-bearing test for discrimination of motor and mental activities; and short- and long-term memory. RESULTS. Immediate recovery did not differ in the three different groups. In all patients psychomotor function was impaired compared with baseline for more than 60 min after general anaesthesia. However, impairment was significantly less pronounced after propofol, and recovery to preanaesthesia values was faster following propofol than after midazolam/alfentanil, and slowest after isoflurane-anaesthesia (Figs. 1, 2). The flicker fusion frequency, a very sensitive parameter for the persisting effects of anaesthetics, was significantly higher following propofol anaesthesia and remained so throughout the entire study period (Fig. 3). By 30 min after extubation, short-term memory was already normal in patients who had undergone propofol anaesthesia, and a statistically significant difference from the midazolam/alfentanil and isoflurane anaesthesia groups was obvious throughout the entire study period. However, no differences in long-term memory were found. At 30 min after propofol anaesthesia all patients were able to perform the ball-bearing test, as against 13 patients following midazolam/alfentanil and 10 patients following isoflurane (Table 3). The maze test was mostly impaired after midazolam/alfentanil anaesthesia. Patients who underwent isoflurane anaesthesia needed the same time for the maze test at 60 min afterwards propofol patients needed after 30 min (Table 2). Side effects, e.g., nausea, vomiting, and double vision, were observed significantly more often in groups 1 and 2 (Table 4). DISCUSSION AND CONCLUSION. The results indicate that in operations of approximately 90 min duration the return of motor and mental abilities is faster following propofol anaesthesia. At 30 min after extubation following propofol anaesthesia patients had test results that allow their transfer from the recovery room, while it took 60 min for patients in the two other groups to reach the same levels of motor and mental function. This is important for the duration of monitoring in the recovery room and, especially, for day case anaesthesia.
Adult↗
A phase II multi-institutional trial of low-dose N-(phosphonacetyl)-L-aspartate and high-dose 5-fluorouracil as a short-term infusion in the treatment of adenocarcinoma of the pancreas. A Southwest Oncology Group study.
Adenocarcinoma of the pancreas is a highly lethal malignancy and chemotherapy has had little impact on the natural history of this disease. PALA, used to potentiate 5-fluorouracil (5-FU), has been shown to have synergy in vivo and in vitro. Twenty-seven patients were treated with an intravenous push dose of PALA (250 mg/m2) followed 24 hours later with a 24-hour infusion of 5-FU (2600 mg/m2). This regimen was repeated weekly. There was one partial response of 21 eligible patients with an estimated response rate of 5%. Toxicity was severe with one toxic death and four patients experiencing Grade 4 toxicity. 5-Fluorouracil and PALA, given in the schedule described, do not appear to be effective against adenocarcinoma of the pancreas.
Adenocarcinoma↗
Molecular cloning and characterization of a rat brain cDNA encoding a 5-hydroxytryptamine1B receptor.
To date, there have been at least eight different receptors for the neurotransmitter serotonin (5-HT) identified in the central nervous system. These receptors fall into four pharmacological classes: 5-HT1, 5-HT2, 5-HT3 and 5-HT4. The 5-HT1 class has been shown to contain at least four pharmacologically distinct subtypes, 5-HT1A-D. Of these, cDNAs encoding the 5-HT1A and 5-HT1C receptors have been previously characterized. We now report the cloning and expression of a rat brain cDNA encoding another member of the 5-HT1 receptor family. Transient expression of this clone demonstrated high-affinity binding of [3H]5-HT with a pharmacological profile corresponding to that of the 5-HT1B subtype: 5-CT, 5-HT greater than propranolol greater than methysergide greater than rauwolscine greater than 8-OH-DPAT. In situ hybridization revealed expression of cognate mRNA within cells of the dorsal and median raphe nuclei, consistent with previous reports that the 5-HT1B receptor acts as an autoreceptor on 5-HT terminals in this species. mRNA expression was also detected in cells within the CA1 region of hippocampus, striatum, layer 4 of cortex and in the cerebellum, suggesting a previously unrecognized post-synaptic role for the 5-HT1B receptor.
8-Hydroxy-2-(di-n-propylamino)tetralin↗
Marked decrease in arterial oxygen tension associated with continuous intravenous nifedipine administration.
Intravenous nifedipine was administered to treat arterial hypertension in a 54-year-old woman presenting for removal of a meningioma. A marked decrease in arterial oxygen tension occurred during the nifedipine infusion. Inhibition of hypoxic pulmonary vasoconstriction by nifedipine is discussed.
Arteries↗
[Transfusion-induced Yersinia infection].
After a primary operation for renal artery stenosis a 48-year-old woman had to be re-operated twice for renewed arterial stenosis and retroperitoneal bleeding. The patient's respiratory and cardiovascular functions were stable two days after the second operation and renal function was recovering. But because of suspected renewed bleeding a transfusion with erythrocyte concentrate was begun. Fifteen minutes later the patient started to shiver and this was followed by signs of cardiocirculatory decompensation under the picture of a septic-toxic shock. Laboratory tests did not indicate a haemolytic transfusion reaction. Controlled mechanical ventilation and circulatory drug support were required over the next two days, renewed anuria persisting for longer than a week. Microbiological tests of the erythrocyte concentrate demonstrated Yersinia enterocolitica, serotype 03. Questioning of the blood donor revealed a mild gastroenteritis at the time of donation. This case underlines the need of excluding donors, if only temporarily, when there is even slight suspicion of a Yersinia infection.
Blood Donors↗
Clonidine as a sedative adjunct in intensive care.
A 63-year-old man underwent distal oesophagectomy and proximal gastrectomy. Postoperatively, controlled ventilation was necessary for 53 days because of anastomotic leakage. Multiple sedative regimens proved to be inadequate. By contrast, a fentanyl-midazolam combination with continuous supplementation of clonidine 0.014 micrograms kg-1 min-1 (1.44 mg 70 kg-1 24 h-1) was very effective in terms of sedation and pain relief. During combined fentanyl-midazolam and clonidine infusion, cardiovascular depression gradually developed over several days necessitating the institution of a dobutamine infusion (dose: 8-12 micrograms kg-1 min-1). Four attempts of abrupt clonidine withdrawal were followed by sympathetic overshoot reactions consisting of tachycardia, hypertension, agitation, and sweating. Discontinuation of clonidine was finally possible after a 12-day weaning period.
Clonidine↗
Trigger thumbs in children: a follow-up study of 37 children below 15 years of age.
37 patients who had been operated upon for trigger thumb, all below 15 years of age, have been reviewed. 75% of the affected thumbs were on the dominant hand and 25% have bow-stringing of 1-2 mm. without any complaints. All had good results. Unlike other authors, we found that operation done after the third year of age gave full correction of the flexion contracture.
Child↗
The complete sequence of the human beta-myosin heavy chain gene and a comparative analysis of its product.
We have isolated and sequenced the gene and the cDNA coding for the human cardiac beta-myosin heavy chain (designated MYH7). The gene is 22,883 bp long. The 1935 amino acids of this protein (Mr223,111) are encoded by 38 exons. The 5' untranslated region (86 bp) is split by two introns. The 3' untranslated region is 114 bp long. Three Alu repeats were identified within the gene and a fourth one in the 3' flanking intergenic region. The molecular organization of this gene reflects the conservative pattern with respect to size, coding ratio, and number or position of introns characteristic of vertebrate sarcomeric myosin heavy chain genes. The protein sequence of the human beta-heavy chain was compared with corresponding (homologous) sequences of rabbit, rat, and hamster as well as with the (heterologous) embryonic heavy chain sequences of rat, chicken, and man. The results show that protein subregions responsible for basic functions of myosin heavy chains (nucleotide binding and actin binding) are very similar in homologous and heterologous heavy chains. Regions that differ in their primary sequences in heterologous heavy chains appear to be highly conserved within mammalian beta-myosin heavy chains. Constant and variable subregions of heavy chains are discussed in terms of functional significance and evolutionary relatedness.
Amino Acid Sequence↗
Adverse haemodynamic effects of high-dose aprotinin in a paediatric cardiac surgical patient.
High-dose aprotinin for reduction of intra- and postoperative blood loss was associated with profound hypotension and flushing in a 3.5-year-old child who underwent cardiac surgery. Treatment with noradrenaline and intravenous fluid was required. Cardiovascular stability was restored after 10 minutes.
Aprotinin↗
[Muscle relaxants for kidney transplantation. A comparison between vecuronium and atracurium].
A total of 26 patients with end-stage renal failure were assigned randomly to receive either atracurium (A) or vecuronium (V) for intra-operative relaxation during kidney transplantation. Following the induction of balanced anesthesia an initial bolus dose of A 0,5 mg/kg body weight (BW) or V 0,1 mg/kg BW was administered. Relaxation was maintained by repeated doses of A 0,1 mg/kg BW or V 0,02 mg/kg BW whenever the twitch height (T1) recovered to 20% of the control value. Neuromuscular function was monitored throughout using the train-of-four twitch technique. There were no significant differences in time of onset (A: 219 +/- 87 s, V: 206 +/- 70 s), initial clinical duration (T1 = 0% to T1 = 20%; A: 39 +/- 12 min, V 39 +/- 8 min) or recovery index (A: 19 +/- 6 min, V: 22 +/- 7 min). The clinical duration (T1 = 20% to T1 = 20%) was significantly different for A, with 27 +/- 9 min than for V, with 32 +/- 7 min (P less than 0.05, Wilcoxon-Mann-Whitney U-Test; all values means +/- standard deviation). Reversal of relaxants was mandatory according to electromyographic and clinical criteria in only one patient in the A group but in 5 in the V group (P less than 0.05, Fisher's exact test). We conclude that A might be more suitable in patients with renal insufficiency and that monitoring of neuromuscular transmission is highly valuable in this risk group.
Adult↗
The dopamine D2 receptor: two molecular forms generated by alternative splicing.
Cloned human dopamine D2 receptor cDNA was isolated from a pituitary cDNA library and found to encode an additional 29 amino acid residues in the predicted intracellular domain between transmembrane regions 5 and 6 relative to a previously described rat brain D2 receptor. Results from polymerase chain reactions as well as in situ hybridization revealed that mRNA encoding both receptor forms is present in pituitary and brain of both rat and man. The larger form was predominant in these tissues and, as shown in the rat, expressed by dopaminergic and dopaminoceptive neurons. Analysis of the human gene showed that the additional peptide sequence is encoded by a separate exon. Hence, the two receptor forms are generated by differential splicing possibly to permit coupling to different G proteins. Both receptors expressed in cultured mammalian cells bind [3H]spiperone with high affinity and inhibit adenylyl cyclase, as expected of the D2 receptor subtype.
Amino Acid Sequence↗