Biomedical subjects
Publications and source records attributed to E L Dunn.
Selective hepatic artery ligation (SHAL) was successfully employed to control delayed massive hepatic hemorrhage in two patients. Preoperative arteriography in one patient identified an anomalous origin of the right hepatic artery and facilitated SHAL.
Temporary ventricular pacing was successfully employed in two patients suffering refractory bradycardia following traumatic cardiac arrest. The hemodynamic response to pacing was dramatic and both patients eventually recovered fully from an apparent moribund state. Cardiac pacing may be an effective adjuvant in the early resuscitation of the massively injured patient.
Although hemostatic defects have been reported with large-volume autotransfusion, the effect on platelet function has not been well defined. Twenty adult mongrel dogs underwent controlled intraperitoneal hemorrhage with collection and reinfusion using the Sorenson System. Each animal was autotransfused twice its E.B.V. over a 4-hour period. A.C.D., delivered at the sucker tip, served as the only anticoagulant. Mean arterial pressure and cardiac output remained stable during the study period with the additional volume support of 50 cc/kg Ringer's lactate. A moderate consumptive coagulopathy ensued. The P.T., P.T.T., and T.C.T. were all significantly prolonged, with a decrease in fibrinogen at 4 hours compared to baseline. Platelet counts fell significantly to 71% of baseline. In addition, platelet aggregation response to A.D.P. and collagen was markedly depressed, with corresponding prolongation in bleeding times at 4 hours. Twenty-four hours following autotransfusion the P.T., P.T.T., T.C.T., and fibrinogen levels returned toward normal. In contrast, the platelet counts continued to fall and the aggregation response remained markedly impaired. Methylprednisolone (30 mg/kg), administered to 10 animals, had no statistically significant effect on the coagulation parameters.
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Anticoagulants in the form of heparin, dipyridimole, steroids, prostaglandin E1, Macrodex, and antithrombin III were administered in separate experiments prior to endotoxin infusion in the dog. The pattern of disseminated intravascular coagulation (DIC) developed consistently when endotoxin alone was administered. Heparin dosages from 1 to 10 mg/kg did not influence the appearance of thrombocytopenia but effectively eliminated the decrease in fibrinogen levels ordinarily found. Antithrombin III (AT III), obtained from the National Red Cross, administered in a dose designed to provide a doubling of the circulating AT III, reduced the fibrinogen utilization to a similar degree as heparin without affecting the platelet loss. Dipyridimole, as administered, was ineffective in this model, and did not alter the development of thrombocytopenia or the hypofibrinogenemia. Steroids, Macrodex, and prostaglandin E1 had minimal effect on the coagulopathy. Our finding would suggest that the endotoxin effect on dog platelets id direct, and not mediated by thrombin, and that the role of heparin in the clinical management of DIC should be considered only in instances in which renal complications exist.
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Early postoperative feeding with an elemental diet has been successful in elective gastrointestinal surgery. This study was undertaken to evaluate whether elemental feedings were feasible through a catheter jejunostomy in patients suffering massive abdominal and retroperitoneal injuries. Eight patients had a combination of hepatic, upper gastrointestinal, and pancreatic injuries. A 16-gauge intercath was placed in the proximal jejunum, and the constant infusion of elemental diet begun at 12 to 18 hr postoperatively. Within 2 days the patients were receiving 2200 to 2400 cal/day and were maintained at this level for 5 to 22 days (average 11 days) before oral intake could be resumed. Body weight, lean muscle mass, and serum albumin were maintained during this period. Transferrin levels and total lymphocyte count improved during the elemental feedings. All patients eventually recovered completely. There were no gastrointestinal complications associated with the early feeding. Catheter jejunostomy can provide early nutritional support in patients with massive abdominal injuries.
OBJECTIVE: To determine whether invasive hemodynamic monitoring resulted in an increased rate of aortic graft infection. DESIGN: Retrospective review with establishment of late follow-up. SETTING: Two referral teaching community medical centers. PATIENTS: Three hundred thirty consecutive patients who underwent elective aortoiliac (174), aortofemoral (91), or aortic tube (65) prosthetic graft placements during a 6-year period at the two institutions. All patients had percutaneous pulmonary artery catheter and radial artery cannula placement before surgery. Monitoring catheters were routinely removed within 72 hours. OUTCOME MEASURES: Early and late complications of catheter placement, perioperative morbidity and mortality, and late graft-related complications. RESULTS: Eighteen (5%) patients died in the perioperative period. Less than 2-year follow-up was possible in 67 patients. The remaining 245 patients were observed from 2 to 9 years (mean, 4.4 years). Graft infection was not identified in any patient. CONCLUSION: Routine invasive hemodynamic monitoring was not associated with an increase in the rate of prosthetic aortic graft infection.