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Biomedical subjects

F S Bongard

Publications and source records attributed to F S Bongard.

At least 19 recordsLinked to original sources
PubMed1992

Continuous dual oximetry in surgical critical care. Indications and limitations.

Continuous dual oximetry combines pulse and venous oximetry to provide real-time information about oxygen utilization and pulmonary function. The authors undertook this study to examine the accuracy, utility, and limitations of the technique in surgical critical care. Twelve critically ill patients underwent placement of a modified pulmonary artery catheter and a pulse oximeter, both connected to an on-line computer. Paired blood gas and oximeter measurements were recorded every 4 to 6 hours, with a minimum of six sets per patient. Blood-gas-derived shunt fraction correlated well with oximeter-derived ventilation-perfusion index (r = 0.78, p less than 0.01). Further, the continuous oxygen extraction ratio (O2EI) and mixed venous oxygen saturation (SpvO2) correlated with the oxygen utilization coefficient (O2EI:r = 0.6, p less than 0.01; SpvO2, r = 0.76, p less than 0.01). Computer modeling of ventilation-perfusion index found limitations in accuracy that occur at high arterial oxygen saturations and when pulse oximetry errors are present. The authors conclude that (1) Continuous dual oximetry offers a significant advantage over routine blood gas analysis for monitoring cardiopulmonary parameters in critically ill patients because of its real-time display; (2) Oximeter-derived determinations parallel traditional parameters; and (3) The most significant technical limitations occur primarily at high arterial saturations and with pulse oximetry errors.

Adolescent↗
PubMed1992

Contemporary management of amebic liver abscess.

In a retrospective review covering 16 years divided into two time periods, 133 patients with amebic liver abscess were evaluated. Most of the patients were young, Hispanic men, and one-third had coexistent disease. A reliable diagnosis can be established in 24 hours using ultrasound or computed tomography scans. Over the entire time period, antiparasitic therapy was evolved to occupy a primary role and surgery was reserved for management of abscess complications.

Academic Medical Centers↗
PubMed1991

Chylous ascites following abdominal aortic surgery.

Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided.

Aged↗
PubMed1991

Are blood cultures effective in the evaluation of fever in perioperative patients?

Blood cultures are routinely performed as part of the evaluation of fever in the perioperative period. Results of 364 blood culture vials representing 108 consecutive febrile events (temperature greater than or equal to 101.5 degrees F) in 72 patients on adult surgical services without evidence of sepsis in a metropolitan hospital were prospectively studied. Eighty-nine percent of patients had undergone an operation prior to the febrile episode. Microorganisms were isolated in blood culture vials from 9 of 108 patient febrile events. Of these blood cultures, five were positive (contained pathogens), and four represented contaminants. Two of five positive blood cultures occurred in patients with an identifiable source of bacteremia. The cost of processing all blood culture vials was $13,992, which amounted to $2,798 spent to identify each of the five patients with positive blood cultures. Blood culture vials were more likely to be positive if blood was drawn during postoperative days 4 through 10, as opposed to days 1 through 3, or if it was drawn from patients with factors depressing immune function or who had indwelling devices. Neither the magnitude of the absolute leukocyte count nor the maximum temperature at the time of phlebotomy predicted a positive blood culture. The use of resin vials produced sterile cultures in the 10 vials submitted. In no case did a positive blood culture have a measurable effect on reducing patient morbidity or mortality.

Adolescent↗
PubMed1991

Time-course of cardiopulmonary effects tumor necrosis factor and endotoxin are similar.

Tumor necrosis factor (TNF) is a postulated proximal septic mediator. The authors compared the time course and extent of the cardiopulmonary effects of recombinant human TNF (rTNF) in swine vs those of Escherichia coli endotoxin (ETX). Intravenous boluses of either rTNF (n = 4), ETX (n = 2), or saline (n = 4) were given to swine. Mean pulmonary artery pressure and extravascular lung water (EVLW) were increased at 60 minutes for rTNF and ETX to 31 +/- 2 mmHg and 33 +/- 3 mmHg and 6.3 +/- 0.9 ml/kg and 7.1 +/- 1.6 ml/kg, while saline animals were unchanged. The authors conclude that rTNF mimics ETX both in time course and magnitude of effects. Right-sided cardiopulmonary effects predominate in both with minimal left-sided effects at these dosages. The time course of early increased EVLW suggests an initial hydrostatic influence on pulmonary edema formation in this septic model.

Animals↗
PubMed1991

Septic embolism complicating infective endocarditis.

Embolic phenomena in patients with infective endocarditis may complicate the placement of a cardiac valvular prosthesis. To evaluate the vascular consequences of these emboli, a 15-year review of 102 patients undergoing valve replacement for proven infective endocarditis was undertaken. Thirty-one patients with 36 episodes of septic embolization were identified. Ten of these were separate extremity occlusive events. All patients with extremity emboli were admitted with pain; four had limb-threatening emboli. All patients grew gram-positive bacteria from their blood except a single Candida albicans isolate. Appropriate antimicrobial therapy was used in all patients. Angiography confirmed the diagnosis in 11 of 12 patients. Embolic targets included the lower extremities in all except a single instance. Four patients had multiple emboli. All but one of the vascular procedures were carried out subsequent to or simultaneously with cardiac valve replacement. Initial operative management included embolectomy (4) and primary amputation (2). Two delayed procedures were required. One patient died. Four patients had limited ischemia that resolved with antibiotics and anticoagulation. This report suggests that infective endocarditis requiring valvular replacement is associated with embolization in one third of patients. The presentation of peripheral vascular emboli is that of acute extremity ischemia. The diagnosis should be confirmed by angiography to rule out the possibility of multiple emboli. When possible, valve replacement should precede peripheral vascular management, which may include operative or medical components as dictated by the extent of limb ischemia.

Adult↗
PubMed1990

Inadequate bicarbonate resuscitation in trauma patients requiring crossclamping of the aorta.

The use of bicarbonate in the management of metabolic acidosis is controversial. We present three patients who required crossclamping of the aorta for control of shock and whose metabolic acidosis was inadequately treated with bicarbonate. Within minutes of aortic declamping, all became hypotensive and two went into refractory ventricular fibrillation and died. Arguments supporting the role of adequate bicarbonate resuscitation in this setting are discussed.

Acidosis↗
PubMed1990

Acute appendicitis in the pregnant patient.

Acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention. To establish a contemporary patient profile and formulate an effective management strategy, a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 27 patients (32%), the second trimester in 37 patients (44%), the third trimester in 13 patients (16%), and the puerperium in 7 patients (8%). Fifty-four patients (64%) had pathologically proven acute appendicitis; the incidence did not vary by trimester. Other intra-abdominal conditions were detected in 15 patients (18%). There were no significant differences between patients with positive and negative laparotomies (or among trimesters) regarding frequency of presenting symptoms and signs or laboratory results. Operation occurred within 24 hours of symptom onset in 19 of 54 (35%) instances of proven acute appendicitis. Perforation occurred in 23 of 54 patients (43%), all of whom had symptoms exceeding 24 hours (p less than 0.0005). Five instances of perinatal death and one case of extreme perinatal morbidity were associated with negative laparotomies; only one of these was attributed to operation itself. No adverse long-term maternal morbidity or mortality occurred. Wound infection developed in seven cases of acute appendicitis (six perforated) and two negative explorations. We conclude that (1) gestational physiologic changes obscure the accurate diagnosis of acute appendicitis; (2) the natural history of acute appendicitis is not affected by trimester of presentation; and (3) adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation.

Acute Disease↗
PubMed1990

Endovascular occlusive intervention in the management of trauma.

This report summarizes a 10-year experience (1978-1987) in a metropolitan hospital with 102 patients sustaining a variety of complex or inaccessible vascular injuries. Management included the application of occlusive interventional arteriographic techniques. Regional injuries included head and neck (56%), trunk (13%), and extremity (32%). Techniques of vascular occlusion were often performed in conjunction with the initial arteriographic evaluation and were comprised of particulate embolization (42%), placement of mechanical devices (36%), or tissue adhesives (1%), or a combination (21%). There were no deaths in this series and the only complications included four cases of dislodgement of the occlusive agent. We demonstrate that endovascular occlusion is a useful, safe and efficacious procedure in selected patients with complex, inaccessible or life-threatening vascular trauma.

Adolescent↗
PubMed1989

Management strategy of complex extremity injuries.

In this retrospective review of 37 patients with combined orthopedic and vascular injuries, our management strategy emphasized the prompt recognition of limb threat. Twenty-two patients had lower-extremity and 15 had upper-extremity injuries. No deaths occurred. Five delayed amputations were performed for limbs left denervated by associated soft tissue or neural injuries. No late vascular insufficiency was recorded in patients who underwent reconstruction with autogenous tissue. Whenever possible, the precise site of vascular injury was identified angiographically to help plan an approach that would provide adequate exposure for vessel repair as well as orthopedic stabilization. Vascular reconstruction typically preceded osseous stabilization. We conclude that improved outcome requires a coordinated multidisciplinary approach, expeditious limb revascularization, fasciotomy as indicated, rapid fixation of osseous injuries, and adequate soft tissue coverage of the underlying repair.

Adolescent↗
PubMed1989

The problem of vascular shotgun injuries: diagnostic and management strategy.

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.

Adult↗
PubMed1988

Neurovascular injuries of the thoracic outlet and axilla.

In this retrospective series of 46 patients with neurovascular injury of the thoracic outlet or axilla, our management strategy emphasized prompt recognition of trauma that may be superficially innocuous. Whenever possible, the precise site of vascular injury was identified arteriographically to help plan an incision that would provide proximal vascular control as well as expedient injury exposure. Vascular reconstruction was accomplished with either end-to-end primary anastomosis (n = 17) or autogenous saphenous vein graft interposition (n = 26). No case of ischemic limb loss occurred, although two repairs failed. Primary neural repair (n = 4) was possible only with simple laceration, but decompression of a tense hematoma led to prompt resolution of neuropraxia in nine patients. Secondary neural reconstruction was largely unsuccessful, and approximately 25 percent of our patients had serious chronic disability related to neural injury. In addition, two patients died as a consequence of numerous associated injuries.

Adolescent↗
PubMed1987

Risk of biliary surgery in patients with hyperbilirubinemia.

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.

Aged↗
PubMed1987

Burns in the elderly.

The records of 327 burn patients over age 65 show that flame burns were the most common causative agent and that more than 70 percent of all burns occurred in the home. Despite improved treatment, mortality from burns remains unacceptably high among the elderly. Future efforts must be directed toward the prevention of these injuries, especially those sustained in the home.

Accidents, Home↗
PubMed1985

New uses of fluorescence in the surgical management of necrotizing soft tissue infection.

The planning of incisions in the management of necrotizing soft tissue infections has largely been carried out by subjective methods. Because of disruption of the fasciocutaneous circulation, the perfusion of randomly based flaps is frequently tenuous. A method that provides safe, rapid, and accurate evaluation of tissue perfusion would therefore prove invaluable in the preoperative planning, as well as in the postoperative management of these infections. The digital dermofluorometer is a recently introduced instrument that objectively evaluates skin blood flow based on the cutaneous delivery of sodium fluorescein. We have used the technique successfully and without incident in patients who presented with necrotizing soft tissue infections. The theory, methods, and application of the test have been presented along with two case reports.

Adult↗
PubMed1985

Report from the California Burn Registry--the causes of major burns.

In its first four years of operation, the California Burn Registry recorded 3,332 cases of burns, of which 73.1% were in male and 26.9% were in female patients of all ages. The average total body surface area burned was 15.4+/-0.3%. Flame burns were the most common (31.4%). Other common sources included scalds (24.5%) and flammable liquids (12.9%). Several other causes were cited with less frequency. Burns taking place at home occurred more commonly than at all other locations combined. In all, 221 deaths (6.6%) were reported, most (66.1%) of which were due to flame burns.

Adolescent↗