Open technique for removal of intraarterial sheath after urokinase infusion in patients undergoing heparinization.
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Catheterization, Peripheral↗
Biomedical subjects
H B Kram
Publications and source records attributed to H B Kram.
Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients.
In a series of 253 high-risk surgical patients, we measured the oxygen consumption (VO2) at frequent intervals before, during, and immediately after surgical operations and calculated the rate of VO2 deficit from the measured VO2 minus the VO2 need estimated from the patient's own resting preoperative control values corrected for both temperature and anesthesia. The calculated oxygen deficit was related to multiple organ failure, complications, and outcome. The 64 patients who died all had organ failure; their cumulative VO2 deficit averaged 33.2 +/- 4.0 L/m2 (+/- SEM) at its maximum, which occurred 17.8 +/- 2.2 h after surgery. In the 31 survivors with organ failure, the cumulative VO2 deficit averaged 21.6 +/- 3.7 L/m2 at its maximum, which occurred 10.1 +/- 2.7 h after surgery (p less than 0.05). In the 158 survivors without organ failure or major complications, the maximum cumulative VO2 deficit averaged 9.2 +/- 1.3 L/m2 at 4.1 +/- 0.6 h after surgery (p less than 0.05). In a prospective randomized clinical trial, a protocol group maintained at supranormal hemodynamic and oxygen transport values had significantly reduced oxygen debt (7.6 +/- 3.4 L/m2 vs 17.3 +/- 6.8 L/m2; p less than 0.05), fewer organ failures, and lower mortality (4 percent vs 33 percent; p less than 0.05) compared with a control group maintained at normal hemodynamic values. The data demonstrate a strong relationship between the magnitude and duration of the VO2 deficit in the intraoperative and early postoperative period and the subsequent appearance of organ failure and death. The latter may be reduced when oxygen debts were prevented or minimized by augmenting naturally occurring compensations that increased oxygen delivery.
Adult↗
Hemodynamic and oxygen transport patterns for outcome prediction, therapeutic goals, and clinical algorithms to improve outcome. Feasibility of artificial intelligence to customize algorithms.
A generalized decision tree or clinical algorithm for treatment of high-risk elective surgical patients was developed from a physiologic model based on empirical data. First, a large data bank was used to do the following: (1) describe temporal hemodynamic and oxygen transport patterns that interrelate cardiac, pulmonary, and tissue perfusion functions in survivors and nonsurvivors; (2) define optimal therapeutic goals based on the supranormal oxygen transport values of high-risk postoperative survivors; (3) compare the relative effectiveness of alternative therapies in a wide variety of clinical and physiologic conditions; and (4) to develop criteria for titration of therapy to the endpoints of the supranormal optimal goals using cardiac index (CI), oxygen delivery (DO2), and oxygen consumption (VO2) as proxy outcome measures. Second, a general purpose algorithm was generated from these data and tested in preoperatively randomized clinical trials of high-risk surgical patients. Improved outcome was demonstrated with this generalized algorithm. The concept that the supranormal values represent compensations that have survival value has been corroborated by several other groups. We now propose a unique approach to refine the generalized algorithm to develop customized algorithms and individualized decision analysis for each patient's unique problems. The present article describes a preliminary evaluation of the feasibility of artificial intelligence techniques to accomplish individualized algorithms that may further improve patient care and outcome.
Algorithms↗
Perforated ulcers related to smoking "crack" cocaine.
This article describes four patients with perforated gastroduodenal ulcers related to smoking "crack" cocaine. All patients came to the hospital with acute abdominal pain; only one patient had a history of ulcer disease. Only one patient had an elevated white blood cell count, and two patients had depressed white blood cell counts. In three patients, the x ray showed that pneumoperitoneum was present. Upon surgical exploration of the abdomen, all patients were found to have extensive peritoneal contamination. Operative repair consisted of omental patching with or without primary closure of the perforation. A history of cocaine smoking should be sought in patients with unexplained abdominal pain or pneumoperitoneum. In patients with acute abdominal pain and a history of smoking cocaine, a perforated gastroduodenal ulcer may be present, despite normal or low white blood cell counts and the lack of pneumoperitoneum on x-ray examination.
Adult↗
Unilateral aortofemoral bypass: a safe and effective option for the treatment of unilateral limb-threatening ischemia.
To determine whether unilateral aortofemoral (AUF) bypass is a safe and effective option for the treatment of unilateral limb-threatening ischemia in patients with aortic or bilateral iliac occlusive disease, we reviewed the results of 42 AUF bypasses performed using polytetrafluoroethylene grafts in patients operated on for limb salvage; 11 (26%) of the patients also underwent femoropopliteal or femorodistal (FP/D) bypasses. The indications for surgery were tissue necrosis or ulceration in 18 (43%) patients and rest pain in 17 (40%) patients. The 5-year primary graft patency and limb salvage rates for AUF bypass were 74% and 84%, respectively. The perioperative mortality rate was 5%. There were no significant differences in the primary graft patency or limb salvage rates in patients who underwent AUF bypass with or without FP/D bypass. Only 3 of 41 (7%) AUF bypass patients required subsequent femorofemoral bypass. We conclude that: (1) AUF bypass is a safe and effective surgical option in patients with unilateral limb-threatening ischemia and aortic or bilateral iliac occlusive disease; (2) the routine performance of an aortobifemoral or axillobifemoral bypass in patients with unilateral limb-threatening ischemia may be unnecessary; and (3) AUF bypass facilitates the combined inflow and infrainguinal operations that are frequently required for limb salvage in these patients.
Adult↗
Fibrin glue sealing of pancreatic injuries, resections, and anastomoses.
Fibrin glue made with highly concentrated human fibrinogen and clotting factors was evaluated as a means of preventing pancreatic fistulas in 15 patients operated on for traumatic and nontraumatic conditions. Fibrin glue was applied directly to penetrating pancreatic injuries, pancreatic suture and staple lines in patients treated by partial resection, and pancreaticointestinal anastomoses. Postoperatively, no patient developed pancreatic fistulas, pancreatic abscesses, or pseudocysts. Fibrin glue sealing of pancreatic injuries, resections, and anastomoses may aid in preventing fistulas after pancreatic surgery. Additional potential uses include the sealing of pancreatic biopsy sites and occlusion of the pancreatic duct in pancreatic transplantation.
Anastomosis, Surgical↗
Antibacterial effects of fibrin glue-antibiotic mixtures.
In the present in vitro study, we investigated the duration of action and antibacterial effects of nonautologous fibrin glue (FG) combined with antibiotics (Abs) including Ciprofloxacin, Teicoplanin, Cefoxitin, and Gentamicin; the effect of FG alone on bacterial growth was also evaluated. The rate of Ab diffusion from combined FG-Ab clots was evaluated by separate elution with pooled human serum (HS) and normal saline (NS); supernatants were removed daily and assayed for active concentrations of each Ab. The effects of FG and combined FG-Ab clots on bacterial growth were evaluated by inoculating brain-heart infusion (BHI) with Staphylococcus aureus, followed by the addition of FG or FG-Ab clots; a separate set of studies was also performed with the addition of mouse lung homogenate (MLH) as well. The addition of Ab to FG clots resulted in continuous diffusion of the Ab into the surrounding HS or NS for up to 5 to 7 days; however, more than two-thirds of the Ab diffused out within 2 to 3 days regardless of the Ab used. The antibacterial effects of FG-Ciprofloxacin and FG-Teicoplanin clots were significant compared to those of FG clots not containing Ab. In addition, the presence of FG clots (in BHI) resulted in a reduction in bacterial growth compared to that of BHI alone. The addition of MLH to BHI resulted in increased bacterial growth, but this effect was inhibited by the presence of combined FG-Ab clots.(ABSTRACT TRUNCATED AT 250 WORDS)
Anti-Bacterial Agents↗
Oxygen transport measurements to evaluate tissue perfusion and titrate therapy: dobutamine and dopamine effects.
BACKGROUND: Increased cardiac index, oxygen delivery (DO2), and oxygen consumption (VO2) patterns were shown to characterize the physiologic status of surviving high-risk surgical patients, and indicate increased metabolic needs; relatively normal DO2 and VO2 values were found to characterize the sequential pattern of nonsurvivors who developed an early oxygen debt followed by lethal organ failure. The cardiac index, DO2, and VO2 values empirically determined from survivors' patterns were shown to improve outcome in prospective randomized trials. The present study considers these criteria to evaluate the tissue perfusion status as well as the effects of therapy on tissue perfusion and oxygenation. OBJECTIVE: To summarize new information on the temporal patterns of DO2, VO2, and oxygen debt on outcome and the effects of fluids and inotropes on these patterns in a wide range of clinical, temporal, and physiologic conditions. DESIGN: Descriptive analysis based on data gathered prospectively using a specified protocol. PATIENTS: High-risk patients with accidental or elective surgical trauma, and patients with or without sepsis or septic shock and organ failure. SETTING: University-run county hospital with a large trauma service. INTERVENTIONS: Fluids, dobutamine, and dopamine at various times and at various doses throughout critical illness of postoperative, posttraumatic, septic, and hypovolemic patients with and without lethal and nonlethal organ failure. MEASUREMENTS AND MAIN RESULTS: The pattern of DO2 plotted against the corresponding VO2 values in 437 consecutive critically ill surgical patients showed a wide variability and poor correlation probably because complex clinical conditions may obscure the supply-dependent and supply-independent VO2 relationships observed in normal dogs bled or given bacterial infusions. However, the use of specific therapy by well-defined protocols was shown to provide objective evidence of efficacy. Significant increases in DO2 and VO2 were previously shown after whole blood, packed red cells, and colloid administration, but not after crystalloid administration. Dobutamine administration in 715 circumstances in postoperative, traumatic, septic patients and patients with adult respiratory distress syndrome, renal failure, and multiple organ failure significantly improved DO2 and VO2. Dopamine under comparable conditions produced less improvement in DO2 and VO2 than that of dobutamine; most of the VO2 changes were not significant. CONCLUSIONS: The monitored patterns of cardiac index, DO2, and VO2 may be used to evaluate the adequacy of tissue perfusion as well as the relative effectiveness of alternative therapies. Second, these physiologic criteria may be used to titrate therapy in order to achieve optimal outcome. Third, after colloids optimally expand the plasma volume, dobutamine may be used to enhance flow and the distribution of flow in order to improve tissue oxygenation. Vasodilators may be used when hypertensive episodes occur or there is an inadequate response to inotropic agents. Vasopressors are used as a last resort, usually in the terminal or preterminal state.
Acute Kidney Injury↗
Effects of prostaglandin E1 in postoperative surgical patients with circulatory deficiency.
Hemodynamic and oxygen transport effects of PGE1 were observed in the early postoperative period before development of ARDS in two series of general surgical patients with circulatory deficiencies. The first was a series of 19 studies in 18 patients, the second was a placebo-controlled series of 20 patients (ten received PGE1 and ten received a placebo). In the first series, PGE1 was given as a trial of therapy after fluid therapy to pulmonary wedge pressures greater than 15 mm Hg failed to correct satisfactorily circulatory and metabolic functions. There were two deaths in the placebo group and none in the PGE1 group. Previous studies indicated that PGE1 disaggregates platelets and reduces local vasoconstriction in pulmonary circulation; this study suggests that PGE1 improves tissue perfusion of systemic circulation. After fluid therapy to PAOP greater than 15 mm Hg fails to restore circulatory function to optimal values. PGE1 should be considered as ancillary therapy in critically ill postoperative patients.
Alprostadil↗
Late results of two hundred seventeen femoropopliteal bypasses to isolated popliteal artery segments.
A 10-year-experience of 217 femoropopliteal bypasses to isolated popliteal artery segments in 207 patients is reported. Thirty-three femoropopliteal bypasses (15%) were performed with reversed saphenous vein and 184 (85%) with polytetrafluoroethylene grafts. Operative indications were gangrene in 121 (56%), nonhealing ulceration in 40 (18%), ischemic rest pain in 51 (24%), and claudication in 5 (2%) cases. The 5-year primary graft patency rate of these bypasses was 59% (reversed saphenous vein, 74%; polytetrafluoroethylene, 55%; p less than 0.05), the secondary 5-year graft patency rate was 61% (reversed saphenous vein, 79%; polytetrafluoroethylene, 56%; p less than 0.05), and the 5-year limb salvage rate was 78% (reversed saphenous vein, 78%; polytetrafluoroethylene, 78%). The 30-day operative mortality rate was 10%, and the 5-year patient survival rate was 38%. Eleven patients (5%) required lower extremity amputation because of progressive gangrene or extensive infection despite a patent bypass to an isolated popliteal artery segment. We conclude that femoropopliteal bypasses to isolated popliteal artery segments (1) have acceptable 5-year graft patency and limb salvage rates; (2) should be performed with reversed saphenous vein grafts when possible; (3) may be performed with polytetrafluoroethylene grafts if necessary, with a resulting limb salvage rate equal to that of reversed saphenous vein grafts; and (4) require sequential extension to an infrapopliteal artery in up to 20% of patients. In addition, the presence of an isolated popliteal artery segment is associated with a high operative mortality rate and limited life expectancy because of coronary artery disease.
Adult↗
Prospective, randomized comparison of ringed and nonringed polytetrafluoroethylene femoropopliteal bypass grafts: a preliminary report.
Kinking and compression with knee flexion are thought to be one cause of failure of below-knee polytetrafluoroethylene femoropopliteal bypass. To prevent this problem polytetrafluoroethylene grafts externally supported with rigid rings have been developed. The present randomized, prospective study compared ringed and nonringed polytetrafluoroethylene grafts in 122 patients who underwent femoropopliteal bypass for severe limb ischemia. Patients were well matched for surgical indications and risk factors. There was no significant difference in the 3-year graft patency rate of ringed versus nonringed polytetrafluoroethylene femoropopliteal bypasses (74% vs 68%, p = 0.5). Similarly, no significant differences were found in the 3-year graft patency rates of ringed versus non-ringed above-knee (82% vs 74%, p = 0.5) or below-knee polytetrafluoroethylene femoropopliteal bypasses (68% vs 59%, p = 0.5). The 3-year graft patency rate of all above-knee polytetrafluoroethylene femoropopliteal bypasses was slightly greater than that of below-knee polytetrafluoroethylene femoropopliteal bypasses (76% vs 62%), but this difference was not statistically significant (p = 0.25). The 3-year limb salvage rate with ringed polytetrafluoroethylene grafts was 92% compared with 79% for nonringed polytetrafluoroethylene grafts, but this difference was not statistically significant (p = 0.25). Data to date from this study fail to support the recommendation that ringed polytetrafluoroethylene grafts be used preferentially over conventional polytetrafluoroethylene grafts in patients who require femoropopliteal bypass with a synthetic graft.
Adult↗
Spraying of aerosolized fibrin glue in the treatment of nonsuturable hemorrhage.
In the present report, the authors describe the use of aerosolized fibrin glue (FG) to achieve hemostasis in patients with nonsuturable hemorrhage. The multicomponent FG was sprayed on bleeding tissues with a dual chamber spray head that allowed simultaneous application and mixing of fibrinogen and thrombin on the tissue surface. Sterile propellant gas was passed through tubing to the spray head and independently controlled, allowing for drying of the tissue surface immediately before FG application. This technique was found to be effective in achieving hemostasis of parenchymal organs, retroperitoneal surfaces, and skin graft donor sites. Additional potential applications of this technique include the control of hemorrhage from mediastinal and pleural surfaces.
Aerosols↗
Clinical algorithm for initial fluid resuscitation in disasters.
This article reviews past experience with branch-chain decision trees for fluid resuscitation of various emergency conditions and analyzes the effects of compliance with the algorithm on mortality and shock-related complications. On the basis of this analysis, the authors propose a new algorithm for fluid resuscitation of mass casualties when only palpable systolic blood pressure is available and when blood pressure, hematocrit, central venous pressure, urine output, and arterial blood gases are available.
Algorithms↗
Evaluation of a blunt and penetrating trauma algorithm for truncal injury.
The authors objective was to develop and test a single branch-chain decision tree for blunt and penetrating truncal injury. Over the 4-month study period there were 979 patients evaluated in the emergency department; 674 of these patients were admitted to the hospital. Thirty-four (5%) of the 674 admitted patients died of truncal injury. The study group consisted of 239 of the most severely injured patients; 41 of these (17%) died. Of the 44 patients managed with major deviations from the algorithm, 27 (61%) died. Only 14 of the 195 patients (7%) whose management complied with the algorithm died. The authors conclude that following the specific management criteria outlined by the algorithm may improve the survival of severely traumatized patients.
Abdominal Injuries↗
The efficacy of central venous and pulmonary artery catheters and therapy based upon them in reducing mortality and morbidity.
The purpose of this study was to (1) evaluate the relative cost effectiveness of the central venous pressure and flow-directed pulmonary artery catheters used to maintain normal hemodynamic values as therapeutic goals in the control groups vs supranormal values empirically observed in critically ill postoperative survivors in the protocol groups, and (2) to evaluate tissue perfusion and oxygenation in relationship to organ failure and mortality. In two prospective clinical trials there were no significant differences in outcome between the central venous pressure and pulmonary artery control groups that used normal values as therapeutic goals. However, there were marked and significant reductions in morbidity and mortality of the protocol groups using the supranormal cardiac index, oxygen delivery, and oxygen consumption values as goals. The cumulative oxygen debt was less and organ failures were fewer and less severe in the protocol groups than in the control groups.
Cardiac Output↗
Measurement of tissue perfusion by oxygen transport patterns in experimental shock and in high-risk surgical patients.
Survivors of high-risk general (noncardiac) surgery were observed to have cardiac index (CI) values averaging 4.5 l/min.m2, oxygen delivery (DO2) of greater than 600 ml/min.m2, and oxygen consumption (VO2) of 170 ml/min.m2. In contrast, these values were relatively normal in patients who subsequently died. A very early predictive index based on these observations was found to predict outcome in 94% of high-risk patients. The hypotheses that increased DO2 and VO2 in the survivors represent compensatory physiologic responses and that these values were appropriate therapeutic goals were tested in prospective randomized clinical trials and found to reduce mortality and morbidity significantly. The optimal goals were more easily attained with colloids, red cells, dobutamine, and vasodilators, according to their capacity to improve tissue perfusion, as reflected by increased flow and oxygen transport. The extremely complex interactions between DO2 and VO2 are reviewed.
Animals↗
Intestinal perforation due to cytomegalovirus infection in patients with AIDS.
Intestinal perforation due to cytomegalovirus (CMV) infection in patients with AIDS is the most common life-threatening condition requiring emergency celiotomy in these patients. The authors describe a patient with AIDS with intestinal perforation due to CMV infection, and review 14 additional cases reported in the English-language surgical literature. The diagnostic triad of pneumoperitoneum on x-ray, evidence or history of CMV infection, and AIDS occurred in 70 percent of patients. The most common site of intestinal perforation was the colon (53 percent), followed in frequency by the distal ileum (40 percent) and appendix (7 percent); perforation usually occurred between the distal ileum and splenic flexure of the colon. Colonoscopy, rather than sigmoidoscopy, is recommended as a screening examination in patients with AIDS suspected of having colonic ulceration due to CMV infection. Multiple biopsies of ulcerated tissue should be obtained. Gross and microscopic analyses of involved intestinal tissue reveal the characteristic findings of ulceration and CMV infection. Despite aggressive therapy, the operative mortality rate in patients with AIDS with intestinal perforation due to CMV infection was 54 percent and the overall mortality rate was 87 percent. Postoperative complications occurred in most patients and consisted mainly of systemic sepsis and pneumonia caused by Pneumocystis carinii infection. An increased awareness of this syndrome by physicians frequently called on to manage patients with AIDS is recommended.
Acquired Immunodeficiency Syndrome↗
Use of a piezoelectric film sensor for monitoring vascular grafts.
Detection of failing arterial reconstructions requires intensive surveillance by frequent physical examination and noninvasive laboratory testing. However, many grafts fail during the intervals between these examinations. For this reason, we have developed an implantable miniaturized piezoelectric flow detection device whose function can be monitored externally by radiotransmission across the skin. Sensors were constructed from ultrathin polyvinylidene fluoride (PVF2) with piezoelectric activity and attached with silicone fixative to 6-mm polytetrafluoroethylene grafts. Ten of these grafts were placed in mongrel dogs as iliofemoral bypasses. Real time data were acquired from the sensors at a rate of 200 Hz, using a DATAQ A/D data acquisition board and CODAS data acquisition software, while simultaneous blood flow (using an electromagnetic flowmeter) and intraluminal pressure were processed by using separate channels of the same data acquisition board. The data were stored on computer storage media and analyzed by the ASYST software, which allows simultaneous signal curves to be compared using regression analysis. In the resting state, the mean blood flow was 123 +/- 16 mL and the mean intraluminal pressure was 124/78 mm Hg, and there was perfect correlation between the PVF2 sensor and the flowmeter and between the sensor and the intraluminal pressure (correlation coefficient, r greater than or equal to 0.99 and r greater than or equal to 0.93, respectively). A tourniquet was applied to the iliac artery proximal to the graft to reduce the flow to approximately half of the resting state (mean flow after tourniquet: 66 +/- 6 mL/minute). Signal tracings from the three sources showed a remarkable similarity with a very high correlation coefficient (r greater than or equal to 0.99 between sensor and flowmeter and r greater than or equal to 0.92 between sensor and the pressure signal). These preliminary results show that the sensors made from low-profile and low-mass PVF2 material have the potential of being implanted around grafts for long-term, continuous monitoring of graft function. Further studies involving long-term implantation to assess the effect of tissue ingrowth and loss of compliance are necessary before this device can be used clinically.
Animals↗