Dehiscence of a prosthetic graft nineteen years after coarctation repair.
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Adult↗
Biomedical subjects
N Snow
Publications and source records attributed to N Snow.
Readmission of patients to the surgical intensive care unit: patient profiles and possibilities for prevention.
Because experience is lacking regarding the profile of patients readmitted to a surgical ICU (SICU), we retrospectively reviewed total admissions, readmissions, patient profiles, and characteristics of illness requiring readmission to a multidisciplinary SICU. During a 1-yr period, the 721 recorded admissions included 68 readmissions for 57 patients (9.4% of the total). Eight patients had multiple readmissions. Seventy-five percent of the original admissions in these 57 patients occurred postoperatively, 9% were due to trauma, and 16% were caused by nonsurgical illness. Mortality for readmitted patients was 26%. Although 53 (78%) discharges were deemed appropriate, 62% of the patients manifested one or more of a retrospectively selected group of warning signs which might have alerted the responsible physician to alter the treatment plan. In half of these patients the reason for readmission was related to the warning sign. Readmission was related to the original disease in 65% of the incidents, while a new patient problem initiated readmission in 38%. The most common new problems were cardiopulmonary insufficiency and infection. All but one patient readmitted with pulmonary problems displayed retrospective evidence of clear warning signs before the original discharge. Recognition of SICU readmission patterns will allow more precise discharge planning: to delay discharge, to effect a lateral transfer, or to initiate a stepdown unit which may be able to help prevent costly and potentially lethal patient outcomes.
Adolescent↗
Traumatic fistula between the descending thoracic aorta and the left main pulmonary artery.
A patient sustained a low-velocity gunshot wound to the left chest which resulted in a clinically silent traumatic fistula between the descending thoracic aorta and the left main pulmonary artery. The bullet remained in the aorta and embolized to the left popliteal artery, from which it was removed 2 days after thoracotomy. Lateral repair of the aorta and pulmonary artery was performed as well as reinforcement of the posterior aortic wall which was weakened by the bullet as it ricocheted within the aorta. This appears to be the first reported case of a traumatic aorta to pulmonary artery fistula involving the descending thoracic aorta.
Adult↗
Utility of pneumonotomy in the treatment of cavitary lung disease.
Three patients were judged to be prohibitive operative risks despite the need for urgent drainage of cavitary pulmonary lesions. Cavernostomy was performed in each case, with a satisfactory long-term outcome in two patients. The third patient recovered from his pulmonary insult, but died much later, secondary to an unrelated illness. One patient had a purulent lung abscess due to aspiration, one had atypical tuberculosis resistant to all antibiotics, and the third patient experienced massive hemoptysis from a tuberculous cavity. Two-stage procedures were utilized in the first two patients, while urgent operation in the third patient was facilitated by adhesions from a previous thoracotomy and pleural infection. Care must be taken to minimize endobronchial and pleural contamination by meticulous attention to detail during the performance of percutaneous tube drainage. There are relatively few indications for percutaneous drainage of cavitary pulmonary lesions in this antibiotic era. However, certain clinical situations should prompt consideration for a pneumonotomy. These include a severely septic or debilitated patient who is unresponsive to medical management, the presence of resistant pathogens in a compromised host, and the presence of severe adhesive pleuritis which may prohibit an expeditious thoracotomy and resection for massive hemoptysis.
Adult↗
Bronchoscopy in the critically ill surgical patient.
Sixty-seven bronchoscopic examinations were performed in a busy surgical intensive care unit on 51 patients, and the techniques, morbidity, and outcome were prospectively analyzed to assess the efficacy and safety of the procedure in this particular patient population. General surgical trauma, cardiothoracic, and orthopedic patients were included. Fifty-three (79%) procedures were performed with the flexible instrument, while 14 patients (21%) underwent rigid endoscopy. Forty-six patients were being mechanically ventilated; 30 had endotracheal tubes, and 16 had tracheostomies. Suspected lobar collapse (60%), persistent pulmonary infiltrates (3%), suspected aspiration (21%), and suspicion of airway trauma (12%) were the primary clinical indications for bronchoscopy. No deaths occurred. Complications were seen in 16 per cent of the procedures and 17 per cent of the patients. There were arrhythmias (other than sinus tachycardia) in seven procedures (11%) and one episode each of hypertension, self-limited endobronchial bleeding, mediastinal emphysema, and increased intracranial pressure. Significant improvement was demonstrated for patients with lobar collapse but not for those with mild atelectasis or pulmonary infiltrates on radiographs taken within 24 hours. Overall, 39 patients (58%) improved radiographically, while 38 patients (42%) did not. Differences in arterial PO2 measured before and after bronchoscopy between groups ventilated with an FiO2 of 1.0, and those who were not did not achieve statistical significance (P less than 0.05).
Bronchoscopes↗
Long esophagomyotomy for esophageal spasm.
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Esophageal Diseases↗
Purulent mediastinal abscess secondary to Ludwig's angina.
A case of Ludwig's angina dissected along deep cervical fascial planes into the mediastinum caused a virulent mediastinitis and abscess. Computed tomography precisely delineated the extent of the infection. Incomplete débridement resulted in a residual abscess and persistent systemic sepsis that culminated in the patient's death. Aggressive antibiotic treatment of the orofacial cellulitis along with complete mediastinal drainage are recommended for optimal outcome.
Abscess↗
Acute myocardial ischemia during pacemaker implantation: implication for threshold determinations and potential complications.
The onset of acute myocardial ischemia during pacemaker implantation may strikingly alter measured threshold values so that unnecessarily high generator output parameters are programmed. In addition, ischemia muscle is more vulnerable to malignant arrhythmias if the stimulating electrode is in an ischemic area. Two patients are presented whose threshold values rose sharply during an ischemic attack and returned to baseline after the angina subsided. Relief of angina is a clinically useful determinant of the safety necessary to proceed with implantation and threshold measurements.
Aged↗
Preinduction use of pulmonary artery catheters during cardiac surgery.
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Cardiac Catheterization↗
Subxiphoid pericardiotomy. A safe, accurate, diagnostic and therapeutic approach to pericardial and intrapericardial disease.
The records of 36 patients who underwent subxiphoid pericardiotomy were reviewed to determine the safety, accuracy, and utility of the procedure. No deaths were attributed to the operation, and complications were minimal. Most operations were performed under local anesthesia. Findings at operation accurately defined which patients required further surgery and which did not. Although clinical, radiographic, and physical findings are inaccurate in determining the nature and extent of pericardial and intrapericardial pathology, a definitive diagnosis was obtained in all diagnostic procedures. Only one patient needed a second operation, attesting to the effectiveness of subxiphoid drainage as a therapeutic modality.
Adolescent↗
Use of the rhomboid major muscle flap for esophageal repair.
A 16-year-old boy sustained vehicular blunt trauma with delayed esophageal rupture that resulted in empyema and an esophagopleurocutaneous fistula. Diverting esophagostomy, gastrotomy, and transpyloric jejunostomy were performed, and these procedures permitted satisfactory nutritional support of the patient. Staged direct closure of the esophagus buttressed by a rhomboid muscle flap preserved normal esophageal function. Both clinical application and cadaver dissections have demonstrated that the rhomboid flap has an excellent blood supply and that it can be used to repair lesions on either side in the upper half of the esophagus. Because this flap is extrathoracic, it is not usually distorted by intrathoracic sepsis or previous thoracic incisions. The rhomboid major muscle flap is an excellent alternative to conventional autogenous grafts for esophageal repair.
Accidents, Traffic↗
Aortoesophageal fistula secondary to reflux esophagitis.
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Aged↗
Intra-aortic balloon counterpulsation for cardiogenic shock from cardiac contusion.
Two patients who sustained cardiac contusions secondary to blunt chest trauma developed refractory cardiogenic shock. Use of intra-aortic balloon counterpulsation improved circulatory dynamics in each case and one patient survived. Requirements for inotropic agents were diminished or eliminated, cardiac output was increased, acidosis was reversed, and the electrocardiogram reverted to normal. Although balloon counterpulsation is most effectively employed in patients with ischemic cardiac deficits, its early application coupled with appropriate pharmacologic treatment is also effective in raising low cardiac output that results from myocardial trauma.
Aged↗
Elimination of lead dislodgement by the use of tined transvenous electrodes.
Pacemaker lead dislodgement has accounted for a large proportion of the postoperative complications seen after transvenous pacemaker insertion. Ninety-two patients underwent implantation of a tined transvenous electrode over a three-year period without a single dislodgement. Excellent thresholds were obtained and no difficulties related to electrode insertion were encountered. Tined transvenous pacemaker leads are preferred for routine use at this time.
Adult↗
Myocardial contusion: implications for patients with multiple traumatic injuries.
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Adolescent↗
Effect of sodium nitroprusside on postoperative blood loss in the cardiac surgical patient.
Sodium nitroprusside (SNP) is known to inhibit platelet aggregation and has been implicated in postoperative hemorrhagic complications. Because it is a useful agent for treating postoperative hypertension and low cardiac output in the cardiac surgical patient, the authors retrospectively reviewed the course of 53 patients undergoing open heart procedures on cardiopulmonary bypass. Twenty-three patients received SNP and 30 did not. There were no differences in baseline hematological or clotting profiles, liver functions, bypass or cross-clamping times or heparin/protamine requirements between the two groups. Analysis revealed no significant differences between the groups in blood product requirements, actual mediastinal drainage, or postoperative measurements of routine clotting parameters. Although biochemical inhibition of platelet aggregation can be demonstrated, the use of SNP in the cardiac surgical patient has no apparent clinical effects which sould detract from its utility in treating hypertension or low cardiac output.
Cardiac Output, Low↗
Management of necrotizing tracheostomy infections.
Management of three patients with necrotizing tracheostomy infections resulting in tracheal dissolution was reviewed with respect to presentation, cause, and management. Loss of tracheal substance led to difficulty in ventilation because of a large air leak. The stomal area cavitated in two patients, denuding the right common carotid artery in one. Purulent peristomal drainage was present in all three patients. Common factors of possible etiologic significance included necrotizing polymicrobial gram-negative tracheobronchial infections caused by Pseudomonas, Enterobacter, and Klebsiella species. Also of possible importance were suture fixation of the appliance, history of neurologic injury, and closure of the incision. Immediate therapy consisted of oral intubation for ventilatory purposes and a regimen of hourly application of 1% neomycin dressings. Seven to 21 days were necessary to allow formation of sufficient granulation tissue to support replacement of the tracheostomy appliance for continued mechanical ventilation. Once spontaneous ventilation was possible, a Montgomery T-tube was inserted for long-term tracheal stenting prior to reconstruction. The two patients treated by tracheal stenting are long-term survivors. Avoidance of suture fixation of the appliance, aggressive treatment of bronchopulmonary infection, and adequate stomal toilet may help to avoid this devastating complication.
Adolescent↗