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Biomedical subjects

R Pokela

Publications and source records attributed to R Pokela.

At least 19 recordsLinked to original sources
PubMed2000

Internal Mammary Artery Harvesting and Antibiotic Concentrations in Sternal Bone During Coronary Artery Bypass.

The concentrations of two antibiotics (vancomycin and cefuroxime) in sternal bone during coronary artery bypass surgery were analyzed to examine whether antibiotic penetration is impaired after dissection and harvesting of the left internal mammary artery for grafting. Bone samples (250 mg of cancellous sternal bone from both halves of the dissected manubrium) were obtained at the time of sternal opening and closure. Twenty patients undergoing primary coronary artery bypass grafting with the left internal mammary artery were randomized so that ten received 1.5 g of vancomycin over 180 minutes and ten 3 g of cefuroxime over 30 minutes beginning at the time of induction of anesthesia. Serum samples were collected at the same time as the bone samples and 12 h after the start of the infusions. There was a slight difference in vancomycin concentration between two sternal halves after IMA dissection at the time of sternal closure (median difference, 0.2 µg/g, and 95% confidence interval, -0.55 to 0.1). This difference was not statistically significant at the P = 0.05 level (P = 0.15, Wilcoxon matched-pair test). The cefuroxime concentration of the bone was below the detection limit (7.6 to 9.2 µg/g) in all ten patients at the time of sternal closure. Harvesting the internal mammary artery for coronary artery bypass grafting may influence the concentration of vancomycin in the manubrium of the sternum.

Journal Article↗
PubMed1998

Computed tomographic evaluation of retrosternal adhesions after pericardial substitution.

BACKGROUND: Reoperative median sternotomy can result in cardiac injury and serious bleeding, with the rate ranging from 2% to 6%. Closure of the native pericardium can maintain a preventing plane of cleavage. In patients in whom primary pericardial closure is not possible, several substitutes have been tried with variable results. We conducted a prospective study to evaluate the clinical feasibility of polytetrafluoroethylene and polyglycolic acid patches as pericardial substitutes, using computed tomography for imaging the postoperative state of the retrosternal space. METHODS: The basic population comprised 540 patients who were scheduled for coronary artery bypass grafting, and 52 of them who met the research criteria were chosen for computed tomographic evaluation after 5 years after the primary operation. RESULTS: As a substitute, polytetrafluoroethylene seemed to be less adhesive to the posterior surface of the sternum. Total adhesion scores were also statistically significant (p < 0.001) to the advantage of polytetrafluoroethylene over polyglycolic acid as a pericardial substitute. CONCLUSIONS: Polytetrafluoroethylene membrane seems to be capable of minimizing retrosternal adhesion formation and thus it may protect the heart during subsequent reoperative sternotomy.

Coronary Artery Bypass↗
PubMed1998

Comparison of vancomycin and cefuroxime for infection prophylaxis in coronary artery bypass surgery.

OBJECTIVE: To investigate clinically significant differences between vancomycin and cefuroxime for perioperative infection prophylaxis in coronary artery bypass surgery. DESIGN: A total of 884 patients were randomized prospectively to receive either cefuroxime (444) or vancomycin (440) and were assessed for infectious complications during hospitalization and 1 month postoperatively. SETTING: A university hospital. RESULTS: The overall immediate surgical-site infection rate was 3.2% in the cefuroxime group and 3.5% in the vancomycin group (difference, -0.3; 95% confidence interval, -2.6-2.1). CONCLUSIONS: The data suggest that vancomycin has no clinically significant advantages over cephalosporin in terms of antimicrobial prophylaxis. We suggest that cefuroxime (or first-generation cephalosporins, which were not studied here) is a good choice for infection prophylaxis in connection with coronary artery bypass surgery in institutions without methicillin-resistant Staphylococcus aureus problems. In addition to the increasing vancomycin-resistant enterococci problem, the easier administration and usually lower price of cefuroxime make it preferable to vancomycin.

Aged↗
PubMed1998

Risk features for surgical-site infections in coronary artery bypass surgery.

OBJECTIVE: To identify preoperative and perioperative features that may lead to a risk of surgical-site infection (SSI) after coronary artery bypass surgery. DESIGN: 884 patients who underwent coronary artery bypass grafting in 1992 and 1993 were studied. The associations between 23 preoperative and perioperative features and the presence of SSI at the donor site or in the chest area were evaluated by univariate analysis followed by multivariate logistic regression analysis. SETTING: A university hospital. RESULTS: 172 patients (19.5%) either had an SSI recorded before discharge or had received antibiotics prescribed for a suspected SSI during the 1-month surveillance period after discharge. Multivariate logistic regression analysis showed an extreme body mass index (BMI; P=.015), female gender (P=.023), and chronic obstructive pulmonary disease (COPD; P=.030) to be independent risk features for SSI. The donor site was infected in 136 patients (15.4%), an event for which female gender (P=.003) was the only independent risk feature. Forty-seven patients (5.3%) had an SSI of the chest area, with diabetes (P=.003) and extreme BMI (P=.010) as independent risk features. CONCLUSION: Extreme BMI, female gender, and COPD are highly significant independent predictors of the development of SSI. Female gender is a risk feature specifically for SSI at the donor site, whereas diabetes and extreme BMI predict it in the chest area.

Antibiotic Prophylaxis↗
PubMed1998

Pericardial closure with polytetrafluoroethylene surgical membrane or biodegradable polyglycolic acid mesh after coronary artery bypass surgery--a baseline report.

BACKGROUND AND AIMS: Complete and tight closure of the native pericardium may kink or even occlude bypass grafts after coronary artery bypass grafting (CABG) and therefore the feasibility of tight closure has been debated. The growing number of reoperations has raised the question how to reduce the risk of damage of the right ventricle and patent grafts. We are performing a prospective randomized trial aiming to evaluate the feasibility of polytetrafluoroethylene (PTFE) surgical membrane and biodegradable polygycolic acid (PGA) mesh as pericardial substitutes for closure purposes in patients undergoing primary isolated CABG surgery. MATERIAL AND METHODS: The series comprises 540 patients who underwent a primary isolated CABG procedure at the Oulu University Hospital from October 1989 to May 1994. RESULTS AND CONCLUSIONS: The baseline results suggest that the PTFE and PGA materials seem to be similar despite the subtle early expression of tamponade related to the PTFE membrane after postoperative bleeding.

Adult↗
PubMed1997

Is single-dose antibiotic prophylaxis sufficient for coronary artery bypass surgery? An analysis of peri- and postoperative serum cefuroxime and vancomycin levels.

Preliminary findings have suggested that a single intravenous dose of antibiotic is effective for infection prophylaxis in cardiac surgery. However there are still insufficient data on this proposed regimen. We measured serum cefuroxime and vancomycin levels after three different dosage regimens, in patients undergoing coronary artery bypass grafting (CABG). Sixty patients were randomized into three cefuroxime and three vancomycin groups with 10 patients in each: a group given a one-day course, or an additional dose during cardiopulmonary bypass or a single dose. Serum levels of the antibiotics were measured at various times throughout the operative procedure and until 48 h after the start of prophylaxis. Each of the six dosage regimens maintained serum levels adequate for infection prophylaxis throughout the operative procedure. Serum levels remained above 2 mg/L for more than 8 h postoperatively, even in the single-dose cefuroxime group and above 4 mg/L for more than 24 h with all the vancomycin dosage regimens. Thus a single dose of cefuroxime (3 g or 1.5 g) or vancomycin (1.5 g) seems to achieve and maintain serum levels sufficient for infection prophylaxis several hours after CABG procedures.

Aged↗
PubMed1997

Surgical and long-term outcome of graft replacement of aneurysms of the descending thoracic aorta. Analysis of 28 consecutive cases.

A consecutive series of 28 patients operated on at the Oulu University Hospital during the years 1974-1994 for aneurysms of the descending thoracic aorta is presented. Twenty-five cases were elective and three were operated on as emergencies. Their mean age was 58 years. During the aortic cross-clamp, circulatory support of the lower body, was used in 27 cases as follows: a direct aorto-femoral shunt without a pump (12/28), left-heart bypass (11/28) or femoro-femoral perfusion (4/28). Hospital mortality was 14% (4/28). One patient with a ruptured aneurysm died of renal failure, but there were no other renal complications. None had paraplegia postoperatively. Three had symptoms of paraparesis, but only one of them had a slight permanent discomfort while walking. The mean follow-up time was 100 months, range 2-242 months. Late actuarial survival including hospital mortality, was 65% at 5 years and 41% at 10 years, reflecting the generalized aortic disease with a high risk of very late rupture (4) and other manifestations of atherosclerosis with myocardial infarction (6) or cerebral atherosclerosis (1), the remaining late deaths being unrelated. The efficacy of lower body circulatory support in avoiding peroperative renal and spinal cord ischaemic complications is demonstrated.

Adult↗
PubMed1996

Ten-year survival after resection for lung carcinoma. Effect of blood transfusion and tumour stage on outcome.

The objectives were to evaluate the prognosis in resected lung cancer and to observe if perioperative blood transfusion adversely affects the prognosis. Of 208 patients with resection for lung cancer in 1978-1980, all but five were smokers: 127 had squamous cell and 81 non-squamous cell carcinoma. Stage I disease was found in 143 patients. (69%), stage II in 18 (9%) and stage IIIa in 47 (23%). Five-year survival was 52% in stage I, 29% in stage II and 7% in stage IIIa tumour; the respective 10-year rates were 37, 19 and 3%. Patients given perioperative blood transfusion (n = 95) had poorer prognosis than the non-transfused patients. According to Cox multivariate analysis, however, the relative risk of death was only slightly increased by perioperative transfusion (p = 0.07). In patients with stage II or IIIa carcinoma at diagnosis, this relative risk was 2.17 and 4.99 times higher than in stage I (p = 0.004 and p = 0.0001). Long-term survival thus was related to extent of the disease at diagnosis rather than to numbers of blood transfusions.

Adult↗
PubMed1996

Cerebral haemorrhage after carotid endarterectomy.

Cerebral stroke is a serious complication related to carotid endarterectomy (CEA), being most frequently caused by thromboembolic events and less frequently on account of cerebral haemorrhage. The present series comprised five out of 857 (0.6%) patients who had undergone CEA at Oulu University Hospital between the years 1974 and 1993 and suffered a postoperative stroke four to 13 days after surgery due to intracerebral haemorrhage (IH). Preoperatively, all these patients were neurologically intact, with transient ischaemic attacked (TIA) as the main indication for CEA. All five patients had a history of arterial hypertension treated adequately preoperatively, and one patient had high blood pressure levels after surgery. Critical ipsilateral stenosis of the internal carotid artery (> 90%) was detected in the preoperative angiogram in all five cases. The primary outcome after CEA was uneventful in every case, without any signs of neurological deficiency. The symptoms, comprising severe headache, convulsions and/or hemiparesis occurred suddenly four to 13 days (mean seven days) after CEA. The diagnosis of IH was based on computed tomography (CT) findings. All five patients were treated conservatively. Three of them died. We conclude that even normotensive, neurologically intact patients without demonstrable cerebral infarction or postoperative hypertension may suffer cerebral haemorrhage after the relief of high-grade carotid stenosis. The role of possible insufficiency of the autoregulatory mechanisms of the cerebral vasculature on account of long-standing critical stenosis of the internal carotid artery and subsequent uncontrolled hyperperfusion following CEA are discussed.

Aged↗
PubMed1996

Outcome of elective infrarenal abdominal aortic aneurysm repair--an analysis of 174 consecutive patients.

The aim of the study was to assess the surgical outcome of elective infrarenal abdominal aortic aneurysm (AAA) repair and the clinical and surgical factors that may predict this outcome. The series comprises 174 consecutive patients who underwent elective surgery for infrarenal AAA. Factors found to be predictive of early hospital death (4.5%) were aneurysm size (> 5 cm), ischaemic heart disease, chronic obstructive pulmonary disease (COPD), preoperatively elevated C-reactive protein (CRP) and a history of aneurysm-related pain preoperatively. The outcome was also very poor if the bacterial culture from the aneurysm sac was positive. On the whole, the abdominal aortic aneurysm operation effectively controls the disease and can be safely employed electively.

Adult↗
PubMed1995

Magnesium substitution in elective coronary artery surgery: a double-blind clinical study.

Magnesium may be beneficial in the control of ventricular ectopy and supraventricular tachyarrhythmias after coronary artery bypass graft (CABG) surgery, but it is not known whether a high-dose magnesium regimen is superior to a regimen keeping the patient normomagnesemic. A prospective randomized and double-blind clinical comparison was performed in 81 elective CABG patients in order to assess the effects of two different magnesium infusion regimens on electrolyte balance and postoperative arrhythmias. Forty-one patients (high-dose group, H) received 4.2 +/- 0.7 g (mean +/- SD), of magnesium sulfate before cardiopulmonary bypass, followed by an infusion of 11.9 +/- 2.8 g of magnesium chloride until the first postoperative (PO) morning, and a further 5.5 +/- 1.0 g until the second PO morning. Forty patients (low-dose group, L) received magnesium sulfate only after bypass to a total of 2.9 +/- 0.5 g at the first, and 1.4 +/- 0.1 g at the second PO morning. A blood cardioplegia technique was used in both groups, including bolus doses of magnesium chloride to a total of 2.4 +/- 0.6 g and 2.3 +/- 0.6 g to H and L patients, respectively. Continuous Holter tape-recording was used for 12 to 15 hours preoperatively, and for 48 hours postoperatively. Serum magnesium peaked in H patients on the first PO morning at 1.60 +/- 0.25 mmol/L, whereafter it declined to the normal level on the third PO morning. Patients in the L group were normomagnesemic, except after the start of bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias, Cardiac↗
PubMed1995

Outcome of thoracoabdominal aortic aneurysm surgery. Analysis of 27 consecutive cases.

Twenty seven patients underwent repair of a thoracoabdominal aortic aneurysm at our hospital during 1978-1993. Sixteen were elective and 11 emergencies. We used a temporary shunt and transsection of the proximal aorta between vascular clamps, so that the whole distal aorta with its branches was perfused through the shunt during suturing of the proximal anastomosis. The aortic branch arteries were revascularized by the step by step technique. Hospital mortality was 6/27 (22%) and two and five-year cumulative survival rates 74% and 52%. Late deaths were not related to aneurysm disease. Paraplegia developed in two patients. Distal aortic perfusion was used as a means of spinal cord preservation.

Actuarial Analysis↗
PubMed1994

Acute type A aortic dissection--diagnostic aspects and surgical experience.

Acute type A aortic dissection was surgically treated in 33 patients aged 20-65 years, all critically ill on admission to hospital. Transthoracic echocardiography revealed pericardiac tamponade in eight cases of extreme emergency, indicating surgery without need of additional imaging. Transesophageal echocardiography provided a definitive diagnosis in 16 cases, with excellent reliability and no false positive findings. Composite graft replacement with button technique was used in 24 patients and other methods of repair in nine. The perioperative mortality was 12% (4/33) and the late mortality 7% (2/29). The actuarial 5-year survival rate was 73%. No aortic root reoperation was required during follow-up for a mean of 4 years. Transesophageal echocardiography proved to be an accurate tool for speedy diagnosis of acute type A aortic dissection and open composite graft replacement with button technique highly satisfactory treatment, avoiding late aortic root problems.

Acute Disease↗