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Biomedical subjects

A B Peitzman

Publications and source records attributed to A B Peitzman.

At least 73 records · Page 4Linked to original sources
PubMed1988

Chronic contained rupture of an abdominal aortic aneurysm presenting as a lower extremity neuropathy.

Rupture of an abdominal aortic aneurysm often presents with a pulsatile abdominal mass, abdominal pain, and hypotension. Recent clinical reports describe patients with less apparent clinical signs and symptoms who were found later in their evaluation to have a contained rupture of an abdominal aortic aneurysm. Even more unusual is a chronic contained rupture of an abdominal aortic aneurysm. Our patient had a chronic contained rupture of an abdominal aortic aneurysm that presented with erosion into the lumbar vertebral bodies and subsequent lumbar neuropathy. CT scan confirmed the contained rupture of the aortic aneurysm and the patient underwent successful repair of his aortic aneurysm. Our report discusses the significance of atypical presentations of abdominal aortic aneurysm rupture and the importance of prompt diagnosis and definitive repair.

Aged↗
PubMed1988

Upper gastrointestinal endoscopy after cardiac transplantation.

Three hundred four patients have undergone cardiac transplantation at the University of Pittsburgh since 1980. Twenty patients have required 27 upper gastrointestinal (GI) endoscopic procedures. After heart transplantation the primary indications for endoscopy were epigastric pain (six patients with gastritis, one with multiple shallow gastric ulcers, and one with normal test results), mild upper GI bleeding (four patients with esophagitis, two with gastritis, and two with multiple shallow gastric ulcers), dysphagia and odynophagia (two patients with esophagitis), persistent nausea and vomiting (one with normal test results), lower GI bleeding (one with normal test results), and routine follow-up (one with normal test results). After heart-lung transplantation the primary indications for the endoscopy were massive upper GI bleeding (three patients with actively bleeding duodenal ulcers), dysphagia and odynophagia (one patient with esophagitis), mild upper GI bleeding (one patient with gastritis), and routine follow-up (one patient with normal test results). No complications resulted from endoscopy. The procedures were performed in the GI suite without cardiac monitoring. Prophylactic antibiotics were not routinely administered. No patient had a fungal infection of the upper GI tract--a finding attributed to the prophylactic use of nystatin in all patients. Opportunistic viral infections were identified histologically in six patients, including two patients with actively bleeding duodenal ulcers. The possibility of opportunistic viral infections in this immunosuppressed group required aggressive diagnostic techniques, including endoscopy and biopsy, which can be safely performed after cardiac transplantation.

Adult↗
PubMed1988

Transcutaneous oxygen measurements in lower extremity ischemia: effects of position, oxygen inhalation, and arterial reconstruction.

Transcutaneous oxygen tension (TcPO2) measurement has been successfully applied to the diagnosis and monitoring of patients with peripheral arterial insufficiency. This study was performed to assess the effects of changes in limb position, oxygen inhalation, and arterial reconstruction on TcPO2 values in patients with peripheral vascular disease. In addition, a TcPO2 index (foot TcPO2/chest TcPO2) was compared with the Doppler-derived ankle-to-brachial index (ABI) to determine which was the more effective monitor of the response to revascularization. Foot TcPO2 values of 22 patients with claudication or rest pain were measured before and after vascular reconstruction. TcPO2 increased after revascularization in both groups regardless of limb position or oxygen (O2) administration. The dependent position and O2 inhalation had an additive effect on TcPO2. Preoperative TcPO2 values in patients with rest pain showed the greatest response to the dependent position, increasing from 14 mm Hg to 33 mm Hg at room air and from 21 mm Hg to 53 mm Hg with O2 inhalation. TcPO2 in both patient groups was remarkably enhanced by O2 administration after revascularization. Postoperative supine TcPO2 values measured at room air increased from 50 mm Hg to 124 mm Hg (148%) in patients with claudication and from 40 mm Hg to 109 mm Hg (173%) in patients with rest pain after O2 inhalation. Comparison of the TcPO2 index with the ABI showed that absolute and normalized TcPO2 values are equally effective in monitoring peripheral arterial insufficiency. This study suggests that placing the limb in the dependent position and administering O2 may augment TcPO2 to levels where symptoms may resolve. The response of TcPO2 to O2 inhalation may be an indicator that reflects the response to revascularization.

Arterial Occlusive Diseases↗
PubMed1987

Relief of nonhemispheric symptoms in low flow states by anterior circulation revascularization: a physiologic approach.

Operative intervention remains controversial for patients with transient nonhemispheric symptoms with occlusive disease of both the anterior and posterior cerebral circulations. In addition to the standard evaluation of these patients, we have used stable xenon-enhanced computed tomographic mapping of cerebral blood flow (Xe/CT CBF). This relatively new and potentially widely available CBF methodology, by measuring approximately 30,000 CBF values within each of three CT levels, provides a readily interpretable means of evaluating extremes of hemodynamic compromise within any or all vascular territories. In the past 30 months, Xe/CT CBF studies in 300 patients with occlusive vascular disease have identified nine patients with global low flow and nonhemispheric symptoms (vertigo, lightheadedness, and/or blurred vision). Blood pressures determined by ocular pneumoplethysmography of Gee were markedly abnormal with reduced ocular/brachial ratios. Each patient had a combination of both segmental carotid and vertebrobasilar occlusive disease. Each patient had a flow-augmenting procedure performed on the anterior circulation in an attempt to improve global flow: carotid endarterectomy (two patients), subclavian-external carotid bypass (one patient), and superficial temporal artery-middle cerebral artery bypass (six patients). In each case disabling transient symptoms were relieved. There were no operative deaths, but one stroke occurred, probably as a result of a brief period of postoperative hypotension. Postoperative Xe/CT CBF studies show a long-term improved global CBF in all patients.

Brain↗
PubMed1987

Noninfectious complications of long-term central venous catheters: radiologic evaluation and management.

During a 5-year period, 416 long-term double-lumen central venous catheters were inserted into 288 patients. In these patients, 106 catheter venograms and nine upper extremity venograms were performed. All studies were reviewed retrospectively to determine the nature and prevalence of noninfectious catheter-related complications, to evaluate the efficacy and safety of streptokinase therapy, and to determine if catheter venography should be performed before streptokinase therapy is started. Noninfectious complications occurred in 66 (23%) patients. Complications that resulted in catheter malfunction included deposition of fibrin around the catheter tip (formation of a fibrin sheath) in 44 (57%) instances, a constricting suture in six, abutment of the catheter tip against the venous wall in eight, catheter leak in two, and migration of the catheter completely out of the vein in three. Venous thrombosis developed in 11 patients. Treatment with low doses of streptokinase successfully relieved catheter obstruction due to a fibrin sheath in 27 (87%) of 31 instances. No bleeding complications occurred. Five patients had malpositioned catheters in the azygous, axillary, or internal jugular veins. By use of a deflector wire or snare inserted via the femoral vein, all five were relocated successfully into the superior vena cava. Recognition of noninfectious complications associated with use of long-term catheters is important for institution of appropriate therapy, which in many instances obviates removal of the catheter. Formation of a fibrin sheath in only 57% of cases of catheter malfunction provides an argument for performing catheter venography before streptokinase therapy is started. Low-dose streptokinase therapy for long-term central venous catheters occluded by a fibrin sheath is safe and efficacious.

Catheters, Indwelling↗
PubMed1987

Limb sparing operations for sarcomas of the extremities involving critical arterial circulation.

Seven patients underwent resection of a sarcoma of the extremity requiring excision of a vital artery and revascularization. These included osteosarcoma of the pubis, osteosarcoma of the distal femur, undifferentiated sarcoma of the thigh, liposarcoma of the thigh, liposarcoma of the popliteal space, chondrosarcoma of the proximal tibia and rhabdomyosarcoma of the thumb. Preoperative evaluation included computed tomographic scan, magnetic resonance imaging and angiography. Operation involved excision of the iliac artery in one instance, femoral artery in three, popliteal artery in two instances and radial artery in one. Wide local resection including revascularization was undertaken when the tumor could be resected with the artery but separated from the nerve and it was a low grade malignant disease or the patient refused amputation for a high grade malignant disease. In five patients, the tumor margins were adequate. One patient with an osteosarcoma of the pubis with distant disease had a palliative resection and one patient had positive margins but refused amputation. Coverage of the soft tissue and vascular grafts was achieved using a distant pedicle flap in two patients. Amputation was avoided and each patient remained ambulatory. Five patients remained free of disease with patent grafts at six months to six years of follow-up study. One patient died of late myocardial infarction and one who underwent palliative resection died eight months later of metastatic disease. Involvement of the major arterial circulation does not preclude adequate resection of sarcomas of the extremity with limb salvage.

Adult↗
PubMed1986

TcPO2 values in limb ischemia: effects of blood flow and arterial oxygen tension.

Transcutaneous oxygen tension (TcPO2) is determined by blood flow and arterial oxygen tension (PaO2) and has been advocated as a measurement of tissue perfusion in peripheral vascular disease. The purpose of this study was to define the relationship between regional blood flow, PaO2, and TcPO2. TcPO2 sensors were placed on the skin of the anterior tibial regions of the hind limbs of 15 dogs. After occluding collateral blood flow, an external flow probe was placed around the femoral artery and an adjustable clamp was used to produce graded ischemia. Progressive reductions in blood flow were correlated with TcPO2 values at inspired oxygen concentrations (FiO2) of 0.21, 0.50, and 1.00. TcPO2 measured at room air decreased nonlinearly in relation to flow with a marked drop occurring below 20% of baseline flow. TcPO2 measured at increased FiO2 was dependent primarily on PaO2 at flow rates greater than 50% of baseline. With reduction in flow below 25% of baseline, TcPO2 was dependent solely on flow and was not augmented by increases in PaO2. The data suggest that TcPO2 can accurately reflect changes in blood flow to an extremity when flow is severely restricted.

Animals↗
PubMed1986

Prospective study of computed tomography in initial management of blunt abdominal trauma.

Physical examination is often unreliable in the evaluation of blunt abdominal trauma. The utility of computed tomography (CT) in the early management of abdominal trauma in the absence of definite signs is controversial. CT was prospectively evaluated as an adjunct to physical examination in the initial assessment of blunt abdominal trauma. Indications for emergency abdominal CT were a stable patient with an equivocal abdominal examination, closed head injury, spinal cord injury, hematuria, or pelvic fracture. One hundred twenty patients were studied. CT was accurate in 98.3% of these patients. With associated head injury, combining head and abdominal CT proved to be expeditious. Splenic, hepatic, and renal injuries were reliably detected with CT. Minor injuries which did not require laparotomy were reliably diagnosed. Patients with acute pancreatic injuries may have normal CT findings. Eighty-six per cent of laparotomies were therapeutic. In conjunction with close clinical monitoring, CT was reliable in evaluation of blunt abdominal trauma in a selected group of patients.

Abdominal Injuries↗
PubMed1986

Streptokinase in the treatment of subclavian vein thrombosis.

During the past 2 years, streptokinase has been used to treat subclavian or axillary vein thrombosis in seven patients of whom two were considered "effort" thromboses and five resulted from use of a central venous catheter. All patients had venography performed before treatment to document the thrombosis, and venography was repeated after streptokinase therapy to determine the status of clot dissolution. Streptokinase was given either systemically or in a lowered dose locally, with low-dose therapy chosen whenever a catheter could be threaded up to the clot through an antecubital vein. Although all seven patients had resolution of their clinical symptoms, only one had complete dissolution of the thrombus. The failure of streptokinase to completely dissolve the thrombus suggests that, although apparent clinical improvement can be achieved after streptokinase infusion, treatment of the underlying cause, whenever possible, may be necessary if complete resolution of the thrombus is to occur.

Adult↗
PubMed1986

The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity.

While the development of a spontaneous iliac arteriovenous fistula is an uncommon complication of arteriosclerotic aneurysmal disease, its association with a distinct clinical syndrome allows timely operative intervention for this potentially life-threatening event. A review of cases reported in the literature reveals a triad of symptoms consistently associated with the presence of a spontaneous iliac arteriovenous fistula: high-output cardiac failure of precipitous onset, a pulsatile abdominal mass accompanied by a thrill and bruit, and unilateral lower-extremity ischemia or venous engorgement. Survival may be anticipated if an aggressive diagnostic and operative approach is employed.

Aged↗
PubMed1985

General surgical complications in heart and heart-lung transplantation.

One hundred forty-three patients underwent cardiac transplantation from 1980 to 1985; 122 received a heart, 19 received a heart-lung, and two received a heart-liver transplant. All patients received immunosuppression with prednisone and cyclosporine. General surgical complications have developed since transplantation in 40 patients (28%). Of these, 17 patients have required surgery: exploratory laparotomy (10 patients), inguinal or ventral herniorrhaphy (two patients), repair of false aneurysm of the femoral artery (two patients), repair of lymphocele of the groin (two patients), and incision and drainage of a perirectal abscess (one patient). Of the 10 patients who required laparotomy, three underwent sigmoid resection for a perforated sigmoid diverticulum (all survived), two underwent small bowel resection for perforation (both died), two had free intraperitoneal air with no site of perforation found (one died), one underwent a cholecystostomy and one a cholecystectomy for acute calculous cholecystitis (one died), and one underwent an elective pyloroplasty for gastric outlet obstruction secondary to vagus nerve injury during heart-lung transplantation and survived. All patients who underwent elective surgery survived. Six patients died without operation and at autopsy were found to have unrecognized general surgical complications including pancreatitis (three patients), cecal ulceration with sepsis (two patients), and jejunal perforation secondary to peritoneal dialysis (one patient). Eleven other patients had severe abdominal pain and five had gastrointestinal hemorrhage not requiring operation. Proper management of these patients includes early and aggressive diagnosis of conditions requiring operative intervention, strict attention to surgical technique, and careful titration of dose of immunosuppressive drugs. The 28% incidence of general surgical complications associated with heart and heart-lung transplantation emphasizes the role of the general surgeon in the management of these complex patients.

Adolescent↗
PubMed1985

Salvage of exposed arteriovenous hemodialysis fistulas.

Arteriovenous fistulas constructed with an interposed segment of expanded polytetrafluoroethylene (PTFE) have been used successfully for long-term hemodialysis, but ultimately these fistulas may fail because of graft thrombosis, infection, or pseudoaneurysm. A PTFE graft may become exposed from skin necrosis at an area of repeated puncture for hemodialysis or from wound breakdown at a site of thrombectomy. Removal of an exposed PTFE graft has heretofore been considered inevitable, especially if a suture line is involved, because of the risk of hemorrhage and infection. We describe coverage of an exposed graft by a simple full-thickness skin flap that is locally rotated and report the successful salvage of five fistulas by this technique. Thus the concept that an exposed graft is infected and must be removed may not always be correct.

Arteriovenous Shunt, Surgical↗
PubMed1985

Cellular function in liver and muscle during hemorrhagic shock in primates.

The results of this study demonstrated that muscle ATP levels were sustained in hemorrhagic shock despite marked deterioration of muscle function as indicated by a decline in PD. This indicated that energy depletion was not the primary basis of the cellular dysfunction in hemorrhagic shock. Cellular dysfunction and metabolic abnormalities in the liver occurred earlier during the course of hemorrhagic shock than in muscle. Other studies were cited in which it was suggested that inhibition of the membrane bound sodium and potassium active transport mechanism is the likely cause of tissue electrolyte and fluid shifts observed during prolonged periods of hemorrhagic shock.

Adenosine Triphosphate↗
PubMed1983

Response of extravascular lung water to intraoperative fluids.

The effect of Ringer's Lactate (RL) and a colloid containing salt solution Plasmanate (PL) on extravascular lung water (EVLW) during aortic surgery was evaluated in a prospective study of 18 patients. Measured blood loss was replaced with packed red blood cells. In addition to red blood cell replacement, either RL or PL was infused (1) to maintain the cardiac output (CO) equal to or greater than the preoperative value, (2) to maintain the pulmonary capillary wedge pressure (PCWP) plus or minus 2 mmHg of preoperative values, and (3) to keep the urinary output greater than or equal to 30 cc/hr. Cardiac output, EVLW, PCWP, serum colloid osmotic pressure (COP), and intrapulmonary shunt fraction (Qs/Qt) were measured serially. All baseline values were similar between groups. The groups were well matched for age, associated disease, operating time, blood loss, and blood transfusions. During operation, the RL group required two times the rate of infusion of the PL group. Urine flow rates were similar on the day of surgery, but by postoperative days one and two, the PL group had approximately one-half of the urine flow rate compared to the RL group. Cardiac output and Qs/Qt increased in both groups. EVLW did not change after operation in either group, despite marked decrease in COP in the RL group. These data indicate that crystalloid resuscitation to physiologic endpoints does not increase extravascular lung water. Thus, manipulation of COP by PL was unnecessary in these patients.

Aged↗
PubMed1983

Changes in red blood cell transmembrane potential, electrolytes, and energy content in septic shock.

Septic shock was induced in adult baboons by the infusion of live Escherichia coli. A progressive derangement in skeletal muscle cell function was documented by the direct measurement of declining transmembrane potential difference (PD). A concurrent depolarization of the red blood cell (RBC) was characterized by cellular uptake of chloride, sodium, and water, and loss of potassium. The decrease in RBC PD was significantly greater than the change predicted to occur from acidosis alone. These findings are compatible with changes in membrane permeability and decreased active transport. The continuous accumulation of RBC adenosine triphosphate during shock suggests decreased energy utilization rather than decreased energy production as a factor leading to diminished active ion transport.

Animals↗
PubMed1982

Pulmonary acid injury: effects of positive end-expiratory pressure and crystalloid vs colloid fluid resuscitation.

Pulmonary acid aspiration results in hypoxemia and hypovolemia. We assessed the effects of positive end-expiratory pressure (PEEP) and fluid resuscitation on oxygenation and alveolar-capillary membrane permeability after acid aspiration. Alveolar-capillary membrane permeability was assessed by determination of extravascular lung water volume, using the thermal-green dye double-indicator technique, extravasation of iodinated 1 125 serum albumin into lung parenchyma, and albumin leak into the alveolar spaces. The data from this study demonstrated that PEEP improved oxygenation after acid aspiration, but did not alter progression of the injury; cardiac output and oxygen transport were improved by plasma volume repletion while receiving PEEP; and resuscitation with 5% albumin solution increased plasma albumin content and tracheal albumin content commensurately and did not modify progression of the injury.

Animals↗
PubMed1982

Carotid endarterectomy under regional (conductive) anesthesia.

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.

Anesthesia, Conduction↗