'Normal' overaction of inferior oblique muscles.
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Adult↗
Biomedical subjects
A W Fleming
Publications and source records attributed to A W Fleming.
Fibrin glue achieves hemostasis in patients with coagulation disorders.
Fibrin glue (FG), made with highly concentrated human fibrinogen and clotting factors, was used to achieve parenchymal organ hemostasis in patients with disordered coagulation secondary to massive transfusion, chronic disease, and disseminated intravascular coagulation; it was effective in controlling liver hemorrhage in seven patients and in the performance of a splenorrhaphy in one other patient. The coagulation profile was grossly abnormal in all patients, and the mean +/- SD intraoperative blood loss was 5.1 +/- 4.2 L; patients received 14 +/- 10 U of blood perioperatively. The amount of FG required to achieve hemostasis varied directly with the extent of injury and intraoperative blood loss (r = .84), and all patients with a blood loss greater than 4 L required at least 25 mL of FG to stop bleeding. Two patients died postoperatively secondary to cardiac arrest and adult respiratory distress syndrome. Because FG does not depend on adequate platelet or clotting factor levels to be effective, it is especially useful in patients with parenchymal organ hemorrhage and disordered coagulation.
Adult↗
Development and testing of a decision tree for blunt trauma.
The aim of the present study was to examine the essential problems in a retrospective study of 381 organ injuries in 260 patients, to identify problems, to define criteria, to describe decision rules, and to organize these rules into branch-chain decision trees or clinical algorithms. The basic hypothesis of this study is that criteria organized into a prioritized decision tree can provide objective standards to evaluate the quality of trauma care and to compare alternative approaches. The algorithm was designed to provide prompt therapy for the most life-threatening problems: respiratory and cardiac arrest, shock, head injury, tamponade, lacerations of the great vessels, cardiac contusion, ruptured parenchymal organs, lacerated viscera, and injury to other intraperitoneal organs. Resuscitation from shock, correction of circulatory problems, and monitoring of physiologic variables were prioritized to evaluate the presence of circulatory deficits and the adequacy of specific therapy to correct them. Concomitantly, diagnosis of the underlying problems was approached using peritoneal lavage, abdominal and chest x-rays, iv urograms, cystograms, endoscopy, upper and lower GI barium or hypaque studies, ultrasound, scintograms, and CT scans. In emergency conditions these are limited to a large extent by time factors. The diagnostic accuracy, priorities, and limitations of each of these were evaluated in emergency conditions. The algorithm was used to track management decisions in a prospective series; the mortality of 51 patients with satisfactory compliance was 4% and 44% in nine patients with major deviations from the algorithm.
Adult↗
Use of fibrin glue in hepatic trauma.
We evaluated the efficacy and safety of fibrin glue (FG) made with highly concentrated human fibrinogen and clotting factors in achieving hemostasis of superficial and deep hepatic injuries. Experimentally produced hepatic injuries were produced in 12 adult mongrel dogs and hemostatically sealed with FG. Half of the dogs each received two penetrating hepatic injuries consisting of a large laceration and a deep stab wound through the liver; the remaining dogs underwent resection of a large segment of the left lobe of the liver. Hemostasis was achieved by applying FG into and over the bleeding wounds; hepatic arterial occlusion was not used. Complete hemostasis was achieved in all animals before skin closure. One dog from each group was re-explored and the liver specimens harvested for gross and microscopic examination at postoperative intervals of 12 hours, 24 hours, and 2, 3, 6, and 8 weeks. There were no cases of intra-abdominal infection, abscess formation, or bile fistulae. Histologic examination demonstrated a thickened capsule containing fibrous connective tissue and neovascular proliferation; there were no signs of local or systemic toxicity. One dog died on postoperative day 1 from rebleeding from the hepatic injury; all other dogs survived without complications. We conclude that FG provides effective hemostasis of superficial and deep hepatic injuries, and has good systemic and local compatibility. Its use in surgery for hepatic trauma may lead to less intraoperative blood loss and transfusion requirements, as well as a reduced need for major hepatic resection to control hemorrhage.
Animals↗
Determination of optimal positive end-expiratory pressure by means of conjunctival oximetry.
A method for determining the optimal level of positive end-expiratory pressure (PEEP) by means of noninvasive conjunctival oxygen (PcjO2) monitoring and arterial blood gas analysis was developed from the pattern of changes in PcjO2 tension, invasive hemodynamic parameters, and oxygen transport variables during PEEP titration in a series of patients with adult respiratory distress syndrome. All patients had radial and pulmonary artery (PA) catheters inserted and blood volume was measured with 125I serum albumin before each study. During progressive increases in the level of PEEP, PcjO2 tensions reflected changes in both PaO2 and cardiac index (CI), depending on whether PEEP produced a significant decrease in CI. In patients with a stable CI, PcjO2 tensions tracked PaO2 values (rw = 0.92); in patients with a greater than a 15% decrease in CI, the conjunctival index, CjI (defined as the PcjO2/PaO2 ratio), tracked CI (rw = 0.87), excluding one patient with high cardiac output-septic shock and severe hypoxemia. PcjO2 correlated with PaO2 in the latter patient (r = 0.99) probably because conjunctival oxygen transport was limited by arterial oxygen content (PaO2 = 34 torr) rather than blood flow (CI greater than 6 L/min X m2). In patients with a greater than a 10% decrease in CI as a result of PEEP, the greater the decrease in CI, the better CjI values correlated with CI. We conclude that PcjO2 monitoring combined with repeated arterial blood gas analysis may be used to titrate PEEP therapy in patients with adult respiratory distress syndrome. In patients whose CjI significantly decreases because of PEEP, PA catheterization and measurement of cardiac output are indicated because of the likelihood of a significant (greater than 15%) decrease in CI. In the absence of a significant decrease in the CjI, optimum PEEP occurs at the level producing maximum PcjO2. It is hoped that by following the described algorithm, many patients will be spared the cost and morbidity of unnecessary PA catheterization.
Adult↗
The utilization of cross-sectional anatomy in a surgical residency training program.
The education of students and residents in a surgical department involves a thorough knowledge of three-dimensional anatomical relationships in the body. In addition, the advances in new imaging modalities demand an in-depth study of cross-sectional anatomy by both students and residents. Traditionally, surgical training incorporated dissections of cadavers and the progressive involvement of the resident in the surgical theater. At the King/Drew Medical Center cross-sectional anatomy has been incorporated into the teaching program. The central focus of this instructional program utilizes problem-solving learning modules that emphasize important surgical and anatomical principles.LEARNING MODULES FOR EACH MAJOR REGION OF THE BODY WERE ESTABLISHED AND INCLUDE THE FOLLOWING: (1) serial cross sections, corresponding computerized tomographic scans and roentgenograms; (2) an atlas (cross sections), case histories, and examination questions; and (3) audiovisual presentation of the normal anatomy, the surgical principles involved, and a discussion of the examination questions. The serial cross sections were prepared at the King/Drew Medical Center.A selected case study is used to illustrate how the knowledge of three-dimensional anatomy can be critical in the evaluation and surgical plan of a patient. Entire learning modules of the thorax and abdomen were used.
Abdomen↗
Noninvasive conjunctival oxygen monitoring during carotid endarterectomy.
Conjunctival oxygen tension (PcjO2) was measured continuously during carotid endarterectomy in 15 patients to evaluate its sensitivity in patients receiving shunts. These studies suggest that PcjO2 tracks brain perfusion during periods of carotid artery occlusion. Reduced PcjO2 was clearly demonstrated with systemic hypotension, carotid artery clamping, and carotid shunt obstruction and clamping. Monitoring of PcjO2 is noninvasive, easy to perform, offers no danger to the patient, and allows real-time assessment of the local tissue perfusion. It provides valuable information on the effectiveness of carotid oxygen transport and, in conjunction with arterial blood gas values, expresses carotid artery perfusion relative to systemic oxygen transport. Further investigations using the PcjO2 sensor may define criteria for intraoperative carotid arterial shunting in patients with tenuous cerebral perfusion, and for prompt intervention in patients with deteriorating perfusion prior to the onset of life-threatening cerebral ischemia.
Aged↗
Resuscitation of the trauma patient: restoration of hemodynamic functions using clinical algorithms.
Two algorithms were developed for immediate fluid resuscitation and subsequent management of emergency trauma patients and critically ill postoperative patients. These algorithms were developed from decision rules based on objective physiologic values attained in patients surviving life-threatening shock and trauma. The improved mortality in prospective studies of these two algorithms supports the hypothesis that compensatory physiologic responses of survivors of life-threatening acute illness are major determinants of outcome. Therapy that supports these compensations and produces the survivor pattern was found to improve survival rates and reduce post-resuscitation complications. These prospective studies confirm the validity of an organized, coherent physiologic approach that has as its goal the achievement of optimal physiologic patterns in contrast to simple restoration of hemodynamic and chemical abnormalities to the normal range, as has been the endpoint of the traditional approach.
Adult↗
Assessment of intestinal and renal perfusion using surface oximetry.
Using a miniaturized polarographic oxygen sensor, we studied the sequential effects of graded hypoxia and standardized hemorrhagic shock on organ surface oxygen tension (PsO2) measurements obtained from the canine small intestine and kidney. During hypoxia, intestinal and renal PsO2 values decreased along with PaO2. The weighted mean correlation coefficients for intestinal and renal PsO2 vs. PaO2 were 0.94 and 0.98, respectively. During severe hypoxia, intestinal and renal PsO2 values fell by 55 +/- 8% and 55 +/- 7% (SEM), respectively, while oxygen delivery fell by 58 +/- 10% (SEM). During active hemorrhage, intestinal and renal PsO2 values decreased along with cardiac output, while PaO2 remained relatively constant. Intestinal and renal PsO2 values correlated with cardiac output during hemorrhage and reinfusion of the shed blood. Initially, intestinal PsO2 values fell more quickly than did renal PsO2; the latter decreased by approximately half as much as intestinal PsO2 after 15 and 30 ml/kg of blood loss. After a 45-ml/kg blood loss, however, the decreases in intestinal and renal PsO2 values were not significantly different from each other. During the terminal stage, cardiac output declined progressively, as did intestinal and renal PsO2 values, despite a relatively high PaO2. Overall, intestinal and renal PsO2 values tracked PaO2 during hypoxia, cardiac output during hemorrhage and reinfusion, and oxygen delivery during both conditions. Clinical and experimental experience indicates that organ PsO2 monitoring is potentially valuable for the intraoperative assessment of tissue perfusion and viability.
Animals↗
Comparison of measurements of cardiac output by bioimpedance and thermodilution in severely ill surgical patients.
In order to evaluate a new thoracic electrical bioimpedance (TEB) system for measurement of stroke volume based on the Sramek-Bernstein equation, 391 paired values of cardiac output were measured simultaneously with the standard thermodilution method. These values were obtained from 16 patients selected for having the most severe illness during a 6-month period; the intent was to evaluate the bioimpedance method in the worst possible situations. The correlation coefficient (r) was 0.83, slope was 0.87, intercept was 1.53, and the mean difference between the two methods was 16.2 +/- 11.8 (SD)% in the total series. In 285 paired samples where satisfactory conditions were met, r was 0.90, slope was 0.98, intercept was 0.34, and the mean difference was 11.8 +/- 8.9%. The data indicate satisfactory correlations between these two methods. When the TEB waveform is satisfactory, the agreement between TEB and thermodilution is as good as the agreement between serial thermodilution methods. Difficulties may arise with dysrhythmias, tachycardia (heart rate greater than 150 beat/min), metal in the chest or chest wall, sepsis, hypertension, and extremely oily skin. Mechanical ventilation did not appear to be a problem.
Cardiac Output↗
Conjunctival and mixed-venous oximeters as early warning devices of cardiopulmonary compromise.
To evaluate potential clinical applications of conjunctival (PcjO2) and mixed venous (SvO2) oximeters in the care of surgical patients, we compared continuous measurements of PcjO2 and SvO2 to conventional invasive hemodynamic and oxygen transport variables during normoxia, hyperoxia, hypoxia, hemorrhagic shock, and resuscitation in dogs. During the normoxic control periods, PcjO2 averaged 76% of the arterial oxygen tension (PaO2). During hyperoxia and hypoxia, PcjO2 correlated well with PaO2 values (r = 0.88) but not with mixed venous oxygen tension (PvO2), whereas the SvO2 correlated well with PvO2 (r = 0.88) but not with PaO2 values. Controlled hemorrhage produced significant, progressive decreases in PcjO2, SvO2, cardiac output, and oxygen delivery (P less than 0.01), whereas PaO2 values remained constant throughout this period (FIO2 = 40%). There were no significant differences between the decreases in PcjO2 and SvO2 at 15, 30, and 45 ml/kg blood loss. Reinfusion of the shed blood resulted in a rapid, significant increase in PcjO2, SvO2, cardiac output, and oxygen delivery (P less than 0.01); the PaO2 remained constant. During hemorrhage and resuscitation, both PcjO2 and SvO2 tracked cardiac output; the weighted mean correlation coefficient, rw, was 0.90 for both PcjO2 versus cardiac output and SvO2 versus cardiac output. The correlation coefficient for PcjO2 versus SvO2 during hemorrhage and resuscitation was 0.72. One dog died unexpectedly during hemorrhage. In the 29 min period immediately prior to death, PcjO2 remained at 9 torr and SvO2 at 10%; the simultaneously measured PaO2 was 133 torr. Both oximeters had in vivo stabilization and 90% response times of less than 2 min. We conclude that both oximetry systems are potentially useful in high-risk surgical patients to provide better cardiorespiratory surveillance and to signal the need for more intensive assessment of hemodynamic stability. This approach may lead to reduced costs from unnecessary invasive procedures as well as reduced morbidity secondary to earlier warning of cardiorespiratory compromise.
Animals↗
Vertical banded gastroplasty vs gastric bypass in the treatment of obesity.
Two hundred consecutive patients undergoing surgical intervention for morbid obesity had either the gastric bypass or the vertical banded gastroplasty. Both groups were similar in patient composition. In the vertical banded gastroplasty patients, operating room time was lessened by 70 minutes, blood loss lessened by 225 mL, and hospital stay shortened by two days as compared with the gastric bypass patients. At 30 months, a 64-percent mean excess weight loss was observed in the gastric bypass vs a 56-percent mean excess weight loss in the vertical banded gastroplasty group. The vertical banded gastroplasty procedure is preferred because there is no late stomal dilation with weight gain, no vitamin B(12) deficiency, and most important, this procedure leaves the remainder of the stomach and duodenum available for endoscopic and radiologic evaluation.
Adult↗
Transcutaneous oxygen recovery and toe pulse reappearance time in the assessment of peripheral vascular disease.
The accuracy of measurements of transcutaneous oxygen tension (Ptco2) in the diagnosis of peripheral vascular disease (PVD) may be significantly increased by stressing limb circulation with the use of temporary ischemia. The purpose of this study was to compare the transcutaneous oxygen recovery half-time (TORT) and the toe pulse reappearance time (PRT/2) in a series of patients with symptomatic PVD before and after vascular reconstruction. The TORT was defined as the time required to recover half of the decrease in the limb/chest Ptco2 ratio caused by temporary limb ischemia, and is conceptually comparable to the toe PRT/2, the time required to recover half of the control toe pulse amplitude. Measurement of TORT was found to be more feasible (100% vs 58%) and to have a greater diagnostic yield (100% vs 92%) than that of the toe PRT/2. When measured on the dorsum of the foot, TORT values were found to correlate well with the severity of symptoms of PVD; toe PRT/2 values did not correlate with severity of symptoms. Patients who underwent successful vascular reconstruction had significant improvement in their calf and foot TORT values after surgery (p less than .005 and .0005, respectively); postoperative values were similar to those obtained in normal subjects. Toe PRT/2 values usually improved postoperatively, but in many patients postoperative values overlapped with values that were considered abnormal. There was no overlap of TORT values in normal subjects with those in patients with symptomatic PVD. The measurement of TORT may be clinically useful for screening patients with suspected PVD and for assessing quantitatively the results of conservative and surgical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Tracheal repair with fibrin glue.
This animal study evaluated Fibrin Sealant, a multicomponent biologic adhesive, in tracheal operations. We conclude that the use of Fibrin Sealant in tracheal reconstruction results in a stable, leakless trachea, has good systemic and local compatibility, promotes tracheal wound healing, and reduces significantly the number of sutures required for end-to-end anastomosis.
Animals↗
Results of myocardial revascularization in black males.
The impact of black-white differences in the prevalence of risk factors for coronary heart disease on the outcome of coronary bypass surgery has not been well defined. Preoperative status, coronary anatomy, and surgical results were reviewed in 54 black males operated on between December 1970 and August 1983. With the use of criteria established by the New York Heart Association, five patients were classified in class II, 34 were in class III, and 15 were in class IV. Five patients had unstable angina. The most common risk factor, cigarette smoking, occurred in 43 patients (80%). Thirty patients (56%) had hypertension, 10 (19%) were diabetic, 14 (26%) were obese, and 23 (43%) had a family history of coronary disease. Elevated cholesterol and triglyceride levels were present in 8 and 12 patients, respectively. An average of 2.9 grafts per patient was placed. Overall operative mortality was 5.6%. Prior to the use of cardioplegia in 1978, there were two deaths among 14 patients (mortality, 14%). Since 1978 there has been one death among 40 patients (mortality, 2.5%). Although immediate operative mortality appears not to be affected by black-white status, long-term prognosis may be influenced significantly by the high prevalence of hypertension and diabetes and the lower prevalence of hyperlipidemia among black patients.
Adult↗
Factors affecting outcome in pancreatic trauma.
Reported mortality from pancreatic trauma remains at approximately 20% and morbidity is about 33%. A recent series was reviewed to highlight unresolved problems associated with this injury. From 54 consecutive patients treated operatively for pancreatic trauma during a recent 7-year period, 44 patients were evaluated. Among these 44, six died and 12 developed fistulas and/or abscesses. Of those who died, four had colon injuries and two had duodenal injuries, one of whom had combined colon and duodenal injuries. Patients with colon injuries also had a higher incidence of intra-abdominal abscesses and fistulas. Indeed, colon injury currently may be the most significant factor causing morbidity and mortality in cases of pancreatic trauma. Despite improved management of duodenal injuries, morbidity and mortality rates for these patients also remain high. Twenty-six patients went into shock before the end of their operation, and all six deaths occurred in this group. The mean number of intra-abdominal associated organ injuries was 2.1 per patient; complications and deaths were directly related to these injuries.
Abscess↗
Injuries to the profunda femoris artery and its branches.
Six cases of uncommon profunda femoris artery injury are analyzed. One half of the cases were not treated surgically at the time of injury and resulted in chronic arteriovenous fistulas. Even after operative correction, residual symptoms persisted in two of these three cases. The generous use of arteriography is recommended in cases of proximal thigh penetrating injuries to avoid this problem. Either repair or ligation of the injured vessel yielded the same good results. The postoperative hospital stay was short in all instances, ranging from four to eight days, and there were no deaths.
Adolescent↗
Initial and long-term results in the management of primary chest wall neoplasms.
One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.
Adolescent↗