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H B Kram

Publications and source records attributed to H B Kram.

At least 19 recordsLinked to original sources
PubMed1999

Minimally invasive endoscopic video-assisted in situ bypass: first 15 cases.

The purpose of the present study was to determine the feasibility of endoscopic video-assisted (EVA) in situ bypass with greater saphenous vein (SV) for femorotibial revascularization. Fifteen consecutive patients who underwent EVA lower extremity revascularization were included in the present report. EVA in situ bypass was successfully accomplished in 12 of 15 (80%) patients. Two patients had major SV injuries (endoscopic scissors), and 6 patients had minor SV injuries (dissecting ring, clip applicator, valvulotome). Postoperatively, 2 patients developed subcutaneous abscesses in the thigh graft tunnel, and 5 patients developed minor calf wound necrosis. Eight of 12 (67%) EVA in situ bypasses were patent at 6- to 32-month follow-up (mean, 24 months), and 2 of 12 (17%) patients died with patent EVA in situ bypasses; one other patient experienced EVA in situ bypass thrombosis 6 months postoperatively without further surgical treatment. Ten of 12 (83%) patients who underwent EVA in situ bypass had successful surgical outcomes, and 11 of 12 (92%) avoided major amputation; 1 patient eventually required below-knee amputation because of nonhealing foot lesions despite a patent EVA in situ bypass. We conclude that EVA in situ bypass with SV is a practical technique for limiting the length and number of incisions necessary to completely eliminate SV tributaries. On the basis of experience gained from the present series, we recommend the following: 1) strategic placement of the initial small skin incisions to maximize exposure of the SV and inflow/outflow arteries; 2) beginning gas insufflation into the perivenous space during initial SV dissection, rather than after creation of the perivenous tunnel; 3) no transection of clipped SV tributaries with the endoscopic scissors; 4) minimal use of the dissecting ring to expose the SV and its tributaries, instead using continuous gas insufflation and the balloon dissector; and 5) completion angiography to inspect the bypass graft and runoff.

Aged↗
PubMed1995

Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma.

The objective was to test prospectively supranormal values of cardiac index (CI), oxygen delivery index (DO2I), and oxygen consumption index (VO2I) as resuscitation goals to improve outcome in severely traumatized patients. We included patients > or = 16 years of age who had either (1) an estimated blood loss > or = 2000 mL or (2) a pelvic fracture and/or two or more major long bone fractures with > or = four units of packed red cells given within six hours of admission. The protocol resuscitation goals were CI > or = 4.5 L/min/m2, DO2I > or = 670 mL/min/m2, and VO2I > or = 166 mL/min/m2 within 24 hours of admission. The control resuscitation goals were normal vital signs, urine output, and central venous pressure. The 50 protocol patients had a significantly lower mortality (9 of 50, 18% vs. 24 of 65, 37%) and fewer organ failures per patient (0.74 +/- 0.28 vs. 1.62 +/- 0.45) than did the 75 control patients. We conclude that increased CI, DO2I, and VO2I seen in survivors of severe trauma are primary compensations that have survival value; augmentation of these compensations compared to conventional therapy decreases mortality.

Adolescent↗
PubMed1994

Temporal patterns of radiographic infiltration in severely traumatized patients with and without adult respiratory distress syndrome.

We prospectively evaluated the patterns of pulmonary structural and functional changes in 100 consecutive surgical intensive care unit trauma patients who had (1) emergent major surgery, (2) a pelvic fracture, or (3) two or more major long bone fractures. For each patient, arterial blood gas measurements (ABGs), central venous pressure (CVP), pulmonary capillary occlusion pressure (PAOP), thoracic compliance, arterial oxygen tension/fraction of inspired oxygen (PAO2/FIO2), pulmonary venous admixture (Qs/Qt), and portable chest roentgenograms were sequentially tracked. The senior staff radiologist interpreted all chest roentgenograms. Pulmonary infiltration was quantitated in each of six fields using a scale ranging from 0 to 4, with 0 being no infiltration and 4 being the maximum. Adult respiratory distress syndrome (ARDS) was defined as follows: Qs/Qt > or = 20%, PAO2/FIO2 < 250 or both; dependence on mechanical ventilation for life support for > or = 24 hours; PAOP or CVP or both < 20 mm Hg; and thoracic compliance < 50 mL/cm H2O. Time zero (T0) the time of onset of ARDS, was defined as the time these criteria were met. Eighty-three of 100 study group patients had penetrating injuries, and 17 were admitted with blunt trauma. Fifty-one of 100 patients developed ARDS: 36 of 51 died. Only 4 of 49 (8%) patients without ARDS died. The injured lungs of patients with and without ARDS had similar amounts of infiltration over most measured time intervals. The noninjured lungs of the ARDS patients, however, had significantly greater infiltration than those without ARDS at T0 and over subsequent time intervals.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Relationship between supranormal circulatory values, time delays, and outcome in severely traumatized patients.

OBJECTIVE: To describe the temporal patterns of hemodynamics and oxygen transport in survivors and nonsurvivors of severe trauma in relation to time delays, mortality, and morbidity. DESIGN: Prospective, empiric analysis. SETTING: University-run, inner city county hospital with a Level I trauma center. PATIENTS: A series of 90 consecutively monitored, severely ill trauma patients. METHODS: We followed 90 patients from admission through their hospital course, and divided the study group into patients with estimated blood loss of < or = 3000 mL and those patients with an estimated blood loss of < 3000 mL. For each patient, vital signs were recorded in the Emergency Department, operating room, recovery room, and surgical ICU. Hemodynamic and oxygen transport variables were measured at least every 12 hrs for 96 hrs postadmission. Final outcome and complications were recorded. RESULTS: In the first 24 hrs, the values of 60 survivors were significantly higher than the values of 30 nonsurvivors for mean cardiac index (4.52 +/- 1.45 vs. 3.80 +/- 1.20 L/min/m2; p < .05), oxygen delivery (670 +/- 230 vs. 540 +/- 200 mL/min/m2; p < .01), and oxygen consumption (166 +/- 48 vs. 134 +/- 47 mL/min/m2; p < .01). Thirteen (50%) of 26 patients who never attained mean survivors' values (defined as the mean survivors' values listed above) died. Also, 12 (57%) of 21 patients who took > 24 hrs to attain these values died. In contrast, only five (12%) of 43 patients who reached mean survivors' values in < or = 24 hrs died. Thirty-five of 90 patients lost < 3000 mL of blood; 17 of these 35 patients failed to reach survivors' values within 24 hrs, and 12 (71%) patients died. However, of 18 patients with an estimated blood loss of > 3000 mL, who reached survivors' values in < or = 24 hrs, only two (12%) died. The patients reaching survivors' values in < or = 24 hrs, > 24 hrs, or not at all had similar Injury Severity Scores (28 +/- 13, 26 +/- 13, and 26 +/- 12, respectively) and Trauma Scores (12 +/- 3, 13 +/- 3, and 12 +/- 3, respectively). Only six (12%) of 43 patients reaching survivors' values in < or = 24 hrs developed adult respiratory distress syndrome (ARDS), while 27 (57%) of 47 patients showed these values in > 24 hrs or never developed ARDS. CONCLUSIONS: Reaching supranormal circulatory values, especially within 24 hrs of injury, may improve survival and reduce the frequency of shock-related organ failure in severely traumatized patients.

Hemodynamics↗
PubMed1993

Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness.

OBJECTIVE: To evaluate the reliability of the vital signs to evaluate circulatory stability as reflected by cardiac index. DESIGN: Descriptive analysis based on data gathered prospectively, using a predetermined protocol. SETTING: University-run county hospital, with a large trauma service. PATIENTS: Sixty-one high-risk trauma patients with accidental injury who were studied immediately after admission to the Emergency Department, and subsequently, 163 critically ill postoperative ICU patients. INTERVENTIONS: Standard fluid therapy, usually crystalloids, but occasionally packed red cell transfusions and colloids, as indicated by clinical criteria. MEASUREMENTS AND RESULTS: Arterial BP was measured by pressure transducer and arterial catheter; heart rate (HR) was measured by electrocardiograph signal, and cardiac output was measured by thermodilution. In sudden severe hypovolemic hypotension, the mean arterial pressure (MAP) nadir (lowest) roughly correlated (r2 = .25) with flow, but there was poor correlation (r2 = .0001) when all pressure and flow values were evaluated. The pressure and flow values were obtained throughout the course of the hypotensive episodes during the initial resuscitation in ICU patients and during terminal illnesses. CONCLUSIONS: Observations at the time of acute severe hypotensive crises that show rough correlation of MAP and cardiac index should not be extrapolated throughout the entire hypotensive period or to other less extreme clinical situations. The stress response to hypovolemia, with endogenous catecholamines and neural mechanisms, tends to maintain arterial pressure in the face of decreasing flow for a variable period of time. However, when these mechanisms are overwhelmed by prolonged hypovolemia, the pressure decreases precipitously, but not synchronously, with flow. We conclude that blood flow cannot reliably be inferred from arterial pressure and heart rate measurements until extreme hypotension occurs.

Blood Pressure↗
PubMed1993

Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery.

OBJECTIVES: To describe temporal hemodynamic and oxygen transport patterns in a large series of high-risk surgical patients in order to document physiologic patterns, to develop therapeutic goals for a wide range of surgical conditions, and to propose a mechanistic model for acute postoperative circulatory failure. DESIGN: Prospective, longitudinal study. Patients identified as high risk were studied prospectively. The data were analyzed immediately after they were acquired, again on formal rounds twice daily, and at a formal data review after completion of monitoring. SETTING: A university-run county hospital. PATIENTS: The patient series consisted of 708 consecutively monitored high-risk surgical patients. INTERVENTIONS: Hemodynamic and oxygen transport values and their responses to surgical trauma are known to vary widely with age and prior medical conditions; they may be used to predict outcome with a high degree of accuracy. Temporal hemodynamic and oxygen transport patterns in a large series of high-risk surgical operations were treated by one group, using a well-developed protocol. MEASUREMENTS AND MAIN RESULTS: Hemodynamic and oxygen transport monitored variables were analyzed before, during, and at frequent intervals after surgical operations. We stratified the temporal patterns of survivors and nonsurvivors in each of the following groups: a) patients without evidence of cardiovascular disease whose preoperative baseline cardiac index values were normal; and b) patients with high or low preoperative baseline cardiac index values due to the presence of preoperatively identified medical conditions that affect the circulatory status. In addition, we stratified patients in various age ranges who were without known cardiovascular diseases. The present study analyzed over 20,000 data sets with up to 32 variables in each data set or > 500,000 values. The major findings were intraoperatively reduced circulatory functions, principally cardiac index values, oxygen delivery (DO2), and oxygen consumption (VO2). These reductions in circulatory functions intraoperatively were followed, in the early postoperative period, by increases in these variables. The postoperative increases in cardiac index, DO2, and VO2 values were greater in survivors than in nonsurvivors; these findings were more apparent when the postoperative patterns of each strata were related to their own preoperative control values. CONCLUSIONS: The data indicate that there are increased metabolic requirements after surgical trauma and that the changes in cardiac index and DO2 represent compensatory increases in circulatory functions stimulated by increased metabolic needs. However, these metabolic needs change with age, gender, severity of illness, type of operation, associated medical conditions, duration of shock, complications, organ failure, and outcome.

Aged↗
PubMed1993

Sequence of physiologic patterns in surgical septic shock.

OBJECTIVES: Gradual, almost imperceptible transitions occur between localized infection, generalized infection, systemic manifestations of the sepsis syndrome, septic shock, and death. The aim of this study was to describe the sequential pattern of hemodynamic and oxygen transport patterns of survivors and nonsurvivors of septic shock, so as to differentiate primary from secondary and tertiary events, to evaluate possible physiologic mechanisms, and to provide a template to relate the appearance of biochemical mediators to the sequence of physiologic events. DESIGN: Prospective, cohort study. SETTING: University-run county hospital. PATIENTS: A series of 300 consecutive surgical patients with septic shock; 85 survived and 215 died. INTERVENTIONS: We used specific criteria to define stages as: a) early period, the first recorded increase in cardiac output; b) middle period, time of maximal metabolic activity defined as the highest recorded oxygen consumption (VO2); and c) late period, the time of death or recovery. MEASUREMENTS AND MAIN RESULTS: Hemodynamic and oxygen transport variables were measured at frequent intervals throughout the course of septic shock. Beginning with increased cardiac index and oxygen delivery (Do2), which were the earliest observed hemodynamic changes, there were progressive increases in cardiac index, DO2, and VO2. The values of these variables in the survivors were both greater than normal and greater than those values of the nonsurvivors at comparable time periods. These values decreased in the late stage in nonsurvivors. There were early transient reductions in VO2 that preceded the increase in temperature and the decrease in blood pressure in both survivors and nonsurvivors. Although 86% of the septic patients were hyperdynamic, there were transient hypodynamic episodes (defined as cardiac index < 2.5 L/min/m2) in < 10% of the measurements. Transient preterminal hypermetabolic periods occurred in 9% of the nonsurvivors. CONCLUSIONS: Increased cardiac index and DO2 represent compensations for circulatory deficiencies that limit body metabolism, as reflected by inadequate VO2. Survivors have higher cardiac index, DO2, and VO2 values than those values of both the nonsurvivors and normal values. These data suggest that therapy should be directed toward increasing cardiac index to > 5.5 L/min/m2, DO2 to > 1000 mL/min/m2, and VO2 to > 190 mL/min/m2 as therapeutic goals; these supranormal values were empirically determined by the patterns of the survivors. Further studies to describe temporal relationships of biochemical mediators of these physiologic patterns are needed.

Adult↗
PubMed1993

Temporal hemodynamic and oxygen transport patterns in medical patients. Septic shock.

STUDY DESIGN: Because of the gradual insidious transitions between localized infection, generalized infection, and septic shock, it is difficult to compare data of patients in various stages and to differentiate primary from secondary and tertiary events. The aim of the present study was to describe the sequential pattern of hemodynamic and oxygen transport patterns of survivors and nonsurvivors of septic shock in order to evaluate possible physiologic mechanisms and to provide a template to relate the sequence of physiologic events to biochemical mediators. PROCEDURE: A previously described defined protocol was used prospectively to study the sequence of physiologic events using specific criteria to define stages as: (a) early period, the first recorded change in cardiac output; (b) middle period, time of maximal metabolic activity defined as the highest recorded oxygen consumption (VO2); and (c) late period, the time of death or recovery. In addition, three time lines were defined as the first time mean arterial pressure fell below 70 mm Hg, the first time temperature rose above 38 degrees C, and the earliest fall in VO2. Physiologic data were aligned in actual time before or after the time these criteria were met. Invasive hemodynamic and oxygen transport variables were measured with systemic and pulmonary artery catheters; intravascular pressures, arterial and mixed venous gas levels, cardiac output, and derived calculations were made at frequent intervals and keyed to the time of the cardiac output; each set of measurements in turn was keyed to the aforementioned time periods to describe the early, middle, and late periods. RESULTS: Beginning with increased cardiac index and oxygen delivery (DO2) as the early physiologic changes, there were progressive increases in cardiac index, DO2, and VO2 throughout the early and middle periods. They were maintained above the normal range in the late stage of survivors, but fell in the last 16 h in nonsurvivors. These values were greater in survivors than in nonsurvivors throughout. There were early transient reductions in VO2 that preceded the rise in temperature and the fall in mean arterial pressure (MAP). Although 84 percent of the septic patients were hyperdynamic, there were transient hypodynamic episodes defined as cardiac index of less than 2.5 L/min.m2 in approximately 10 percent of the measurements. There were also transient preterminal hypermetabolic periods in about 8 percent of the nonsurvivors. CONCLUSION: We conclude that increased cardiac index and DO2 represent compensations for circulatory inadequacies that limit body metabolism as reflected by VO2. Cardiac index, DO2, and VO2 values of survivors were higher than those of nonsurvivors and normal values. Therapy directed toward increasing cardiac index to supranormal values empirically determined by survivors has been reported to improve outcome. Additional studies to describe temporal relationships of biochemical mediators of these physiologic patterns are needed.

Analysis of Variance↗
PubMed1993

Hemodynamic and oxygen transport monitoring to titrate therapy in septic shock.

Traditionally, shock has been recognized or diagnosed by subjective signs and symptoms, particularly in septic shock, where transition from localized to systemic infection and then to septic shock may be gradual and subtle. Management has been directed toward normalizing these subjective symptoms as well as BP, heart rate, urine output, hematocrit, central venous pressure, and blood gases. The major problem is that restoration to normal values of these secondary aspects of shock do not correct the underlying tissue perfusion defect. The aim of this review is to describe a physiologic mechanistic model based on the concept that uneven vasoconstriction and maldistribution of flow are directly related to tissue hypoxia, oxygen debt, shock, shock-related organ failure, and death; second, to show that titration of therapy to optimal physiologic end-points using hemodynamic and oxygen transport monitoring is a potentially cost-effective therapeutic approach. This physiologic approach is based on the hypotheses that: a) the physiologic patterns of high-risk postoperative and septic survivors are significantly different from septic nonsurvivors; b) tissue perfusion can be evaluated by the sequential patterns of cardiac index, oxygen delivery (DO2), and oxygen consumption (VO2) measurements; c) the observed increased cardiac index and DO2 in the survivors are compensations that improve tissue oxygenation, which is reflected by the VO2 pattern; and d) the supranormal values that were documented in survivors provide objective physiologic criteria for therapeutic goals. The data suggest that a mechanistic analysis of the pathogenesis of shock may be elucidated by temporal patterns of the nonsurvivors' physiologic variables. That is, the predictive indices calculated for each variable quantitatively reflect the relationship of the early changes leading to death or survival. In essence, early changes in those variables statistically related to death may reflect pathogenic mechanisms, while early changes related to survival may be used as a first approximation to therapeutic goals. The application of this approach in prospective, randomized trials has demonstrated that prompt attainment of optimal goals (empirically defined from survivors' patterns) improved outcome in postoperative shock with and without sepsis, as well as in medical sepsis and accidental trauma. Specifically, when the optimal values of cardiac index, DO2, and VO2 used as therapeutic goals were attained in 8 to 12 hrs, there was marked and significant reduction in mortality and morbidity rates. This finding was also confirmed in 12 prospective, controlled trials, four of which were randomized. We conclude that driving septic shock patients into the survivors' patterns improves outcome, as has been shown in other shock syndromes.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

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↗