Pericardial flap and resternotomy injury.
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Cardiac Surgical Procedures↗
Biomedical subjects
V A Ferraris
Publications and source records attributed to V A Ferraris.
Comparison of blood reinfusion techniques used during coronary artery bypass grafting.
A comparison of intraoperative autologous blood conservation techniques was carried out in 100 patients undergoing coronary artery bypass grafting. To facilitate comparisons of similar groups, patients were stratified into high-risk and low-risk groups based on the ratio of preoperative bleeding time to preoperative red blood cell volume. Our previous work suggested that patients with an elevated ratio have increased risk of excessive post-operative blood transfusion. We used this ratio to stratify the 100 patients to either the high-risk (39 patients) or low-risk (61 patients) strata. Within each stratum, patients were randomized to one of three groups: no intraoperative autologous blood conservation (control group), infusion of autologous platelet-rich plasma obtained from intraoperative plasmapheresis (PRP group), and infusion of autologous whole blood harvested immediately before cardiopulmonary bypass (whole blood group). Variables of postoperative blood loss and transfusion requirements were measured in each patient. Analysis of variance showed significant differences in blood product transfusions between groups. Patients in the high-risk stratum required significantly more blood product transfusions than those in the low-risk stratum (5.4 +/- 0.7 versus 2.0 +/- 0.6 units per patient; p < 0.001). In the high-risk stratum, PRP patients required significantly less postoperative blood transfusion compared with patients in the high-risk control group (2.9 +/- 2.1 versus 8.1 +/- 2.2 units per patient; p = 0.05). In the low-risk stratum, no intraoperative blood infusion method resulted in significant improvement in postoperative blood use.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Loss, Surgical↗
Pericardial closure without pericardial substitute.
Primary closure of the native pericardium is recommended whenever possible, and pericardial substitutes are advocated when primary closure is not feasible. To avoid foreign material, we have employed a unique method of dissection to allow mediastinal coverage without tension.
Humans↗
Alternative conduits for coronary revascularization: a novel approach for harvest of the lesser saphenous vein.
Previous use of the greater saphenous vein limits the subsequent availability of conduit for coronary artery bypass grafting (CABG). One readily available alternative conduit is the lesser saphenous vein (LSV). During a 4-year period, 34 LSVs were explored in 23 patients using a novel surgical approach. The incision used for LSV harvest was carried through and deep into the muscular fascia, posterior to the tibia, along the length of the leg, developing a fascial-cutaneous flap. The LSV in all patients was imaged before operation by venous duplex scanning. Important anatomic details were mapped on the patient's leg before surgery using indelible ink. Findings at operation correlated well with the duplex imaging results. Of the 34 LSVs explored 31 were judged usable by the operating surgeon. In eight patients bilateral LSVs were used and in two this vein was the only conduit available. Among patients undergoing LSV harvest there was no operative mortality and minimal operative morbidity related to harvesting. Only one wound infection developed at the incision site. There were no documented cases of deep vein thrombosis. A case-control study was performed in which a control group of 25 patients undergoing CABG without use of the LSV were compared with the 23 who had LSVs harvested; patients in both groups underwent preoperative venous duplex studies. There were no significant differences in operative mortality or morbidity rate between groups (statistical power > 0.8 for these negative observations), suggesting that harvest of the LSV is usually successful when used in conjunction with preoperative venous duplex scanning.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Outcome in critical care patients: a multivariate study.
OBJECTIVE: To identify patient variables that were significantly associated with outcome in the ICU. DESIGN: Retrospective chart study of ICU patients. SETTING: Letterman Army Medical Center, Presidio of San Francisco. PATIENTS: A total of 110 consecutive patients who remained in the ICU for greater than 72 hrs. METHODS: Univariate analysis of 26 input variables, representing physiologic status and chronic health assessment at the time of ICU admission of the patients, and adverse events that occurred during their ICU stay. The dependent variable assessed was the outcome of patients after ICU intervention. A bad outcome included patient mortality or discharge from the ICU in worse condition or in a chronic vegetative condition. Five selected input variables were used in a multivariate logistic regression analysis to identify independent predictors of a successful outcome. RESULTS: Univariate statistical techniques comparing the values of 26 input variables of patients who improved during their ICU stay (46 patients) with those values of patients who did not improve (52 deaths and 12 unimproved patients) indicated that the following nine variables were significantly different in these two groups: a) age (p = .04), b) acute physiologic score (p = .047), c) Acute Physiology and Chronic Health Evaluation (APACHE II) score (p = .040), d) the number of repeat ICU admissions during a given hospitalization (p = .019), e) development of respiratory complications while in the ICU (p = .033), f) sepsis developing while in the ICU (p = .0001), g) renal failure developing while in the ICU (p less than .0001), h) disseminated intravascular coagulation while in the ICU (p = .0028), and i) the occurrence of any iatrogenic complication while in the ICU (p less than .0001). Five of these nine variables were used in a stepwise logistic regression analysis to develop a model to predict ICU outcome. This model showed the following three variables to be significantly associated with unfavorable ICU outcome: a) occurrence of any iatrogenic event while in the ICU (p less than .001), b) development of renal failure in the ICU (p = .001), and c) occurrence of sepsis while in the ICU (p = .042). A common iatrogenic complication associated with unfavorable ICU outcome was related to drug therapy (frequently aminoglycoside toxicity). Twenty-one iatrogenic drug complications occurred in 64 patients who did not improve in the ICU, whereas only three iatrogenic drug complications occurred in 46 patients who improved (p less than .001). CONCLUSIONS: For patients who remain in the ICU for greater than 72 hrs, events occurring after ICU admission are negatively associated with ICU outcome, more so than ICU admission status as reflected by such indices as APACHE II scores. Iatrogenic complications, often due to inappropriate drug therapy, have a significant association with adverse outcome by multivariate analysis. We suggest that iatrogenic complications influence ICU outcome, and that they are potentially preventable. By lessening their frequency, ICU outcome may be improved.
Age Factors↗
The dangers of gathering data.
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Cardiac Surgical Procedures↗
Cardiopulmonary bypass.
There has been a recent renewed interest in certain aspects of cardiopulmonary bypass employing extracorporeal circulation. Several areas have received special attention. Among these is the institution of extracorporeal circulation using a percutaneous technique for circulatory assistance during high-risk percutaneous transluminal coronary angioplasty. A national registry has been established to review and monitor results using this percutaneous technique. Several recent developments in the delivery of cardioplegia during ischemic arrest have stimulated investigative efforts. In particular, the delivery of cardioplegia in a retrograde manner through the coronary sinus has proved an effective and useful adjunct to myocardial protection during cardiopulmonary bypass with extracorporeal circulation. A newer investigative technique employing only warm cardioplegia delivered primarily through the retrograde coronary sinus route seems to offer some promise in providing optimal myocardial protection while minimizing hemorrhagic complications and other cold-induced myocardial injury. Because of concerns regarding blood transfusion-related communicable disease (eg, acquired immune deficiency syndrome and non-A, non-B hepatitis), there has been increasing research effort into postoperative hemorrhage related to cardiopulmonary bypass with extracorporeal circulation. Specifically, various drugs that may serve as hemostatic adjuncts have been investigated extensively. These drugs include aprotinin and desmopressin acetate. Likewise, several studies have evaluated other drugs (mainly aspirin) that have a negative influence on postoperative hemostasis. Additionally, there has been continued research interest in the activation of the inflammatory system during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)
Aprotinin↗
Double valve replacement for lupus valvulitis: report of a case and review of the literature.
Hemodynamically significant lupus valvulitis, requiring valve replacement, is rare: 21 cases have been reported so far in the literature, and only 2 of these have involved double valve replacement. We describe an additional case of double valve replacement in a patient with systemic lupus erythematosus. The histopathologic and clinical features of this case suggest that valvular involvement resulted from both acute and chronic disease processes. Medical success in the treatment of systemic lupus erythematosus, especially that achieved through prolonged or high-dose steroid therapy, may cause chronic valvular disease to become a more common surgical problem. A review of the literature supports this contention.
Journal Article↗
Predictors of excessive blood use after coronary artery bypass grafting. A multivariate analysis.
One hundred fifty-nine consecutive patients who underwent coronary artery bypass grafting were studied to determine clinical and laboratory predictors of excessive postoperative packed red blood cell transfusion. Consideration of the distribution of packed red blood cells administered revealed that the patients could be divided into two groups: those patients who received 5 units of red blood cells or less (group I, n = 139) and those patients who received more than 5 units of packed red blood cells (group II, n = 20). The Mann-Whitney test or Fisher's exact test was used whenever appropriate to test differences between these two groups with respect to twelve patient variables. Patients in group II were found to have a significantly longer preoperative template bleeding time and decreased preoperative packed red blood cell volume (p less than 0.0008 for both variables). In addition, group II patients were significantly older (p = 0.026), were more likely to have had preoperative heparin therapy (p = 0.049), and contained a greater proportion of women (p = 0.0048). Of interest, variables that did not achieve statistical significance between groups were partial thromboplastin time, prothrombin time, platelet count, preoperative hematocrit level, urgency of operation, recent ingestion of aspirin, and recent heparin administration. All of the measured variables were used in a stepwise logistic regression analysis to identify the best predictors of the need for more than 5 units of packed red blood cells after operation. Of the variables examined, bleeding time (p less than 0.001; chi 2 improvement = 15.1) and red blood cell volume (p = 0.009; chi 2 improvement = 6.8) were the best predictors of excessive postoperative packed red blood cell use. On the basis of a 50% logistic probability level, the specificity and sensitivity of these two variables in predicting greater than a 5-unit transfusion requirement were 85% and 99%, respectively. A clinically useful nomogram based on this logistic model is presented. This nomogram suggests that a ratio of bleeding time to red blood cell volume of 0.0071 or greater is associated with a greater than 70% chance of requiring more than 5 units of packed red blood cells. We conclude that preoperative bleeding time and red blood cell volume are useful predictors of excessive postoperative blood transfusion. These results suggest that factors other than aspirin therapy may be associated with bleeding time prolongation leading to excessive postoperative transfusion.
Aged↗
Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting.
Thirty-four patients were entered into a non-blinded, randomized study to test the effect of preoperative aspirin ingestion on postoperative blood loss and transfusion requirements after coronary artery bypass grafting. Sixteen patients in the aspirin-treated group had significantly increased chest-tube blood loss 12 hours after operation (1,513 +/- 978 versus 916 +/- 482 ml; p = 0.038). In addition, aspirin users had significantly increased requirements for postoperative packed red blood cells (4.4 +/- 3.5 versus 1.8 +/- 1.3 units; p = 0.014), platelets (1.3 +/- 1.3 versus 0.2 +/- 0.4 six-donor units, p = 0.0049), and fresh-frozen plasma (3.6 +/- 5.0 versus 0.78 +/- 1.6 units; p = 0.042) transfusions. The only patients requiring reoperation for bleeding were in the aspirin-treated group (2 patients). Six patients were not entered into the randomized part of the study because of excessively prolonged post-aspirin bleeding times (greater than 10 minutes). This finding suggests that a subset of patients are particularly sensitive to aspirin and have significantly prolonged bleeding times after aspirin ingestion. We conclude that aspirin ingestion increases postoperative blood loss and transfusion requirements, and we recommend discontinuation of aspirin therapy before cardiac procedures.
Aged↗
Pericardial substitutes: a survey.
Many thoracic surgeons have used pericardial substitutes to reduce the risk of reoperation, but there have been few reports of these procedures. Therefore, we used a questionnaire to gather information on experience with use of pericardial substitutes and to document the findings at reoperation. A six-question survey was sent to 2,344 members of The Society of Thoracic Surgeons, requesting surgeons to list their experience with pericardial substitutes and at reoperation in patients with these substitutes in place. Of the 634 surgeons who responded to the survey, 120 reported the insertion of 3,828 pericardial substitutes. Two hundred thirty-six reoperations were reported by 89 surgeons. None of the pericardial substitutes was reported to be completely successful in facilitating reoperation. The experience with polytetrafluoroethylene (PTFE) pericardial substitutes was reported to be significantly more satisfactory than that with all other substitutes (p = 0.0004 by chi-square analysis), but 14% of surgeons who used PTFE said they were dissatisfied at reoperation. Based on the results of this survey, we suggest caution, careful documentation, and long-term follow-up studies before widespread use of pericardial substitutes can be recommended.
Biocompatible Materials↗
Verapamil prophylaxis for postoperative atrial dysrhythmias: a prospective, randomized, double-blind study using drug level monitoring.
Orally administered verapamil hydrochloride (80 mg every 8 hours) or a placebo was given to 109 patients after coronary artery bypass grafting in a randomized, double-blind manner to test the efficacy of verapamil in preventing postoperative atrial dysrhythmias. The test drug was given through a nasogastric tube beginning 4 to 6 hours after operation until oral ingestion was possible. Serum levels of verapamil were measured at selected times after operation and when postoperative atrial dysrhythmias occurred. Postoperative atrial dysrhythmias occurred in 10 of the 53 verapamil-treated patients and in 20 of the 56 placebo-treated patients. Patients with verapamil drug levels higher than 150 ng/ml had fewer postoperative atrial dysrhythmias than those with lesser verapamil levels (p = .034) or than placebo-treated patients (p = .012). Only 2 of 31 patients with drug levels higher than 150 ng/ml experienced postoperative atrial dysrhythmias. Approximately 40% of verapamil-treated patients had drug levels lower than 150 ng/ml at 48 hours after operation. It is concluded that oral administration of verapamil prevents postoperative atrial dysrhythmias in a dose-dependent fashion.
Administration, Oral↗
Routine template bleeding time determinations before cardiac procedures.
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Bleeding Time↗
The empty gallbladder syndrome--results of operation for noncalculous biliary disorders.
Based on results of long-term follow-up and pathophysiologic considerations in 38 consecutive patients, it was possible to speculate on the frequencies of the various causes of the empty gallbladder syndrome. In approximate percentages, these are as follows: bile stasis causing chronic acalculous cholecystitis, 47%; physiologic dysfunction of the gallbladder, 24%; psychogenic illness, 16%; sphincter of Oddi dysfunction, 13%; ulcerative colitis, 3%. Because as many as 30% to 35% of these patients will not benefit from cholecystectomy, I feel that it should be undertaken with caution in cases of this syndrome.
Adolescent↗
Modified fundoplication technique for correction of gastroesophageal reflux in children.
A modification of the Nissen fundoplication for correcting GER in children is described. This method involves creating a reinforced fundoplication below the diaphragm at the gastroesophageal junction. Two additional lateral rows of sutures are used to reinforce the conventional Nissen fundoplication. This modified technique prevents symptomatic recurrence by lessening the chance of disruption of fundoplication sutures, and it prevents formation of paraesophageal hiatal hernia. We conclude that the modified fundoplication technique is both safe and effective for use in treating children with GER.
Age Factors↗
Mass screening for tuberculosis in an isolated United States Army outpost.
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Adult↗
Adult duodenal web associated with peptic ulcer disease.
Three new instances of adult duodenal web and associated peptic ulcer disease are presented. In addition, 33 instances of adult duodenal web from the literature are reviewed. Peptic ulcer disease occurred in association with duodenal web in six of these 33 patients. Operative management of these patients was reviewed and the difficulty in diagnosis of duodenal web was emphasized. Optimal treatment of adult duodenal web was web excision and duodenoplasty. This treatment was successful in all 20 instances in which it was used. The added complication of peptic ulcer disease in nine patients with duodenal web required an anti-ulcer procedure in addition to standard treatment of duodenal web. The outcome in these nine patients was excellent.
Adult↗
Exploratory laparotomy for potential abdominal sepsis in patients with multiple-organ failure.
We studied 29 patients with multiple-organ failure (MOF) who underwent exploratory laparotomy because of suspected intra-abdominal sepsis. The purpose was to identify predictors of continuing abdominal sepsis and to assess outcome of operation in these severely ill patients. The strongest predictor of continuing intra-abdominal sepsis was development of unexplained single-organ failure, which occurred in 17 patients. Physical findings were not a totally reliable indicator of abdominal sepsis since only 15 of 29 patients had acute abdominal findings. The main clue to sepsis in patients without acute abdominal findings was worsening organ failure. Fifteen of 29 patients died of continuing MOF. Only one patient older than 50 years survived. We suggest that earlier operation is indicated in certain patients with organ failure. Particularly aggressive operative therapy seems justified in young patients with unexplained single-organ failure or worsening MOF.
Abdomen, Acute↗