Venous thromboembolism in spinal cord injury patients.
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Anticoagulants↗
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Four-week negative pressure ventilation improves respiratory function in severe hypercapnic COPD patients.
Studies on respiratory muscle resting by negative pressure ventilation (NPV) in patients with stable COPD have given conflicting results. Probable explanations lie in criteria of patients' selection, method of NPV application, and lack of supervision of respiratory muscle rest. Thirteen hypercapnic patients with COPD were, therefore, randomly assigned to either a NPV group or a control group. The NPV was applied by an airtight jacket (pneumosuit), 5 h a day, 5 consecutive days a week for 4 weeks. Both NPV group and control group performed in-hospital pulmonary rehabilitation program for a 4-week period. Arterial blood gases, spirometry, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), breathing pattern, and electromyogram (EMG) of the diaphragm and parasternal intercostal muscles were measured on the preintervention day, and at the end of the second and fourth weeks of treatment (days 13 and 27, respectively). The short-term effect of NPV on EMG suppression was also checked throughout the ventilatory sessions in three different days (1, 12, and 26, respectively). A 6-min walking test (WT) and level of dyspnea by a modified Borg scale were evaluated on the preintervention and the last days. Negative pressure ventilation resulted in a significant reduction in EMG activity of both diaphragm and parasternal muscles, associated with significant increase in MIP, tidal volume, and ventilation, and increase in PaO2 and decrease in PaCO2. A significant relationship between change in MIP and change in PaCO2 was observed (r = 0.72, p < 0.01). Improve-ment in 6-min WT and dyspnea sensation was also observed, both being the sole changes in the control group. These data seem to indicate a beneficial role of respiratory muscle rest in improving respiratory function. Adequate supervision by personnel familiar with the equipment is likely to contribute to successful treatment.
Action Potentials↗
Lack of oxygen supply dependency in patients with severe sepsis. A study of oxygen delivery increased by military antishock trouser and dobutamine.
BACKGROUND: During severe sepsis, the existence of a pathologic oxygen supply dependency remains controversial. STUDY OBJECTIVE: To evaluate the relationship between oxygen delivery (DO2) and oxygen consumption (VO2) during severe sepsis and to compare, in this respect, survivors and nonsurvivors and patients with normal or increased concentration of plasma lactate. STUDY DESIGN: Cohort analytic study. SETTING: Three European ICUs in university hospitals. PATIENTS: Seventeen mechanically ventilated patients with severe sepsis (six with high blood lactate levels) studied within the first day of diagnosis. INTERVENTIONS AND MEASUREMENTS: Pulmonary elimination of carbon dioxide, or carbon dioxide production (VCO2) and VO2 were measured by indirect calorimetry before and after two interventions designed to increase DO2 (calculated from the Fick equation): inflation of a military antishock trouser (MAST) and infusion of dobutamine. RESULTS: During MAST inflation, DO2 increased by 19% in patients with a normal concentration of plasma lactate (p < 0.01), but remained unchanged in patients with high lactate levels. During dobutamine infusion, DO2 increased in both groups by 16% (p < 0.01) and 20% (p < 0.05), respectively. In both groups, we found that the VO2 and VCO2 were not affected by either the MAST or the dobutamine-induced increase in DO2. There was no difference between survivors and nonsurvivors. CONCLUSION: There was no evidence of a pathologic oxygen supply dependency in patients with severe sepsis, even in those who had an elevated concentration of plasma lactate and in those who ultimately died. These results do not favor the conclusion that maximizing DO2 is a primary therapeutic objective in such patients.
Acute Disease↗
The incidence of deep venous thrombosis in ICU patients.
STUDY OBJECTIVE: To determine the incidence, clinical presentation, and risk factors of deep venous thrombosis (DVT) in a high-risk group of ICU patients receiving DVT prophylaxis. DESIGN: A prospective cohort study. SETTING: Two ICUs of a university-affiliated teaching hospital. PATIENTS: Patients admitted to the ICUs within 48 h of hospitalization and who had an ICU stay of > or = 4 days underwent venous duplex scans. INTERVENTIONS: None. RESULTS: One hundred two patients were studied. Ninety-four (92%) patients received DVT prophylaxis. Twelve patients (12%) were documented to have DVT by venous duplex scans. There was proximal clot extension in eight of these patients, four of whom had high-probability ventilation/perfusion scans. Of the 56 patients without signs or symptoms of DVT, only two (3.6%) had abnormal scans. Leg swelling was present in 11 patients, six of whom had DVT (p = 0.004). One of 11 patients with unexplained fever had an abnormal scan. Five of the 26 patients (19%) receiving pneumatic compression developed DVT compared with five of 68 patients (7.4%) receiving subcutaneous heparin (not significant). No specific factor was identified that increased the risk of DVT. CONCLUSION: In this study, the incidence of DVT in a group of high-risk ICU patients receiving DVT prophylaxis was 12%. Since scans in patients without signs or symptoms suggestive of DVT were abnormal in only 3.6% of patients, venous scans should be performed only in patients with features suggestive of DVT or pulmonary embolism.
Aged↗
Right ventricular function in human sepsis: a thermodilution study.
STUDY OBJECTIVE: To assess the relations among right ventricular (RV) pressures and volumes in sepsis. DESIGN: Prospective study. SETTING: ICU. PATIENTS: Eighteen patients with sepsis who were in hemodynamically stable condition. INTERVENTION: Stepwise increases and decreases in RV end-diastolic volume (EDV) as induced by military antishock trousers (MAST) inflation of 0, 15, 30, 50 and then 0 mm Hg over 15-min intervals. MEASUREMENTS AND RESULTS: RV volumes and pressures were measured using a rapid response thermistor pulmonary arterial catheter based on RV ejection fraction (RVEF) calculations. RV EDV was estimated as stroke volume (SV)/RVEF, while RV end-systolic volume (ESV) was estimated as EDV-SV. Right atrial pressure (Pra) was taken as end-diastolic pressure, and pulmonary artery pressures (Ppa), both mean and end-systolic, were used as RV ejection pressures. MAST inflation to 15 mm Hg had no measurable effects on the measured variables. However, inflation to 30 and 50 mm Hg increased Pra, both mean and end-systolic Ppa, EDV, and ESV, whereas SV and RVEF remained unchanged. The relation between either Pra and EDV (r=0.33) or the change in Pra and EDV, mean or end-systolic Ppa and ESV (r=0.5 and 0.28, respectively), or the change in mean or end-systolic Ppa and ESV for both the group and individual subjects was poor. Furthermore, SV correlated poorly with EDV (r=0.32), while RVEF correlated better with both EDV and ESV (r=-0.41 and -0.69, respectively), although it showed no definable relation to mean or end-systolic Ppa. However, both absolute and relative changes in EDV corresponded closely with respective ESV values (r=0.93). CONCLUSIONS: During sepsis, RV EDV and ESV vary independently of changes in Pra and ejection pressure. These data can be explained by assuming that the RV is a highly compliant chamber during filling, such that changes in RV EDV do not alter RV wall stress (preload) or ejection efficiency (RVEF). Thus, changes in RV EDV should proportionally alter RV ESV. Furthermore, the slope of the ESV/EDV relation should be inversely proportional to ejection efficiency.
Adult↗
Echocardiographic evaluation of left ventricular function in critically ill patients: dynamic loading challenge using medical antishock trousers.
STUDY OBJECTIVE: We hypothesized that a dynamic left ventricular (LV) evaluation during a loading challenge might enhance diagnostic capabilities of routine transesophageal echocardiography in critically ill patients and selection of therapeutic options against circulatory failure, particularly the choice between volume expansion and vasoactive agent infusion. DESIGN: Prospective clinical study in a group of 26 patients requiring hemodynamic support by vasoactive infusion because of low systemic arterial pressure (< 90 mm Hg by invasive monitoring) during mechanical ventilation. SETTING: University hospital ICU. PATIENTS: Patients required respiratory support for an episode of acute respiratory failure of various causes or for an episode of coma. They were studied by transesophageal echocardiography during mechanical ventilation in the controlled mode, before and during a loading challenge made using the legs compartment of medical antishock trousers inflated at 80 mm Hg. MEASUREMENTS: A short-axis view of the left ventricle was obtained by a transgastric approach, and end-diastolic and end-systolic areas were measured. LV stroke area (LVSA) and LV fractional area contraction (LVFAC) were calculated. RESULTS: Changes in LV echocardiographic measurements permitted separation of the patients into two groups. In nine patients (group 1), LVSA, used as an index of stroke output, was significantly increased during the challenge, together with a significant increase in LV end-diastolic area, suggesting preload improvement by the challenge. Conversely, in 17 patients (group 2), LVSA was significantly reduced by the challenge, together with a significant decrease in LVFAC, suggesting a negative effect of increased afterload by the challenge. CONCLUSION: Study of the changes in LV dimensions during loading challenge in hemodynamically unstable patients was used to evaluate the balance between the adequacy of preload and the ability of the heart to pump against an increased load, and might thus guide hemodynamic support.
Critical Illness↗
Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis.
CONTEXT: Venous thromboembolism (VTE) is the most frequent complication following craniotomy for brain tumors. At Brigham and Women's Hospital, VTE after craniotomy for brain tumor is the leading cause of deep vein thrombosis (DVT) and pulmonary embolism (PE) among patients hospitalized for conditions other than VTE. OBJECTIVE: To minimize VTE among patients undergoing craniotomy for brain tumor. DESIGN: Randomized, prospective, double-blind clinical trial. SETTING: Brigham and Women's Hospital. PATIENTS: One hundred fifty patients undergoing craniotomy for brain tumor randomized to enoxaparin, 40 mg/d, vs heparin, 5,000 U bid, with all patients receiving graduated compression stockings and intermittent pneumatic compression. MAIN OUTCOME MEASURES: The rate of DVT detected by venous ultrasonography prior to hospital discharge. RESULTS: Symptomatic DVT or PE developed in none of the patients. The overall rate of asymptomatic VTE was 9.3%, with no significant difference in the rates between the two prophylaxis groups. Ten of the 14 patients identified with VTE had thrombus limited to the deep veins of the calf. CONCLUSIONS: Enoxaparin, 40 mg/d, or unfractionated heparin, 5,000 U bid, in combination with graduated compression stockings, intermittent pneumatic compression, and predischarge surveillance venous ultrasonography of the legs, resulted in 150 consecutive patients without symptomatic VTE. The low 9.3% frequency of asymptomatic VTE comprised mostly isolated calf DVT. Therefore, this comprehensive, multimodality approach to VTE prophylaxis achieved excellent efficacy and safety.
Bandages↗
The management of acute quinidine intoxication.
A 16-year-old patient survived severe intoxication with quinidine. Hypotension, rapidly progressing to oliguria and shock, was resistant to the usual therapeutic interventions but responded favorably to the use of an intra-aortic balloon pump. Some hemodynamic implications are discussed. Pulmonary edema occurred and was treated with positive end-expiratory pressure. Electrocardiographic disturbances in conduction, transient bradycardia and recurrent ventricular arrhythmias characterized the initial 36-hour critical period. Unexplained electrolyte abnormalities occurred and further complicated management.
Adolescent↗
Military antishock trouser (MAST). Application as a reversible fluid challenge in patients on high PEEP.
Fluid management in the critically ill patient receiving high levels of positive end-expiratory pressure (PEEP) can be difficult. PEEP may cause the cardiac index to fall due to a decrease in left ventricular preload. However, the high intrathoracic pressures produced by PEEP negate the usefulness of the pulmonary artery occlusion pressure (PAo) as a measurement of left ventricular preload. The military antishock trouser (MAST), which has been presumed to compress the venous capacitance reservoir and auto-transfuse 500 to 1,000 ml to the central circulation, was used as a reversible predictor of the effects of fluids on 12 critically ill patients receiving PEEP greater than 10 cm H2O with a decreased cardiac index. Hemodynamic variables were measured before, during, and after MAST inflation. Fluids were given in a quantity sufficient to maintain the same PAo after MAST deflation as achieved with the initial inflation. A significant improvement of cardiac performance and a high correlation between MAST and post-MAST variables was observed. Application of MAST as a reversible fluid challenge is a useful method for predicting optimal fluid management.
Adult↗
Decreased paradoxic pulse from increased venous return in severe asthma.
During severe asthma, paradoxic pulse may result from increased impedance to left ventricular ejection, mechanical impairment of left ventricular filling by ventricular interdependence or decreased pulmonary venous return augmented by hypovolemia. We studied the effect of reversible blood volume expansion by MAST inflation during severe attacks of asthma. Ten patients with clinically detectable paradoxic pulse of more than 20 mm Hg were studied. All had a history of reversible bronchial asthma with evidence of respiratory and circulatory failure. Standard therapy for asthma was started. We observed no difference in respiratory and heart rates during MAST inflation. Paradoxic pulse was consistently decreased during MAST inflation; paradoxic pulse returned to baseline values after MAST deflation. The decrease in paradoxic pulse was produced by an increased inspiratory systolic arterial pressure. We conclude that a reduction in pulmonary venous return is more important than ventricular interdependence in producing paradoxic pulse during severe asthma.
Adolescent↗
The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia.
A prospective, randomized trial was done to evaluate the prevalence of deep venous thrombosis following primary unilateral or bilateral total hip arthroplasty with use of hypotensive epidural anesthesia, external pneumatic-compression boots, and aspirin (Group I) and with use of hypotensive epidural anesthesia and aspirin (Group II). All operations were performed by two of us (E. A. S. and T. P. S.) through a posterolateral approach. Two hundred and thirty-one patients who were more than thirty-nine years old and who had a total of 250 primary total hip arthroplasties were included in the study. There were 113 patients (124 hips) in Group I and 118 patients (126 hips) in Group II. All patients had venography on the sixth, seventh, or eighth postoperative day. Group I had no proximal thrombi, seven distal thrombi (6 per cent), and one late pulmonary embolus (1 per cent). Group II had one proximal thrombus (popliteal) (1 per cent), eight distal thrombi (6 per cent), and one late pulmonary embolus (1 per cent). The difference was not significant (p = 0.65). However, a significant difference may have been noted if the study population had been larger. The combination of hypotensive epidural anesthesia and aspirin is effective prophylaxis against deep venous thrombosis in patients who have a primary total hip arthroplasty. The extremely low rate of deep venous thrombosis in the present study may be attributed to the use of hypotensive epidural anesthesia and the associated decrease in blood loss and transfusion requirements.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Efficacy of prophylaxis against thromboembolism with intermittent pneumatic compression after primary and revision total hip arthroplasty.
BACKGROUND: Thromboembolism is a common and important complication after total hip arthroplasty. A variety of pharmacological and mechanical measures have been proposed for prophylaxis. The purpose of the present study was to evaluate the efficacy of intermittent pneumatic compression as prophylaxis against thromboembolism following total hip arthroplasty. METHODS: The prospective study involved a consecutive series of 425 patients in whom a total of 502 (324 primary and 178 revision) total hip arthroplasties had been performed by two surgeons. The patients were managed intraoperatively and postoperatively with use of thigh-high elastic compression stockings and thigh-high intermittent pneumatic compression sleeves. Experienced vascular technologists performed venous duplex ultrasonography on both lower extremities of all patients at a mean of six days (range, two to fifteen days) postoperatively. All patients were followed for at least one year in order to detect late thromboembolism. RESULTS: An asymptomatic deep-vein thrombosis was noted on the scans made after twenty-three (4.6 percent) of the 502 procedures. Nineteen (3.8 percent) of the arthroplasties were followed by the development of a proximal thrombosis and four (0.8 percent), a distal thrombosis. Nineteen of the thromboses were ipsilateral (eighteen were proximal and one, distal), and four were contralateral (one was proximal and three, distal). No symptomatic deep-vein thrombosis developed in the hospital. In addition, three (two proximal and one distal) symptomatic ipsilateral deep-vein thromboses (a prevalence of 0.6 percent) developed three to twenty-three weeks after postoperative scans revealed negative findings and the patients were discharged from the hospital. Three symptomatic pulmonary embolisms (a prevalence of 0.6 percent) were confirmed by ventilation-perfusion scanning while the patients were in the hospital. There were no symptomatic pulmonary embolisms after discharge, and there were no fatal pulmonary embolisms. With the numbers available, we were unable to detect an association between deep-vein thrombosis and age (p = 0.76), gender (p = 0.13), body-mass index (p = 0.12), type of arthroplasty (primary or revision) (p = 0.12), operative approach (p = 0.37), duration of the operation (p = 0.21), type of anesthesia (general or regional) (p = 0.51), units of blood transfused (autologous, p = 0.79; homologous, p = 0.57), blood type (p = 0.18), or the presence of a so-called classic risk factor for the development of thrombosis (p = 0.22). Five arthroplasties (1.0 percent) were followed by the development of a wound hematoma, but only one hematoma necessitated operative drainage. CONCLUSIONS: The use of intraoperative and postoperative thigh-high intermittent pneumatic compression, combined with duplex ultrasonography performed by experienced vascular technologists, is effective for prophylaxis against thromboembolism after both primary and revision total hip arthroplasties. The low prevalence of deep-vein thrombosis (4.6 percent) and symptomatic pulmonary embolism (0.6 percent) is comparable with that associated with pharmacological prophylaxis.
Arthroplasty, Replacement, Hip↗
Effect of mechanical compression on the prevalence of proximal deep venous thrombosis as assessed by magnetic resonance venography.
BACKGROUND: Patients have been shown to be at greater risk for deep venous thrombosis, particularly proximal thrombosis, after total hip arthroplasty. Proximal thrombi are more likely to develop into pulmonary emboli than are distal thrombi. The purpose of this randomized, prospective study was to compare the prevalence of pelvic and proximal lower-extremity deep venous thrombosis after primary total hip arthroplasty between patients treated with an impulse mechanical compression device for prophylaxis and those treated with prophylactic stockings. METHODS: One hundred patients were evaluated, with use of magnetic resonance venography, for proximal deep venous thrombosis after total hip arthroplasty. Fifty patients were treated with a mechanical compression device on both lower extremities, and the other fifty patients received only prophylactic stockings. Both groups of patients received hypotensive epidural anesthesia and 325 mg of aspirin twice a day. RESULTS: Overall, proximal deep venous thrombi were found in 15% of the 100 patients. Of the fifty patients treated with mechanical compression, 8% (four) had a positive venogram. Of the fifty control patients, 22% (eleven) had a positive venogram (p < 0.05). However, overall the rate of occlusive thrombi was 6% (six) compared with an overall rate of nonocclusive thrombi of 9% (nine). The rate of occlusive thrombi was 2% (one of fifty) in the study group and 10% (five of fifty) in the control group (p = 0.04). CONCLUSIONS: On the basis of this study, we concluded that patients managed with total hip arthroplasty benefit from a reduction in the rates of femoral and pelvic deep vein thrombosis when they are treated with hypotensive epidural anesthesia, mechanical compression, and aspirin and are subsequently assessed with magnetic resonance venography.
Arthroplasty, Replacement, Hip↗
Effect of intermittent pneumatic soft-tissue compression on fracture-healing in an animal model.
BACKGROUND: The fracture-healing process is closely related to blood supply. Intermittent pneumatic compression of the surrounding soft tissue may alter blood flow and, therefore, modify the healing process. The object of the present study was to evaluate the effect of intermittent pneumatic compression on fracture-healing in an animal model. METHODS: Unilateral, transverse, mid-tibial osteotomies with a 3-mm gap were performed in thirty rabbits. The osteotomy site was stabilized with a double-bar external fixator. The femoral vein was ligated to induce venous stasis. Beginning on the fourth postoperative day, fifteen rabbits were treated with intermittent pneumatic compression with use of four rubber balloons, two around the distal part of the calf and two around the midpart of the calf, for one hour daily for four weeks (the study group) and fifteen rabbits were not treated with intermittent pneumatic compression (the control group). Peripheral computerized tomographic examination was performed biweekly to measure callus area and mineral content at the fracture gap. At eight weeks, the rabbits were killed, and the biomechanical properties of the healing fractures were evaluated with a torsional test. RESULTS: An increase in callus area and mineral content at the osteotomy gap was observed in the study group, compared with the values in the control group, starting four weeks after the index procedure. At six weeks, the rabbits treated with intermittent pneumatic compression exhibited, on the average, a 32.2% larger callus area (p = 0.035) and a 49.7% higher mineral content (p = 0.01) at the osteotomy site compared with the values in the control group. The torsional stiffness, maximum torque, angular displacement at maximum torque, and energy required to failure of specimens in the study group were an average of 27.0% (p = 0.05), 61.5% (p = 0.0001), 35.4% (p = 0.0003), and 110.8% (p = 0.0001) higher, respectively, than those in the control group at eight weeks. CONCLUSIONS: Intermittent pneumatic compression enhanced callus mineralization and development and it improved the biomechanical properties of a healing osteotomy site in the rabbit tibia.
Animals↗
Unresolved issues in the prevention of venous thromboembolism.
Venous thromboembolism is a potentially fatal complication of surgery. The use of graded pressure stockings in combination with unfractionated heparin (UFH) or a low molecular weight heparin (LMWH) appears to be the safest and most effective method of prevention. With some LMWHs, the risk of venous thromboembolism appears to be lower than that associated with the use of standard UFH. A comparison of heparin given before versus after surgery (with all patients receiving graded pressure stockings) is justified. More information on the benefit-risk ratio of minidose warfarin is also required. The risk of pulmonary embolism (PE) following discharge from hospital after general surgery is relatively low and the extended use of heparin may not be justified. The value of graded pressure stockings and minidose warfarin for the prevention of PE should be determined. The risk of late PE after orthopaedic surgery is unknown and also needs to be determined.
Anticoagulants↗
Apparent arterial occlusion due to pneumatic antishock garment: pitfall in trauma angiography (case report).
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Angiography↗
Our routine in pressure treatment of hypertrophic scars.
It is well-known that burns can result in hypertrophic reddening, thick, itching scars with contractions. Since 1978 the Burns Unit in Copenhagen has treated this condition with Jobst pressure garments. The patients are regularly controlled in the Jobst day-clinic by a team consisting of a surgeon, physiotherapist, occupational therapist and a nurse. Close to 500 patients have been treated and controlled in the clinic for periods of half a year to one and a half years and, in a few cases, for 3 years.
Adult↗
A new device producing ambulatory intermittent pneumatic compression suitable for the treatment of lower limb oedema: a preliminary report.
The ideal conservative treatment for lower limb oedema would be one that provided intermittent compression whilst allowing the patient to remain mobile. In this article we describe the development of a pneumatic ambulatory compression device that utilizes the patient's weight applied, during walking, to air cells under the foot to provide compression to the ankle and calf. In volunteer studies this device typically produced a cycle of interface pressure changes from 20 to 45-50 mmHg on the lower calf and 20 to 35-40 mmHg on the upper calf.
Bandages↗