Absence Of Hemodynamic Instability Research Articles

Early transfusion and crystalloid infusion strategy in infants undergoing cranioplasty surgery

IR—Cranioplasty for craniosynostosis is a procedure associated with large incision of the vascular scalp and resection of the bone (1). This represents major surgery for young infants that have small blood volumes. The extensive blood loss requires transfusion of packed red cells in most patients (2). The exact determination of blood loss and fluid deficit in these procedures may be difficult because the absolute amount of shed blood is small although relatively high for the patient itself. Furthermore, 20–50% of the patient’s blood volume may be lost in less than 30 min (3). Transfusion strategies currently developed are based on the acceptance of intraoperative level of hemoglobin (Hb) of 7 gAEdl )1 and hemodilution [hematocrit (Hct) lower than 30] in absence of hemodynamic instability. We wish to describe our retrospective clinical study investigating the effectiveness of a preemptive transfusion

Acute pulmonary embolism revisited

Acute pulmonary embolism (PE) is of interest to physicians of almost all disciplines, as it is encountered across the entire spectrum of clinical medicine. It is estimated that as many...

Functional limitation and right ventricular dysfunction at 6-month follow-up in patients with non-massive pulmonary embolism: useful outcomes for testing therapy of acute submassive pulmonary embolism?

Acute pulmonary embolism (PE) is a syndrome with a significant annual incidence, potentially associated with an elevated morality rate.1 Patients presenting with acute PE and persistent systemic hypotension, cardiogenic shock, or cardiac arrest are classified as having massive PE; in the absence of haemodynamic instability, PE is defined generically as non-massive. The latter, however, is classified as submassive acute PE in the presence of right ventricular (RV) dysfunction,1 to indicate that patients with normotensive acute PE and RV dysfunction may suddenly need escalation of therapy (vasopressor and/or inotropic support, rescue fibrinolysis, cardiopulmonary resuscitation).2–4 While clinical manifestation of acute PE may vary widely and significantly between patients, acute RV dysfunction is more quantifiable and uniform objective information in PE with relation to the severity of pulmonary vascular impairment.5 RV failure is the prominent cause of death in acute PE. This is further supported by the fact that in the setting of non-massive acute PE, RV dysfunction correlates with brain natriuretic peptide and troponins, which are in turn biomarkers of the severity of RV overload,6 providing additional information for risk stratification of the heterogeneous group of patients with normotensive PE.7–11 However, whether aggressive treatment (i.e. fibrinolysis or catheter-based pulmonary embolectomy) should be employed in acute submassive PE in addition to anticoagulation is controversial.1 In fact, while fibrinolysis or thromboembolectomy are associated with partial recovery of RV dysfunction,12 … *Corresponding author. Tel: +39 081 2543536; fax: +39 081 2543536. E-mail address : vpalmier{at}med.cornell.edu

Tension Pneumothorax Managed Without Immediate Needle Decompression

Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases. There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.

Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention

Background Nonoperative management of blunt pediatric liver injuries has become the standard of care in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have found better outcomes with surgical intervention. In this study, we report on our experience with interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who underwent unsuccessful surgical interventions. Methods We conducted a retrospective review of medical records of all pediatric patients who were admitted with major blunt liver trauma and bile duct injuries over a period of 5 years. Results There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All 5 patients were eventually treated successfully with interventional endoscopic and radiologic techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percutaneous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to 2.5 years with normal liver function test and bile duct ultrasound. Conclusion With the current advancement in endoscopic retrograde cholangiopancreatography and intervention radiology techniques, we believe that interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious even after multiple laparotomies.

The Radiation-Induced nackt (nkt) Allele Is a Loss-of-Function Mutation of the Mouse Cathepsin L Gene

Congenic nonobese diabetic mouse strains fail to confirm linkage of a marginal zone B lymphocyte phentoype to the Idd11 locus on chromosome 4-Response.

Adjunctive therapies in sepsis: An evidence-based review

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for adjunctive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis. The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. Glycemic control (maintenance of glucose <150 mg/dL) is recommended. The beneficial effect of glycemic control appears to be related control of glucose and not the administration of insulin. Glycemic control should be combined with a nutritional protocol. The dialysis dose is important in sepsis-induced acute renal failure. Continuous hemofiltration offers easier management of fluid balance in hemodynamically unstable septic patients but in the absence of hemodynamic instability is equivalent to intermittent hemodialysis. It is uncertain whether high-volume hemofiltration improves prognosis in sepsis. Bicarbonate therapy is not recommended for the purpose of improving hemodynamics or reducing vasopressor requirements in the presence of lactic academia and pH >7.15.

Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma.

Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury. A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Student's t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fisher's exact test. Statistical significance was assigned to values of p < 0.05. Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy. Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.

High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ.

Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events. Prospective observational study. High-volume academic level I trauma center. For 26 months, 78 consecutive unselected patients with liver injuries were followed up prospectively. In the absence of hemodynamic instability or signs of hollow visceral trauma, NOMLI was offered irrespective of the magnitude of the liver injury. Main Outcome Measure Failure of NOMLI, defined as a laparotomy after an initial decision to treat the patient nonoperatively. Of the 78 patients, 23 (29%) were operated on immediately, but only 12 (15%) for bleeding from the liver. All 12 patients required packing in addition to other maneuvers (hepatorrhaphy [n = 8], resection [n = 4], and liver isolation [n = 1]). Of the remaining 55 patients selected for NOMLI, the method failed in 8 for reasons unrelated to the liver injury: 2 underwent a splenectomy, 1 underwent a nephrectomy, 1 had a small-bowel repair, 1 underwent abdominal decompression for abdominal compartment syndrome, and 3 underwent a nontherapeutic laparotomy. The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%. Compared with those in whom NOMLI was successful, patients in whom it failed had a higher Injury Severity Score and underwent more blood transfusions, but they had similar liver injury grades. In total, 66 (85%) of liver injuries did not bleed significantly. No adverse events were attributed to NOMLI. Nonoperative management of liver injuries is safe and effective regardless of the grade of liver injury. Failure of NOMLI is caused by associated abdominal injuries and not the liver. Fluid and blood requirements, the degree of injury severity, and the presence of other abdominal organ injuries may help predict failure.

Effects of brain death and hemodynamic status on function and immunologic activation of the potential donor liver in the rat.

To assess the effect on the function and immunologic status of potential donor livers of the duration of brain death combined with the presence and absence of hemodynamic instability in the donor. Brain death, regarded as a given condition in organ transplantation, could have significant effects on the donor organ quality. Brain death was induced in Wistar rats. Short or long periods of brain death in the presence or absence of hemodynamic instability were applied. Sham-operated rats served as controls. Organ function was studied by monitoring standard serum parameters. The inflammatory status of the liver was assessed by determining the immediate early gene products, the expression of cell adhesion molecules, and the influx of leukocytes in the liver. Progressive organ dysfunction was most pronounced in hemodynamically unstable brain-dead donors. Irrespective of hemodynamic status, a progressive inflammatory activation could be observed in brain-dead rats compared with controls. Brain death causes progressive liver dysfunction, which is made worse by the coexistence of hemodynamic instability. Further, brain death activates the inflammatory status of the potential donor liver, irrespective of the presence of hypotension. The changes observed may predispose the graft to additional damage from ischemia and reperfusion in the transplant procedure.

Surgical treatment of infected aortic aneurysm

We report results of infected aortic aneurysms treated by a single group over 20 years. Retrospective review. Seventeen patients were treated, 10 with infrarenal and 7 suprarenal infections. All had abdominal/back pain, 88% were febrile, 71% had leukocytosis, and 24% were hemodynamically unstable. The most common responsible organism was Staphylococcus aureus (29%) followed by Salmonella organisms (24%). All suprarenal infections were gram-positive organisms. Infrarenal infections were treated with preliminary axillofemoral bypass followed by aortic resection. Suprarenal infections were treated with either in situ prosthetic graft or patch repairs. Operative survival was 90% for infrarenal and 57% for suprarenal infections. Operative deaths occurred in the setting of overwhelming sepsis and/or severe preoperative hemodynamic instability. There was no limb loss, renal failure, or intestinal ischemia. Late deaths occurred in 4 patients at 1.3 to 6.3 years postoperatively and were unrelated to their aortic repairs. Nine patients remain alive with a median follow-up of 2 years. There have been no late aortic or graft infections. In the absence of hemodynamic instability and uncontrolled sepsis, infected aortic aneurysms can be successfully repaired with durable results.

Intrahepatic Biliary Lesions Following Blunt Liver Trauma in Children - Is Nonoperative Management or Conservative Operative Treatment Always Safe?

Nonoperative management of blunt liver injuries has become standard care for children, in the absence of hemodynamic instability. However, attention has to be drawn to biliary complications which can manifest themselves after a latent period, even in the presence of rupture of main biliary ducts. Peripheral bile duct lesions are easily treated by wide drainage. However, the extremely rare intrahepatic main bile duct lesions require other treatments. We report 2 cases of severe liver trauma associated with intrahepatic bile duct lesions: the first, managed nonoperatively, developed biliary peritonitis on day 21. Lesions of the main right biliary ducts were discovered. Because the right liver vascularization was not compromised, an intrahepatic biliary reconstruction was performed through a large hepatotomy according to the functional anatomy. The second child, who had an emergency laparotomy on admission, suffered nevertheless from a bilioma, drained on day 38. Because of increasing daily bile flow through the drain a second laparotomy was performed that demonstrated a biliary leak from a main segmental duct. Resection of the segment cured the patient. These two cases illustrate the occurrence of intrahepatic main bile duct lesions, clinically apparent after a latent period, following blunt trauma of the liver treated by nonsurgical or conservative surgical management. Intrahepatic biliary reconstruction is an alternative to liver resection when viable vascularization of the involved sector justifies its preservation.