Urgent Replacement Research Articles

The infusion therapy in surgical patients with regard to monitoring of stroke volume and cardiac output

The infusion therapy is the most important element of complex treatment of surgical patients at the stage of preparation to operation and narcosis directly during operation and also in post-operational period. Number of clinical situations dictates necessity of implementation of massive infusion therapy for urgent replacement of volume of circulating blood. In these cases, is extremely important comparison of velocity and volume of introduction of infusion mediums with capacity of human cardiovascular system adequately receive infusion load. This is an important clinical problem especially because of increasing in the structure of surgical patients of elder age and persons suffering with cardiovascular diseases. The article considers actual approaches to monitoring of stroke volume and cardiac output during infusion therapy in surgical patients under out-cardiosurgery operations.

Towards developing a backing layer for proton exchange membrane electrolyzers

Current energy policies require the urgent replacement of fossil energy carriers by carbon neutral ones, such as hydrogen. The backing or micro-porous layer plays an important role in the performance of hydrogen proton exchange membrane (PEM) fuel cells, reducing contact resistance and improving reactant/product management. Such carbon-based coating cannot be used in PEM electrolysis since it oxidizes to CO2 at high voltages. A functional titanium macro-porous layer (MPL) on the current collectors of a PEM electrolyzer is developed by thermal spraying. It improves the contact with the catalyst layers by ca. 20 mΩ cm2, increasing significantly the efficiency of the device when operating at high current densities.

Persistent BCG bacilli perpetuate CD4 T effector memory and optimal protection against tuberculosis

Tuberculosis (TB) remains one of the most important infectious diseases of man and animals, and the only available vaccine (BCG) requires urgent replacement or improvement. To facilitate this, the protective mechanisms induced by BCG require further understanding. As a live attenuated vaccine, persistence of BCG bacilli in the host may be a crucial mechanism.We have investigated the long term persistence of BCG following vaccination and the influence on the induced immune response and protection, using an established murine model. We sought to establish whether previously identified BCG-specific CD4 TEM cells represent genuine long-lived memory cells of a relatively high frequency, or are a consequence of continual priming by chronically persistent BCG vaccine bacilli.By clearing persistent bacilli, we have compared immune responses (spleen and lung CD4: cytokine producing T effector/TEM; TCR-specific) and BCG-induced protection, in the presence and absence of these persisting vaccine bacilli. Viable BCG bacilli persisted for at least 16 months post-vaccination, associated with specific CD4 T effector/TEM and tetramer-specific responses. Clearing these bacilli abrogated all BCG-specific CD4 T cells whilst only reducing protection by 1log10.BCG may induce two additive mechanisms of immunity: (i) dependant on the presence of viable bacilli and TEM; and (ii) independent of these factors.These data have crucial implications on the rational generation of replacement TB vaccines, and the interpretation of BCG induced immunity in animal models.

Management of limb ischemia in acute proximal aortic dissection

Management of limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of limb ischemia without additional peripheral revascularization. We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent limb ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without limb ischemia were made. We repaired 335 cases during the study period. Sixty-one patients had limb ischemia (18.2%), of whom 51 were classified with lower limb ischemia (15.2%). All patients with upper limb ischemia survived to discharge without limb loss or death. Only 11 of the 51 patients with lower limb ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower limb loss resulting from delayed recognition of persistent ischemia. Renal dysfunction occurred in 21% of patients with isolated lower limb ischemia and in 31% of patients with uncomplicated dissection (P = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower limb ischemia (P = .89). There was no difference in long-term survival between isolated limb ischemia and uncomplicated cases (P = .54). Most cases of limb ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated limb ischemia and those with nonmalperfusion dissection. If ischemia persists, limb salvage is successful if revascularization is expeditious.

Rapid Evaluation of Ventriculoperitoneal Shunt Function in a Pediatric Patient Using Emergency Ultrasound

A 9-year-old girl with a ventriculoperitoneal shunt presents to the emergency department with progressive positional headaches, vomiting, fatigue, and pain over her shunt tract. Emergency ultrasound was used to diagnose discontinuity in the cervical portion of the shunt allowing for expedited care while waiting for confirmatory testing. She underwent urgent shunt replacement with good outcome.

Low Cost Laser Triangulation System for Rail and Guide Wear Evaluation

Periodic rail and guide wear evaluation is essential for their reliability and safety. By regular measurement it is possible to determine whether certain rail or guide fragments need urgent replacement reducing the risk of accidents. In the paper at first we present the measurement system, which is intended to operate in small rail systems such as trams, light rail, narrow gauge rail, mine rail. It can be adopted to operate in two modes: manual pulled along the rail or guide or automatic attached to a measurement car. The measuring system is flexible enabling the measurement of different features of rail or guide geometry depending on the needs. By simplifying the design, the system can be operated by an unqualified personnel, however final wear evaluation has to be done by a qualified engineer. Finally we present the exemplary results of measurements performed on a selected rail section and the full data processing path. The method of relative calibration and synchronizing data from several measurement modules is also reported.

Coronary Ostial Stenosis in a Young Patient

Coronary Ostial Stenosis in a Young Patient

Spontaneous rupture of a papillary muscle in acute myocarditis

A 33-year-old male patient was admitted to the coronary care unit with an infl ammatory syndrome and elevated troponin T. Shortly after admission the patient developed cardiogenic shock due to an anterior papillary muscle rupture and died after an urgent surgical replacement of the mitral valve. Histological examination of the excised papillary muscle showed signs of an acute myocarditis but no myocardial ischaemia. This case represents the fi rst description of a papillary muscle rupture, a potentially lethal complication, due to acute myocarditis.

Pull-through technique for entire thoracic aortic dissection without additional left thoracotomy

Urgent single-staged replacement of the aortic dissection involving the entire thoracic aorta was performed by using the modified pull-through technique via median sternotomy. Distal anastomosis was achieved via posterior pericardium to avoid the lateral thoracotomy and then the graft was pulled through the false lumen of the descending aorta into the aortic arch. Each lumen between proximal and distal anastomosis was closed for hemostasis. The aortic arch was replaced with a four-branched graft. Postoperative course was uneventful. This procedure might be an alternative in selected patients to the left thoracotomy.

Discussing the Advantages of Saline and Silicone Implants in Clinical Practice

The review by Spear and Jespersen titled “Breast Implants: Saline or Silicone?” ( Aesthetic Surg J 2010;30:557-570) was informative and thorough. I am writing to expand on a few points. The authors did not discuss one of the strong advantages of silicone over saline, which relates to the impact on a plastic surgery practice. One reason many plastic surgeons favor silicone gel implants is that when there is a failure, there is no need for the surgeon to alter schedules on short notice in order to accommodate an urgent replacement, as there would be for a failed saline implant. Replacing a failed saline implant, if done promptly, can be a very rapid and …

Urgent replacement of a mechanical mitral prosthesis in an anticoagulated patient with Bombay red blood cell phenotype

Bombay red blood cell phenotype is an extremely rare blood type for which patients can receive only autologous or Bombay phenotype red blood cells. We report a case of urgent repeat sternotomy for replacement of a mechanical mitral prosthesis in a patient with Bombay phenotype anticoagulated with warfarin, to emphasize the transfusion challenges in such patients. A male of Indian descent presented to hospital with New York Heart Association IV symptoms. His medical history revealed previous mitral valve replacement with a mechanical prosthesis in 2005 and Bombay phenotype blood. Preoperative transthoracic echocardiography demonstrated thrombus obstruction of the mitral prosthesis despite anticoagulation with warfarin. Right ventricular systolic pressure was >100 mmHg with 3+ tricuspid regurgitation. The patient's condition was temporized with diuretics, bronchodilators, and bi-level positive airway pressure ventilation while transfusion medicine and cardiac surgery were consulted for urgent surgery. The patient received vitamin K and prothrombin complex concentrate prior to repeat sternotomy and successful mitral prosthesis replacement. After cardiopulmonary bypass, heparinization was corrected with protamine and followed by a second dose of prothrombin complex concentrate and recombinant activated factor VIIa. Postoperatively, the patient received four units of packed red blood cells, two autologous units and two units of Bombay specific red blood cells. Right ventricular pressures stabilized at 40 mmHg following surgery. The patient recovered following several days of inotropic support with milrinone, diuretics, and bronchodilators. Patients with Bombay phenotype red blood cells present as type O, but they are unable to receive red blood cells from any phenotype other than Bombay phenotype. They are able to receive all other blood products, including fresh frozen plasma, cryoprecipitate, platelets, prothrombin complex concentrate, and recombinant activated factor VIIa. Coordination between Canadian Blood Services, transfusion medicine, surgery, and anesthesia is important in managing these patients.

Syndrome de compression des loges bilatéral des membres inférieurs et myonécrose sévère due à l’usage inapproprié de la simvastatine

Bilateral leg compartment syndrome due to myonecrosis caused by inappropriate use of statins is a rare but potentially fatal complication of this lipid lowering medication. We report a case of a 39-year-old woman who presented with suspicious critical lower limb ischemia. Subsequently, bilateral leg compartment syndrome and myonecrosis developed. The primary cause of myonecrosis was due to misuse of simvastatin mistaken by the patient for a weight-reducing drug. Urgent fasciotomies were performed and the patient underwent urgent renal replacement therapy with continuous hemodialysis for acute renal failure due to myoglobinuria. After this complex treatment, the patient was discharged. She almost fully recovered with only a residual paresis of the left fibular nerve. According to literature, this is a unique case of bilateral compartment syndrome and myonecrosis with acute renal failure due to statin overdose leading to acute renal failure and bilateral fasciotomy.

Ultrasound Can Accurately Guide Gastrostomy Tube Replacement and Confirm Proper Tube Placement at the Bedside

Background: Malfunctioning or dislodged gastrostomy tubes (G-tubes) often require urgent replacement and reinsertion in the Emergency Department (ED). Few data exist regarding the best technique for bedside catheter replacement and verification, and individual operator preferences vary. Although a few reports have described the use of ultrasound guidance during the initial percutaneous insertion, no data are available concerning its role during subsequent G-tube replacements. Objective: We sought to investigate the utility of bedside ultrasonography during G-tube replacements in the ED. Methods: This was a prospective pilot study conducted at a Level 1 Trauma Center with an annual census of 90,000 patients. Seven adults and three children with malfunctioning G-tubes were enrolled. Three tubes were cracked and leaking, and seven tubes had been dislodged. Under ultrasound, a new G-tube was inserted through the previously fashioned tract. After insertion, color Doppler was applied over the catheter tip to enhance visualization during gentle tube oscillation. Results: Ultrasound successfully visualized G-tube replacement in all 10 patients. Application of color Doppler over the G-tube tip during catheter oscillation enhanced placement confirmation. Sonographic findings were corroborated with gastric content aspiration, contrast-enhanced radiographs, and successful use of the new G-tubes. No false tracts were identified during ultrasound-guided insertion, post-procedure sonographic confirmation, or subsequent radiographs. Conclusion: The improper replacement of a G-tube can lead to devastating consequences. Verifying appropriate placement through aspirate evaluation can be misleading, and post-procedure radiographs increase radiation exposure and ED wait times. Bedside ultrasonography can be used to guide catheter insertion while providing a safe and quick adjunct to confirm proper G-tube placement.

210: Gastrostomy Tube Replacement and Confirmation Under Ultrasound Guidance

Over 250,000 patients receive a percutaneous gastrostomy tube (G-tube) each year. Malfunctioning or dislodged G-tubes often require urgent replacement and reinsertion in the ED. Little data exists regarding the best technique for bedside catheter replacement and verification, and individual operator preferences vary widely. Although a few reports have been published describing the use of ultrasound guidance during the initial percutaneous insertion, no data is available concerning its role during subsequent G-tube replacements.

Urgent Pump Exchange for Stroke Resulting From a Distorted HeartMate XVE Inflow Conduit

Long-term left ventricular assist device (LVAD) implantation is associated with an inherent risk of transient ischemic attacks (TIAs). When TIAs occur in patients who have undergone placement of a HeartMate XVE LVAD, the pump must be assumed to be the likely source of the TIA. The HeartMate XVE is unique in that it has a pumping surface of flocked Biomer and a pump housing and inlet cannula coated with sintered titanium. This design facilitates coating of the surfaces with the patient's own cells, usually within 48 hours of implantation, effectively eliminating the pumping surface as a source of thromboemboli. Similarly, neither the outflow conduit nor the porcine outflow valve have been shown to be sources of thromboemboli, as they are both subjected to the wash-out of pulsatile systolic pressure. In our experience, the only components vulnerable to pannus formation are the inflow conduit and its associated valve, and then only when the inflow conduit is distorted at implantation. We describe an illustrative case of a patient supported with a HeartMate XVE LVAD who suffered a device-related stroke that was attributed to the inflow conduit, which was distorted during implantation to configure the pump for the patient's narrow body habitus. The resultant disruption in laminar flow was the most likely cause of the TIAs and stroke. Therefore, documented TIAs in patients with an implanted HeartMate XVE are an indication for urgent pump replacement, even if pump performance is otherwise normal. In this case, the pump was exchanged for a smaller, continuous-flow HeartMate II LVAD.

Uncuffed endotracheal tubes should not be used in seriously burned children

To document a complication associated with placement of uncuffed endotracheal tubes in seriously burned children. Retrospective review. Verified pediatric burn center. Acutely burned children requiring urgent replacement of uncuffed endotracheal tubes with cuffed endotracheal tubes over a 5-yr period. In all children, the reason behind the need for urgent tube change was uncontrollable air leak, despite properly sized uncuffed endotracheal tubes, as respiratory failure progressed and compliance worsened. : These two girls and three boys had an average age of 2.2 +/- 1.0 yrs, burn size of 41% +/- 6.1% of the body surface, and subsequently required mechanical ventilation for an average of 23.6 +/- 6.3 days. Urgent tube change was required an average of 64.2 +/- 43.8 hrs after arrival in the burn unit (87.6 +/- 49.4 hrs after injury). Although successful in all children, massive facial edema rendered tube change potentially dangerous. The intervention would not have been necessary if cuffed endotracheal tubes had been placed initially. All children went on to survive their injury, without further tube change or tracheostomy. If children are critically burned and expected to require more than transient mechanical ventilatory support, low-pressure cuffed endotracheal tubes should be placed, regardless of the child's age.

Portrack, Scotland—a major railway realignment

Crossing the volatile River Nith at Portrack in Dumfriesshire has presented railway engineers with severe problems for over 150 years, at least one previous attempt having been destroyed in a flood. Despite ongoing maintenance and repairs, the existing 11 span wrought iron structure, which carries the increasingly important Glasgow and South West Scotland line over the river, needed urgent replacement to reduce long-term costs and improve the safety and efficiency of the route. Carillion Rail and Scott Wilson Scotland carefully evaluated a number of options before recommending a realignment of the railway, which involved the replacement of two viaducts. Working in an environmentally sensitive location, adjacent to a ‘live’ railway and to a tight deadline required a tremendous amount of planning, cooperation and ingenuity by all parties; even the local estate owner became the project's architectural advisor. The centre-piece of the scheme is a spectacular 90 m curved truss-girder crossing the river, which was erected using the world's largest mobile crane. The meticulous planning and teamwork paid off with the construction of the entire project being completed on time, within budget and without disruption to the railway.

Portrack, Scotland?a major railway realignment

Crossing the volatile River Nith at Portrack in Dumfriesshire has presented railway engineers with severe problems for over 150 years, at least one previous attempt having been destroyed in a flood. Despite ongoing maintenance and repairs, the existing 11 span wrought iron structure, which carries the increasingly important Glasgow and South West Scotland line over the river, needed urgent replacement to reduce long-term costs and improve the safety and efficiency of the route. Carillion Rail and Scott Wilson Scotland carefully evaluated a number of options before recommending a realignment of the railway, which involved the replacement of two viaducts. Working in an environmentally sensitive location, adjacent to a ‘live’ railway and to a tight deadline required a tremendous amount of planning, cooperation and ingenuity by all parties; even the local estate owner became the project's architectural advisor. The centre-piece of the scheme is a spectacular 90 m curved truss-girder crossing the river, which was erected using the world's largest mobile crane. The meticulous planning and teamwork paid off with the construction of the entire project being completed on time, within budget and without disruption to the railway.

Lateral Sliding of Two Bridges near Antwerp, Belgium

Several bridges on the motorways from Antwerp to Eindhoven and Hasselt, built in the sixties, have suffered from alkaline reactions resulting in fast deterioration and therefore requiring urgent replacement. The highly increased road traffic limited disturbance to road traffic on the motorway to an absolute minimum.

Intramural hematoma of the thoracic aorta.

This study was designed to clarify the optimal treatment mode of patients with intramural hematoma (IMH) of the thoracic aorta. From 1992 through 1997, 51 patients underwent surgical repair or medical treatment of IMH of the thoracic aorta. There were 36 male and 15 female patients, aged between 49 and 79 years with a mean of 67 years. The ascending aorta and/or aortic arch was involved in 18 patients (group I), whereas the descending thoracic aorta was affected in 33 (group II). The presence of intimal disruption in IMH was confirmed in 10 of group I and 13 of group II patients. For group I patients 13 required aortic arch repairs and the remaining 5 underwent conservative therapy including anti-hypertensive medication. Primary indications for immediate surgery were: cardiac tamponade in 5 patients, aortic dissection superimposed on IMH in 2, and persistent pain with an aortic arch aneurysm in 1, respectively. Early elective operations were done for enlarged ulcer in 3 patients and aneurysmal dilatation in 2 of which 1 had a coexisting aortic arch aneurysm. The 2-year survival rate after diagnosis was 94% with an operation-free rate of 25%. Nine of the group II patients experienced surgical intervention of which 8 had intimal disruption, 4 patients received urgent replacement of the descending thoracic aorta for massive pleural effusion and 1 had the aortic arch replaced for a coexisting aneurysm with persistent pain. All other patients underwent conservative treatment and 4 of them had to be shifted to early surgery during the initial hospitalization because of an enlarged ulcer. The 5-year survival rate in group II patients was 63% with an operation-free survival rate of 66%. On the basis of our experience early operation is recommended for almost all patients with ascending aortic IMH, and medical therapy for those with descending aortic involvement unless complication developed. However, the presence of intimal disruption may require early surgical treatment even in the patients with descending thoracic IMH.