Determination of heart time volume using the Fick principle in the early postoperative phase after correction of congenital heart defects. Comparison of the calculation of arterio-mixed venous oxygen differences and pulmonary oxygen uptake with the calculation of arterial-central venous oxygen differences and pulmonary oxygen uptake

Comparison of the calculation by means of the arterio-mixed venous oxygen difference and the oxygen uptake with the calculation by means of the arterio-central venous oxygen difference and the oxygen uptake. OBJECTIVE: How reliable is the measurement of cardiac output on Fick's principle without a pulmonary artery catheter? SETTING: PICU in an University hospital. DESIGN: In the postoperative period following complete repair of congenital heart disease we carried out 91 simultaneous measurements of blood gases in 45 infants and children (mean age 18.6 months, mean body weight 8.9 kg) from a systemic artery, the A. pulmonalis, and the V. cava superior. We also determined the pulmonary oxygen uptake in 24 patients (48 measurements). Cardiac output was calculated on Fick's principle using the arterio-mixed venous oxygen difference and the pulmonary oxygen uptake (HZV a-pa) and compared to the cardiac output derived from the central venous values (HZV a-zv). We differentiated between patients with a left to right shunt of 10% or more postoperatively (group A, n = 18) and all others (group B, n = 27). RESULTS: In both groups the correlation coefficient between HZV a-zv and HZV a-pa was high (group A: r = 0.97, group B: r = 0.94). In group A HZV a-pa (mean: 1958 ml/min) was higher than HZV a-zv (mean: 1340 ml/min), group B showed the opposite situation (mean HZV a-pa: 1136 ml/min, mean HZV a-zv: 1373 ml/min). With the Wilcoxon signet-rank test we found significant differences between the partial pressure of oxygen and the saturation of central venous and mixed venous blood samples in both groups, but HZV a-zv and HZV a-pa were different significantly on a level of p < or = 0.01 only in group A. CONCLUSIONS: In both groups HZV a-pa and HZV a-zv correlated well. Therefore, if a pulmonary artery catheter is not inserted; the course of the cardiac output can be calculated with acceptable reliability from the central venous blood gases. By means of Fick's principle the pulmonary blood flow is determined, which is higher than the systemic blood flow in cases of left to right shunting, because of the recirculation in the pulmonary blood circuit. Interpreting the results this has to be taken into account.     

Central venous pressure, pulmonary capillary wedge pressure and intrathoracic blood volumes as preload indicators in cardiac surgery patients

OBJECTIVE: Monitoring of cardiac preload is mainly performed by measurement of central venous and pulmonary capillary wedge pressure in combination with assessment of cardiac output, applying the pulmonary arterial thermal dilution technique. However, the filling pressures are negatively influenced by mechanical ventilation and the pulmonary artery catheter is criticized because of its inherent risks. Measurement of right atria, right ventricular, global end diastolic and intrathoracic blood volume index by arterial thermal dye dilution utilizing the COLD-system may represent an alternative. METHODS: In 30 CABG patients with an uncomplicated postoperative course the mentioned parameters were measured 1, 3, 6, 12 and 24 h postoperatively to prove their qualification as preload indicators: As patients received no inotropic support, changes of cardiac index and stroke volume index must correlate to changes of presumably preload indicating parameters. RESULTS: When arterial and pulmonary arterial thermal dilution were compared, no differences were found; the correlation coefficient being 0.96, the bias 0.16 l/min per m2 (2.4%) and coefficients of variation did not exceed 7%. Changes of central venous pressure, capillary wedge pressure, right atrial end diastolic volume index and right ventricular end diastolic volume index did not correlate at all to changes of cardiac and stroke volume index (coefficients ranged from -0.01 to 0.28). In contrast, intrathoracic and global end diastolic blood volume indices with coefficients from 0.76 to 0.87, did show a good correlation to cardiac and stroke volume index. CONCLUSION: Central venous pressure, capillary wedge pressure, right atrial and right ventricular end diastolic volumes are no suitable preload parameters in cardiac surgery intensive care, compared to intrathoracic and global end diastolic blood volumes. The latter show a higher clinical value and can be obtained by less invasive methods, as no pulmonary artery catheter is required.     

Early hemodynamic effects of olprinone hydrochloride after coronary artery bypass grafting

Our purpose was to evaluate the hemodynamic effects of olprinone hydrochloride early after coronary artery bypass grafting (CABG). Fifteen patients undergoing CABG were administered a constant infusion of 0.1 microgram/kg/min of olprinone and continued for 4 hours. No bolus infusion of olprinone was administered before continuous infusion. Systolic systemic arterial pressure, systolic pulmonary arterial pressure, systemic vascular resistance and pulmonary vascular resistance were significantly decreased. There were no significant changes in heart rate, mean central venous pressure, mean left atrial pressure and left ventricular stroke work index. Cardiac index was significantly increased, but a correlation between cardiac index and mixed venous blood oxygen saturation was not found. Double product was significantly decreased, which described above suggest that olprinone achieved improvement of left cardiac function without more myocardial oxygen consumption. Severe transient hypotension (systolic arterial pressure < 80 mmHg) after infusion of olprinone was observed in three patients. Olprinone administered soon after CABG surgery had beneficial effects in terms of improvement of hemodynamic status without more oxygen consumption and reduction of pulmonary vascular resistance. However transient hypotension was a serious clinical problem in patients after open heart surgery, especially in CABG patients who need suitable systolic arterial pressure to keep enough blood perfusion of arterial bypass grafts.     

Catheter-induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography

BACKGROUND: To present the role of transesophageal echocardiography (TEE) in the diagnosis and management of catheter-related superior vena cava thrombosis. CASE HISTORY: A 42-year-old woman with severe Crohn's disease presented with septic shock and pulmonary embolism three weeks after emergency laparotomy and ileocolic resection for small-bowel perforation with peritonitis. Cardiopulmonary evaluation with ECG, pulmonary artery catheter and TEE demonstrated no evidence of acute myocardial ischemia or ventricular dysfunction; hemodynamic indices were consistent with severe sepsis. TEE revealed a large sheathing thrombus surrounding a central venous catheter used for parenteral nutrition. A spiral CT scan of the chest confirmed multiple peripheral pulmonary emboli. Treatment consisted of systemic anticoagulation and antibiotics. To avoid further pulmonary embolism, the central venous catheter was not removed until six days later under TEE monitoring, which revealed that the thrombus was firmly adherent to the superior vena cava. The patient made an uneventful recovery and was discharged from hospital on long-term anticoagulant therapy. CONCLUSION: In a case of catheter-induced superior vena cava thrombosis with septicemia and pulmonary embolism, bedside TEE was very helpful to make the correct diagnosis early, assess thrombus size during anticoagulation, and monitor cardiac performance and thrombus disposition during central venous catheter removal.     

Laparoscopically assisted abdominal aortic aneurysm repair: first 20 cases

PURPOSE: Laparoscopic surgery decreases postoperative pain, shortens hospital stay, and returns patients to full functional status more quickly than open surgery for a variety of surgical procedures. This study was undertaken to evaluate laparoscopic techniques for application to abdominal aortic aneurysm (AAA) repair. METHODS: Twenty patients who had AAAs that required a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of transperitoneal laparoscopic dissection of the aneurysm neck and iliac vessels. A standard endoaneurysmorrhaphy was then performed through a minilaparotomy using the port sites for the aortic and iliac clamps. Data included operative times, duration of nasogastric suction, intensive care unit days, and postoperative hospital days. Pulmonary artery catheters and transesophageal echocardiography were used in seven patients. For these patients data included heart rate, pulmonary artery systolic and diastolic pressures, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index, and end diastolic area. Data were obtained before induction, during and after insufflation, during aortic cross-clamp, and at the end of the procedure. RESULTS: Laparoscopically assisted AAA repair was completed in 18 of 20 patients. Laparoscopic and total operative times were 1.44 +/- 0.44 and 4.1 +/- 0.92 hours, respectively. Duration of nasogastric suction was 1.3 +/- 0.7 days. Intensive care unit stay was 2.2 +/- 0.9 days. The mean length of hospital stay was 5.8 days excluding three patients who underwent other procedures. There were two minor complications, one major complication (colectomy after colon ischemia), and no deaths. For the eight patients who had intraoperative transesophageal echocardiographic monitoring, no changes were noted in heart rate, pulmonary artery systolic pressure, pulmonary capillary wedge pressure, and cardiac index. Pulmonary artery diastolic pressure and central venous pressure were greatest during insufflation without changes in end-diastolic area. Volume status, as reflected by end-diastolic area and pulmonary capillary wedge pressure, did not change. CONCLUSIONS: Laparoscopically assisted AAA repair is technically challenging but feasible. Potential advantages may be early removal of nasogastric suction, shorter intensive care unit and hospital stays, and prompt return to full functional status. The hemodynamic data obtained from the pulmonary artery catheter and transesophageal echocardiogram during pneumoperitoneum suggest that transesophageal echocardiography may be sufficient for evaluation of volume status along with the added benefit of detection of regional wall motion abnormalities and aortic insufficiency. Further refinement in technique and instrumentation will make total laparoscopic AAA repair a reality.     

Kaposi''s sarcoma-associated herpesvirus and human herpesvirus 8 (KSHV/HHV8)-associated lymphoma of the bowel. Report of two cases in HIV-positive men with secondary effusion lymphomas

BACKGROUND: We evaluated the ability of the standards issued by the Danish Society of Anaesthesiologists to reflect a blood loss. METHODS: In 9 pigs bled (0-24 ml kg-1 and retransfused (to 28 ml kg-1) during halothane anaesthesia central cardiovascular, thoracic electrical impedance (TI), oxygen, acid-base and temperature variables were recorded. RESULTS: With the recommendation for minor surgery (mean arterial pressure (MAP) and heart rate (HR)), the correlation to the blood loss was 0.74 (P < 0.001) and with that for major surgery (MAP, HR, central venous pressure (CVP) and rectal temperature (Tempr)) it was 0.79 (P < 0.001). With the recommendation for extensive surgery (MAP, HR, CVP, pulmonary artery catheter variables and the central-peripheral temperature difference (delta Tempr-t)), the correlation was 0.84 (P < 0.001). Non-invasive monitoring (MAP, HR, delta Tempr-t, TI and near-infrared spectroscopy of the brain (SinvosO2)) was only slightly better than basal monitoring (r = 0.76, P < 0.001). However, adding arterial base excess (BE), TI, and peripheral temperature (Tempt) to the recommendation for major surgery resulted in a correlation of 0.87 (P < 0.001), while adding BE and TI to the recommendation for extensive surgery raised correlation to only 0.88 (P < 0.001). CONCLUSION: When the recommendations were followed the correlation to the blood loss ranged from 0.74-0.84. However, with the recording of MAP, HR, CVP, delta Tempr-t, BE and TI a correlation of 0.87 was achieved, indicating that a pulmonary artery catheter may not be in need for patients undergoing surgical procedures with expected haemorrhage.     

Pulmonary artery catheterisation

The introduction of balloon-tipped pulmonary artery flotation catheters revolutionised monitoring of the cardiovascular system and the management of seriously ill patients. Advances in design allow direct measurement of cardiac output and continuous mixed venous oxygen saturation, while intracardiac electrocardiogram monitoring and passage of pacing wires is now possible. The technique of insertion must be meticulous as must the method of obtaining central venous, pulmonary artery, pulmonary artery wedge and pulmonary capillary wedge pressures. Sources of error are highlighted as are methods to avoid and detect them. Correct interpretation of the data is essential for proper patient management and must be taken in light of information obtained by other methods. Complications of insertion are numerous and potentially serious or even lethal. It is mandatory that the information obtained by insertion of a pulmonary artery catheter be used to optimize patient management.     

Simultaneous measurement of pulmonary venous flow by intravascular catheter Doppler velocimetry and transesophageal Doppler echocardiography: relation to left atrial pressure and left atrial and left ventricular function

OBJECTIVES: The aim of our study was to compare measurements of pulmonary venous flow velocity obtained either by transesophageal Doppler echocardiography or by intravascular catheter Doppler velocimetry. Furthermore, the relation among pulmonary venous flow velocity, left atrial compliance and left atrial pressure was evaluated. BACKGROUND: Data about the relation between left atrial pressure and pulmonary venous flow velocity are controversial. METHODS: A total of 32 patients undergoing elective open heart surgery for coronary artery bypass grafting were included prospectively in the study. Pulmonary venous flow velocity (Doppler catheter) and left atrial pressure (microtip pressure transducer) were recorded simultaneously with recordings of pulmonary venous flow velocity obtained by transesophageal Doppler echocardiography. RESULTS: Agreement between Doppler catheter and Doppler echocardiographic measurements of pulmonary venous flow velocity (n = 18 patients) was analyzed using the Bland-Altmann technique. The 95% limits of agreement were -0.16 to +0.11 m/s for systolic peak velocity, -0.14 to +0.09 m/s for diastolic peak velocity and -0.12 to +0.10 m/s for atrial peak velocity. The closest agreement between both methods was found for the ratio of systolic to diastolic peak velocity, the ratio of systolic to diastolic flow duration and the time from Q deflection on the electrocardiogram to maximal flow velocity. Mean left atrial pressure was strongly correlated with the ratio of systolic to diastolic peak velocity (r = -0.829), systolic velocity-time integral (r = -0.653), time to maximal flow velocity (r = 0.844) and the ratio of systolic to diastolic flow duration (r = -0.556). The ratio of systolic to diastolic peak velocity and the time to maximal flow velocity were identified as strong independent predictors of mean left atrial pressure. Left atrial compliance was not found to be an independent predictor of mean left atrial pressure. CONCLUSIONS: Flow velocity in the left upper pulmonary vein can be reliably recorded by transesophageal pulsed wave Doppler echocardiography. Our data reveal further evidence that mean left atrial pressure can be estimated by the pattern of pulmonary venous flow velocity.     

Use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area: a survey of 251 centres

A survey of the use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area was performed. Questionnaires were sent to a total of 251 burns units in the UK, USA, Canada, Australia and New Zealand. The overall response rate was 68 per cent. Most centres reported that they managed less than 20 of these patients each year. Fifty-five per cent of centres used central venous pressure monitoring in more than half of their patients. In contrast, only 8 per cent of burn units used pulmonary artery catheters in over half of their patients. Few centres described the use of predetermined goals to direct therapy associated with PA catheter insertion.     

Evaluation of a continuous cardiac output and mixed venous oxygen saturation catheter in critically ill surgical patients

OBJECTIVE: To evaluate the agreement of continuous cardiac output and mixed venous oxygen saturation measurements, obtained with a modified pulmonary artery catheter, with those values obtained by standard intermittent bolus thermodilution and cooximetry. DESIGN: Prospective, clinical investigation. SETTING: A surgical intensive care unit in a tertiary referral center. PATIENTS: Twenty-one adult critically ill surgical patients, requiring pulmonary artery catheter monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A modified pulmonary artery catheter capable of continuous monitoring of cardiac output and mixed venous oxygen saturation was used with either an 8.5-Fr or a 9-Fr introducer. At random intervals, the continuous cardiac output measurement was compared with the cardiac output obtained using standard intermittent bolus thermodilution. The system was calibrated every 24 hrs for mixed venous oxygen saturation monitoring. Each saturation obtained by the laboratory cooximeter was compared with that value recorded using the catheter. Data points for 202 pairs of cardiac output (21 patients, 31 catheters) and 65 pairs of mixed venous oxygen saturation (20 patients, 28 catheters) were obtained. The bias and precision of the cardiac output data were 0.49 and 1.01 L/min, respectively. The agreement between the continuous and bolus values decreased as the cardiac output increased. Heart rate did not affect the agreement between the continuous and bolus techniques. The bias and precision of the mixed venous oxygen saturation data were -0.57% and 3.76%, respectively. The hematocrit did not affect the bias or precision of the venous saturation data over the hematocrit range observed (23.2% to 44.6%). Fewer catheter malfunctions were observed when the catheter was used with a 9-Fr introducer than with an 8.5-Fr introducer. CONCLUSIONS: The test catheter adequately measures continuous cardiac output and mixed venous oxygen saturation in the clinical setting. Because intermittent bolus thermodilution is not a true "gold standard" for cardiac output determination, new techniques compared with bolus thermodilution may fail to achieve accuracy expectations. A 9-Fr introducer is recommended, as fiberoptic damage may have occurred when the 8.5-Fr introducer was used.     

Malnutrition in geriatric patients: a neglected problem?

PURPOSE: The authors report their experience with the translumbar inferior vena cava (IVC) approach for central venous access during a 6-year period at three teaching hospital sites. PATIENTS AND METHODS: Twenty-nine percutaneous IVC central venous access catheters were inserted in 22 patients during a 6-year period in the radiology departments of three teaching hospital sites. All patients had undergone unsuccessful attempts at conventional central venous access. Information was gathered by retrospective radiologic and hospital chart review. RESULTS: All attempted placements were successful. Catheters were in place for a total of 3,510 catheter days. The average length of catheter placement was 121 days (range, 14-536 days). Life-table analysis predicted catheter function rates of 55% and 29% at 6 and 12 months, respectively. Three procedure-related complications occurred. A lower pole branch of the right renal artery was inadvertently entered with a 22-gauge needle during attempted IVC puncture in one patient without clinical sequelae. A second patient developed a small groin hematoma at the femoral venous puncture site, which resolved spontaneously. A third patient developed a moderate retroperitoneal hematoma, which resolved without specific intervention. The sepsis rate was 2.8 infections per 1,000 catheter days with an average time to infection of 127 days (range, 10-536 days). CONCLUSION: In the authors' experience of 29 translumbar central venous catheter insertions, all attempts were successful. Percutaneous central venous access via the IVC is a safe and effective option for patients in whom more conventional access is not possible.     

Venous leg ulcers. Part 1: Aetiology

Cardiogenic pulmonary edema is a frequent cause of reparatory failure. We investigated the effects of nasal continuous positive airway pressure (CPAP) in patients with severe pulmonary edema associated with acute myocardial infarction. Twenty-nine consecutive patients were divided into 3 groups: firstly, 7 intubated patients who received mechanical ventilation at study entry comprised the intubation group. The rest of the patients were randomly assigned to either of the following 2 groups: 11 patients who received oxygen plus CPAP delivered by a nasal mask (CPAP group), and 11 patients who received oxygen only via face mask (oxygen group). All patients in the intubation group had cardiogenic shock. Two patients (18%) in the CPAP group and 8 patients (73%) in the oxygen group required mechanical ventilation with endotracheal intubation (p=0.03). The hospital mortality rate in the CPAP group (9%) was significantly lower than the oxygen group (64%, p=0.02). The pulmonary artery wedge pressure and heart rate were significantly lower in the CPAP group than in the oxygen group 24 h after study entry (p<0.05 and p<0.01). The mean pulmonary artery pressure 48 h after study entry was 18+/-5 mmHg in the CPAP group and 25+/-8 mmHg in the oxygen group (p<0.05). The PaO2/FiO2 ratio increased in the intubation group (168+/-69 to 240+/-57, p<0.05) and the CPAP group (137+/-17 to 253+/-67, p<0.01) 24 h after study entry. Arterial plasma endothelin-1 concentrations decreased significantly earlier in the CPAP group than in the oxygen group (p<0.05). In patients without cardiogenic shock, nasal CPAP lead to an early improvement in oxygenation and hemodynamics, and decreased the mortality rate. Early and active respiratory management is recommended in patients with pulmonary edema associated with acute myocardial infarction.     

Laparoscopy in high-risk cardiac patients

Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.     

Mitochondrial gene mutations and human diseases: a prolegomenon

OBJECTIVE: To compare "central venous pressure" in pediatric patients in a clinical setting as measured from catheters in the infrahepatic inferior vena cava and the right atrium. DESIGN: Prospective, unblinded study. SETTING: Cardiothoracic intensive care unit of a tertiary care university hospital. PATIENTS: Thirty-three pediatric cardiac surgical patients, 2 days to 92 months of age (mean 24 +/- 4 months). INTERVENTIONS: All patients had intraoperative placement of an 8-cm, double-lumen, femoral venous catheter and a transthoracic right atrial catheter. Patients were studied for 0 to 2 days after surgery. MEASUREMENTS AND MAIN RESULTS: Measurements were obtained during mechanical and spontaneous ventilation. Although not statistically identical, measurements of "central" venous pressure in the inferior vena cava and right atrium correlated well (r2 = .87 for mechanical ventilation; r2 = .83 for spontaneous ventilation). Of 31 data pairs in mechanically ventilated patients, the absolute difference in pressures was as large as 3 mm Hg in three patients and <3 mm Hg in all the rest. In 15 spontaneously breathing patients, there were only three data measurements where the difference in pressure was 2 mm Hg and none of the differences was greater. In spontaneously breathing patients, the phasic changes due to respiratory variations in venous pressure were in phase in both the intrathoracic and intra-abdominal catheter positions. CONCLUSIONS: We conclude that while "central" venous pressures measured in the inferior vena cava and in the right atrium are not statistically identical, any differences are well within clinically important limits. Placement of central venous pressure catheters in the inferior vena cava by the femoral venous approach is a reliable alternative to cannulating the superior vena cava in pediatric patients without clinically important intra-abdominal pathology and with anatomic continuity of the inferior vena cava with the right atrium. Relatively short femoral vein catheters allow adequate measurement of central venous pressure without concern for exact catheter tip position and without the risk of right atrial perforation, intracardiac arrhythmias, and inadvertent puncture of carotid and intrathoracic structures. Unlike previously reported results in neonates, we found that the phasic changes of venous pressure with the respiratory cycle were similar in both intrathoracic and intra-abdominal recordings, making this an inappropriate clinical indicator of venous catheter tip position.     

Surgical retrieval of an embolized central venous catheter in a premature baby

Embolization of central venous catheter fragments is usually treated with percutaneous interventional techniques, which are difficult to apply in infants with very low birth weight. We surgically removed a catheter fragment in a preterm neonate, to avoid the impending thrombosis of the right pulmonary artery. The operation was performed with a nerve hook introduced through a tiny incision in the vessel's wall. The procedure was well tolerated, and no stricture remains at the site of incision.     

Intensive medical monitoring with transesophageal echocardiography in fulminant pulmonary embolism

HISTORY AND FINDINGS: A 60-year-old man underwent a continence-preserving anterior rectal resection for a high rectal carcinoma. After mobilisation on the 5th postoperative day dyspnoea and cyanosis suddenly developed requiring emergency intubation and mechanical ventilation. INVESTIGATIONS: His heart rate was 160/min, blood pressure 80/50 mmHg, mean pulmonary artery pressure by indwelling catheter was 70 mmHg. The electrocardiogram had the classical signs of acute right-heart overload. Transoesophageal echocardiography (TOE) demonstrated marked right-heart and pulmonary artery dilatation. TREATMENT AND COURSE: Despite thrombolytic treatment (bolus of 50 mg r-TPA; one day later bolus of 1 million IU urokinase followed by 100,000 IU/h) a new thromboembolus was seen by TOE to straddle the pulmonary artery bifurcation. After the urokinase dosage had been raised to 200,000 IU/h TOE on the 6th day no longer showed the embolus and documented a reduction in right-heart dilatation associated with improved haemodynamics. CONCLUSION: TOE is an ideal method for the rapid diagnosis and for monitoring the response to treatment of fulminant pulmonary arterial embolism. As it can also diagnose thromboembolism without significant haemodynamic consequences it is possible to adjust fibrinolytic treatment accordingly.     

Precipitation of hard exudate after resorption of intraretinal edema after treatment of retinal branch vein occlusion

BACKGROUND: The use of centrally positioned venous catheters plays an indispensable role in the care of infants and children. METHODS: Since 1992 the authors have seen nine patients who experienced fragmentation and migration of catheter fragments into the central circulation. The patients ranged in age from 6 days to 15 years. RESULTS: Sites of migration included pulmonary artery (five patients), superior vena cava (two patients), hepatic vein and innominate vein (one patient). The elapsed time from recognition of retained catheter fragments until retrieval ranged from a few hours to 6 weeks. CONCLUSION: All retained fragments were successfully removed during cardiac catheterization without complications.     

Progressive neuronal degeneration of childhood (Alpers syndrome) with hepatic cirrhosis

A new technique for right heart catheterization using a Mullins' sheath is described. This device allows a Swan-Ganz catheter to reach pulmonary artery position easily and permits simultaneous pressure recordings in right heart chambers, thus avoiding a double venous puncture and two catheters. This new technique, its indications, and our experience in 29 patients are described. It is most useful in patients with severe pulmonary hypertension and in those conditions in which accurate right heart pressure measurements are needed.     

Atrial fibrillation after bypass surgery: does the arrhythmia or the characteristics of the patients prolong hospital stay?

STUDY OBJECTIVES: The goal of this study was to determine whether prolonged hospital stay associated with atrial fibrillation or flutter (AF) after coronary artery bypass graft (CABG) surgery is attributable to the characteristics of patients who develop this arrhythmia or to the rhythm disturbance itself. DESIGN: An investigation was conducted through a prospective case series. SETTING: Patients were from a single urban teaching hospital. PARTICIPANTS: Consecutive patients undergoing isolated CABG surgery between December 1994 and May 1996 were included in the study. INTERVENTIONS: No interventions were involved. RESULTS: Of 436 patients undergoing isolated CABG surgery, 101 (23%) developed AF. AF patients were older and more likely to have obstructive lung disease than patients without AF, but both patients with and without AF had similar left ventricular function and extent of coronary disease. ICU and hospital stays were longer in patients with AF. Multivariate analysis, adjusted for age, gender, and race, demonstrated that postoperative hospital stay was 9.2+/-5.3 days in patients with AF and 6.4+/-5.3 days in patients without AF (p<0.001). CONCLUSIONS: Although AF is strongly associated with advanced age, most of the prolonged hospital stay appears to be attributable to the rhythm itself and not to patient characteristics.     

Pulmonary function and respiratory symptoms in forest firefighters

As part of a national study of surgical departments is Israel, cardiac surgery patients undergoing open heart surgery between 1987 and 1989 were followed-up prospectively. Of these, 1,046 patients had coronary artery bypass grafting (CABG) and are the subject of this report. The six-months mortality after surgery was 12.9% among 202 women and 4.1% among 844 men. Female gender was an independent predictor of mortality even after controlling for the effect of 14 putative risk factors. The adjusted relative risk for mortality in women compared to men was 2.79 (1.5-5.2). In an attempt to understand this excessive mortality among women, a detailed analysis in one of the participating hospitals revealed differences associated with surgical technique by gender, such as proportion of patients with entirely venous grafting vs internal mammary artery grafts (IMA). Thirty percent of women vs 4.8% of men had entirely venous grafting. Adjusting the data for differences in the proportion of venous grafting has obliterated the difference in mortality between the genders in that hospital. We suggest that interventions to reduce mortality among women should involve a more careful choice of female candidates for CABG surgery, as well as introduction of modifications in the operating technique.