Dilutional and modified ultrafiltration reduces pulmonary hypertension after operations for congenital heart disease: a prospective randomized study

OBJECTIVE: A prospective randomized study was performed to test whether removal of endothelin-1, by ultrafiltration techniques, will reduce pulmonary hypertension after operations for congenital heart disease. METHODS: Twenty-four patients with pulmonary hypertension (systolic pulmonary/systemic arterial pressure ratio > 60%) undergoing cardiac operations were randomized into a control group (n = 12) having conventional ultrafiltration and an experimental group (n = 12) undergoing dilutional ultrafiltration during and modified ultrafiltration after cardiopulmonary bypass. Plasma endothelin-1, nitric oxide metabolites, and cyclic guanosine monophosphate were assayed before bypass, 10 minutes into bypass, after bypass, and 0, 3, 6, and 12 hours after the operation in both groups, as well as in the ultrafiltrates and after modified ultrafiltration in the experimental group. Both groups received alpha-blockers (chlorpromazine and/or prazosin) postoperatively using the same guidelines. RESULTS: The ultrafiltrates contained significant amounts of endothelin-1 (1.81 +/- 0.86 pg/ml, dilutional, and 6.44 +/- 1.82 pg/ml, modified ultrafiltrate). Endothelin-1 and the pulmonary/systemic pressure ratio were significantly lower in experimental compared with control patients. Nitric oxide metabolites and cyclic guanosine monophosphate increased similarly in both groups for 12 hours after the operation (p = not significant). Three of 12 control patients (25%) but no experimental patients had pulmonary hypertensive crises (p = 0.07). The experimental patients required significantly less ventilatory support (67 +/- 47 hours vs 178 +/- 139 hours for control patients, p = 0.048). CONCLUSIONS: Dilutional and modified ultrafiltration reduce endothelin-1 and the pulmonary/systemic pressure ratio postoperatively and may become an important adjunct for preventing pulmonary hypertension after operations for congenital heart disease in high-risk patients.     

Effect of ultrafiltration during cardiopulmonary bypass for pediatric cardiac surgery

The effect of ultrafiltration during cardiopulmonary bypass (CPB) was evaluated for correcting ventricular septal defects with associated pulmonary hypertension in patients less than 18 months old. Interleukin (IL)-6 and IL-8 concentrations in the blood, ultrafiltrate, and urine were measured. The blood IL-6 concentration increased to 128.4+/-20.2 pg/ml by the end of surgery, which is lower than the concentration seen in adult patients (273.1+/-48.2 pg/ml, p < 0.02). The blood IL-8 concentration was not significantly different than that of adults. The total amounts of excreted IL-6 in the ultrafiltrate and urine during CPB were 11.5+/-0.32 pg/kg and 0.32+/-0.07 pg/kg, respectively (p < 0.05). The total amounts of excreted IL-8 in the ultrafiltrate and urine were 4.64+/-0.69 pg/kg and 1.92+/-0.56 pg/kg, respectively (p < 0.05). No differences were seen in these values for excretion between children and adults. We conclude that ultrafiltration during CPB in pediatric patients is more effective in removing proinflammatory cytokines than in adults and more effective than renal filtration alone.     

Effect of veno-venous ultrafiltration on myocardial performance immediately after cardiac surgery in children. A prospective randomized study

OBJECTIVES: This study sought to evaluate the effects of veno-venous ultrafiltration on myocardial contractility in children undergoing cardiopulmonary bypass (CPB) for repair of congenital heart defects. BACKGROUND: Ultrafiltration (UF) is currently used to diminish postoperative fluid accumulation following CPB in children. Previous reports indicate improvement in hemodynamics immediately after UF, but the mechanism of its action is unknown. METHODS: Twenty-three patients (ages 2 months to 9.1 years; 13 males, 10 females) underwent UF for 10 min after CPB. Twelve patients underwent UF immediately after CPB (Group A). They were studied: (1) before and (2) after CPB, (3) after UF, and (4) 10 min after UF. Eleven patients underwent UF 10 min after CPB (Group B). They were studied: (1) before and (2) after CPB, (3) after a 10-min delay before UF, and (4) after UF. Contractility was determined by the difference in the observed and predicted velocity of circumferential fiber shortening for the measured wall stress, using transesophageal echocardiography. Left ventricular wall thickness was also measured. RESULTS: There was significant improvement in contractility after UF in both groups (mean+/-SD, Group A: -0.28+/-0.13 to -0.01+/-0.21 circ/s, p < 0.05; Group B: -0.26+/-0.16 to -0.11+/-0.17 circ/s, p < 0.05). Myocardial thickness to cavity dimension decreased in both groups following UF (Group A: 0.19+/-0.04 to 0.14+/-0.03, p < 0.05; Group B: 0.18+/-0.04 to 0.14+/-0.03, p < 0.05). CONCLUSIONS: UF improves hemodynamics by improving contractility and possibly by reducing myocardial edema in children following cardiac surgery. Enhanced patient outcome after ultrafiltration may in part be due to these changes.     

Influence of cataract surgery on the diabetic eye: a prospective study

The aims of treating patients with asthma are to relieve symptoms, to prevent symptoms and exacerbations, and to prevent long-term deterioration in lung function. It is the role of medical practitioners to inform the patient what asthma is, and to develop a plan to achieve the aims for the individual, recognizing that asthma is frequently a chronic, lifelong disease. Most patients can be diagnosed, assessed for severity and causes, and treated in primary care practices, however, sometimes help from an asthma clinic of a specialist is required. The most important management decision is to determine whether the patient needs inhaled corticosteroids; subsequently, decisions about dose, duration and method of delivery of treatment can be tailored to the individual depending on the preferences and social conditions of the patient. The aim of this article is to present the latest strategies for the management of asthma and the simplest methods for their implementation. Important new strategies include careful assessment of the severity; immediate introduction of a plan that is tailored of the individual and aimed at the possible reversing of the disease; detailed instructions for management of exacerbations and the combined use of inhaled corticosteroids with a long-acting bronchodilator. It is becoming clear that these strategies obviate dependence on oral corticosteroids in newly diagnosed asthmatic patients. Furthermore, relatively low doses of inhaled corticosteroids can be used to maintain good control if used in conjunction with other therapies. The role of newly developed antagonists to leukotrienes is not yet known but it may well be useful in mild asthma and in special forms of the disease, such as those sensitive to aspirin. In the future, the most important strategy will be to prevent the disease.     

Postoperative arrhythmias in open-heart surgery, A study on fifty cases

50 consecutive patients undergone open heart surgery were analyzed regarding postoperative arrhythmias in the first postoperative 3 days. Disturbances of rhythm occurred in each case of our group, serious or not serious (100%). Ventricular premature beats were the most frequent type of arrhythmia in the first and second postoperative days (80%). Two cases expired postoperatively. In one of them complete atrioventricular block developed after double valvular replacements (mitral and tricuspid). The other died of low cardiac output syndrome. Etiology of the arrhythmias after open heart surgery is not clear in the absence of electrolyte and metabolic disturbances, digitalis intoxication and surgical trauma to the conduction system and coronary arteries. Low cardiac output syndrome, hypotension and hypoxia can also be blamed in the formation of these arrhythmias. Other factors such as the prolongation of anoxic arrest, irritation of the ventricular septum by valvular prostheses, cardiac irritation by thoracic tubes, psychologic trauma, halothane anesthesia and coronary arterial disease in the old age group may be the possible predisposing factors in these patients.     

Effect of blood conservation in open-heart surgery: a comparison of 3 different methods

Conventional blood conservation techniques have been insufficient to decrease blood transfusion requirement in open-heart surgery. Blood conservation and erythropoietin administration were performed to avoid homologous blood transfusion. Intraoperative autotransfusion has been routinely used in cardiac operations with cardiopulmonary bypass in our hospital. To evaluate the effect of conservation techniques, 286 patients were divided into four groups. In group I (23 patients), autologous whole blood was drawn and saved one to two weeks before operation. In group II (50 patients), erythropoietin preparation was given subcutaneously once a week and autologous blood conservation was also performed in the same manner as group I. In group III (48 patients), intra-operative hemodilutional autologous blood transfusion was performed. In group IV, as a control group (165 patients), only intra-operative autotransfusion was used. Homologous blood transfusion was avoided in 83% of group I patients, in 90% of group II, in 82% of group III, and 29% of group IV. In addition, in group II the hemoglobin value at the time of discharge was significantly higher than those of other groups (p < 0.05-0.01). Thus, conventional blood conservation techniques plus subcutaneous administration of erythropoietin was very effective to increase the rate of "non-blood" open-heart surgery.     

Starplasty: a new technique of pediatric tracheotomy

OBJECTIVE: To report a new technique of pediatric tracheotomy that reduces the problems of pneumothorax and recannulation after accidental decannulation in a recently performed tracheotomy. DESIGN: Retrospective chart review for 1990-1997. PATIENTS: Sixty-eight children aged between 2 days and 14 years. METHOD: The starplasty procedure is based on the geometry of a 3-dimensional Z-plasty. The technique of the procedure is described and illustrated in detail. RESULTS: There were 27 short-term complications, including 4 accidental decannulations. There were no instances of pneumothorax or tracheotomy-related deaths. There were 25 long-term minor complications. There were no instances of tracheotomy-related death, suprastomal collapse, or tracheal stenosis. Thirty-eight children remain tracheotomy tube dependent, 17 underwent decannulation, 7 died of primary disease, and 6 were lost to follow-up. All 17 children who underwent decannulation have a persistent tracheocutaneous fistula. CONCLUSIONS: I conclude that starplasty reduces the incidence of major complications and death. Its only drawback seems to be persistent tracheocutaneous fistula.     

Septic complications after biliary tract stone surgery: a review and report of the European prospective study

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.     

Use of a rate-limited ultrafiltration circuit with centrifugal ventricular assist

Renal insufficiency and pulmonary edema are frequently observed in patients who require centrifugal ventricular assist for postcardiotomy ventricular failure. We describe a technique of using a rate-limited ultrafiltration device in parallel with the assist device circuit to remove excess intravascular volume.     

Use of power Doppler in pediatric neurosonography: a pictorial essay

In pediatric neurosonography, conventional color Doppler imaging has been the primary adjunct to routine gray-scale imaging. Power Doppler sonography is a relatively recent development that does not have the limitations of conventional color Doppler ultrasound. The power Doppler technique measures the energy of moving red blood cells instead of the velocity and direction of flow. Advantages of this technique include increased sensitivity for identifying flow in slow-flow states, more complete evaluation of a vessel, and more accurate evaluation of the course of the vessel. Power Doppler sonography is helpful in evaluation of the neonatal brain in a variety of clinical situations: identifying the exact locations of extraaxial fluid collections, differentiating intraventricular clot from normal choroid plexus, detecting intraventricular hemorrhage, and demonstrating asymmetries in cerebral perfusion. However, in certain difficult cases, use of both conventional color Doppler sonography and power Doppler sonography produces increased diagnostic accuracy because these techniques furnish complementary information.     

Laparoscopic cholangiography: a prospective study

This paper describes the analysis of injury-related linked hospital morbidity data by admissions and by individual patients in Western Australia (WA) from 1990 to 1994. Over this five-year period, there were an average of 35,385 admissions and 30,524 people admitted each year for injuries in WA. The age-standardised rates for injury-related hospital admissions and persons admitted for injuries increased significantly, by 2.4% and 1.5% per year respectively, over the five-year period. The number of admissions and the number of persons admitted peaked in the 20-24 years age group but the highest rates were among those aged 75 years and above. Injuries accounted for nearly 10% of all hospital bed day costs and cost about $50 per head of population per year. The cost of hospitalisation rose steadily from $85.2 million in 1990 to $113.6 million in 1994, the average cost being nearly $100 million per year. The average cost per injury related hospital episode was $2,748. Generally, the cost per hospital episode was higher for males and increased with age, following a similar pattern to that for the average length of stay.     

The use of the Synthes 7.3-mm. cannulated screw in rearfoot and ankle surgery: a preliminary prospective study

The authors present a preliminary prospective study of the Synthes 7.3 mm. cannulated screw used in 31 rearfoot and ankle surgeries on 29 patients. The patients had a variety of rearfoot and ankle procedures performed, in which a total of 75 screws were placed across 47 arthrodesis or osteotomy sites. The percentage of union or healing was 95.74% for the joints or sites involved. The average healing time was 2.71 months. The techniques for placement of the screw are described.     

Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery

PURPOSE: To find out whether there is a "hidden" group of patients with posterior capsule opacification (PCO) 5 years after cataract surgery and to establish the incidence of PCO. SETTING: Department of Ophthalmology, Sahlgrenska University Hospital, Gothenburg, Sweden. METHODS: A random sample (n = 164) was selected among patients who had extracapsular cataract extraction (ECCE) with intraocular lens implantation in 1991 (N = 1672). All surgically treated cases that required neodymium:YAG (Nd:YAG) laser capsulotomy (n = 37) within the first 5 years after surgery were recorded. Patients still alive 5 years after surgery who had not had Nd:YAG treatment were offered an eye examination to determine whether PCO requiring capsulotomy existed. RESULTS: Thirty-seven of 110 patients (34%) alive 5 years after surgery had an Nd:YAG capsulotomy during the first 5 postoperative years. Follow-up was possible in 51 of 73 untreated patients (70%). Clinically significant PCO according to specified criteria was found in 7 cases (14%). Half of them would benefit from treatment; the other half had visual impairment from other eye disease. CONCLUSIONS: The estimated incidence of PCO 5 years after ECCE was 43%. Five years after surgery, there was an untreated group with clinically significant PCO, approximately 9% of the surgically treated population. This hidden group must be considered in PCO studies.     

A prospective study of Clostridium difficile infection and colonization in pediatric oncology patients

BACKGROUND: Tumescent liposuction has proven to be an extremely safe and effective method of liposuction. However, the infusion of tumescent anesthesia can take 1 hour or more to complete. OBJECTIVE: To document the types, dosages, and routes of administration of premedication utilized by four experienced tumescent liposuction surgeons. To determine if infusion rates for tumescent anesthesia are affected by types of premedication. METHODS: Four experienced liposuction surgeons were asked to review their most recent 100 tumescent liposuction patients with respect to types and dosages of premedication and routes of administration. Data were also provided on corresponding infusion pump settings and infusion rates. Volumes of tumescent anesthesia and corresponding volumes of fat aspirated were also collected on the same 400 patients. RESULTS: Infusion of tumescent anesthesia could be performed more rapidly in patients who were given greater amounts of premedication. Volumes of tumescent anesthesia infused were generally two or more times the volume of fat aspirated. Patients could be infused with less premedication if slow infiltration was employed. CONCLUSION: Infusion rates for tumescent anesthesia can be increased of greater amounts of premedication are given. However, this must be balanced against the safety of the premedication.