Correlation of arterial PaCO2 to end tidal CO2 in children undergoing laparoscopic abdominal surgery: An observational study.

Background and Aims: The reliability of end tidal carbon dioxide (ETCO2) as a measure of arterial carbon dioxide (PaCO2) in pediatric laparoscopy is unclear. We evaluated the correlation of arterial to end tidal P(a-ET) CO2 during pediatric laparoscopy at two hours of pneumoperitoneum as the primary objective. We also compared P(a-ET) CO2 and alveolar to arterial oxygen gradient P(A-a) O2 and haemodynamics at fixed time points during surgery. Material and Methods: A cross-sectional study was conducted in 25 children undergoing laparoscopic abdominal surgery. Arterial blood gases were drawn at T0, baseline, T10: ten minutes, T1h: 1 hour, T2h: 2 hours of pnuemoperitoneum and T 10d: 10 mins after deflation. The P(a-ET) CO2, P(A-a) O2, were measured from the blood gas and ETCO2 and FiO2 values on the monitor. The Pearson's correlation coefficient, the Wilcoxon rank test and Chi square test were used for statistical analysis. Results: At T2h moderate correlation of P(a-ET) CO2 (r = 0.605, P = 0.001) with 40% children documenting accurate P(a-ET) CO2, -1 to +1 mm Hg was seen. Moderate correlation was also seen at T0, T10, T 10d but poor correlation at T 1h. The P(A-a) O2 increased progressively with surgery and did not correlate with P(a-ET) CO2. Heart rate was stable, but systolic blood pressures at T 10 and diastolic at T10, T 1h, T 2h were higher than baseline. Conclusion: Moderate correlation was seen between PaCO2 and ETCO2 at 2 h of pnuemoperitoneum and at T0, T 10, and T 10d. P(A-a) O2 increased with surgery but did not correlate with P(a-ET) CO2.

Pathological fibrinolysis secondary to pseudoaneurysms.

Pathological fibrinolysis due to pseudoaneurysms was observed in a patient 4 years after aortobifemoral bypass graft. The patient presented with a pulsatile abdominal mass and ischemic changes in the legs. Excessive bleeding from venipuncture sites prompted coagulation screening, which disclosed rapid clot lysis, fibrin split products, and low fibrinogen suggestive of pathological fibrinolysis. Therapy with epsilon amino caproic acid (EACA, Amicar) controlled the coagulopathy, permitting angiography and operation. Resection of the pseudoaneurysms resulted in resolution of the abnormal fibrinolysis. Normally, there is a balance between coagulation and fibrinolysis protecting against excessive bleeding or clotting. Clot itself is a powerful stimulus for the activation of the fibrinolytic system, although many other factors have been shown to initiate and sustain the process. Fibrinolysis is pathological when the process becomes excessive or inappropriate. Plasminogen is activated to plasmin which digests fibrin. Both plasmin and fibrin split products inhibit polymerization of fibrin monomers (which is the final step in the coagulation cascade in the formation of a stable clot), resulting in an unstable clot which is rapidly lysed. To our knowledge such a coagulopathy has not been reported to be a complication of pseudoaneurysms.

Monitor-guided responses. Operability with safety is increased in patients with peripheral vascular diseases.

Poor cardiopulmonary reserve was demonstrated in a group of 75 elderly patients undergoing elective vascular reconstruction when cardiovascular hemodynamics were analyzed with the automated physiologic profile (APP) preoperatively. Only 25 patients (33.3%) had normal left ventricular function (LVF) and did not need any corrective therapy before surgery. Increment in preload was necessary in 20 patients (26.7%) to improve myocardial function; 30 patients (40%) revealed abnormal LVF and hence required pharmacologic modulation and preload adjustment, inotropic support, and afterload reduction to enhance the ventricular performance. Conventional methods of clinical evaluation did not reveal the degree of compromised ventricular function and potential high risk of surgical morbidity and mortality in many of these patients. The APP disclosed subtle and important physiologic aberrations indicating modification of anesthetic and operative procedures and precise modulation of physiologic factors. Optimization was achieved in all except two patients, and only one was denied the benefits of vascular reconstruction.

Use of the centrifugal flow pump for vena caval shunting.

We have used the Bio-Medicus centrifugal flow pump for vena cava shunting during surgical resection of renal cell carcinoma with extension of the tumor into the inferior vena cava. The active shunt can provide optimal blood return to the heart to promote hemodynamic stability, help provide an isolated field for resection of the involved kidney and its tumor extension into the vena cava, and avoid use of full-dose heparin to minimize blood loss in this extensive operation.

Celiac territory ischemic syndrome in visceral artery occlusion.

Abdominal angina that is characterized by postprandial pain, and often associated with weight loss, is a well-recognized symptom complex of mesenteric artery insufficiency (mesenteric territory symptoms). In the past 5 years, we have observed six patients with atypical symptoms who had mesenteric artery occlusion combined with stenosis or occlusion of the celiac artery. Atypical symptoms included severe nausea and vomiting at the sight or smell of food, anorexia, weight loss, and right upper quadrant or epigastric discomfort (celiac territory symptoms). An extensive work-up to rule out gastric, pancreatic, biliary, or colonic pathology was undertaken in these patients. The findings included gallbladder dysfunction, diffuse micro-ulceration of gastric mucosa, and colonic mucosal ulceration. The diagnosis of visceral artery occlusion was initially missed in all six patients. Four patients had cholecystectomy. Visceral angiography confirmed occlusion of the celiac, superior, and inferior mesenteric arteries. Five patients had dramatic resolution of symptoms after restoration of visceral circulation. One patient who developed intestinal infarction before revascularization died. Symptoms suggesting upper abdominal visceral pathology may be a manifestation of celiac artery stenosis/occlusion coexisting with mesenteric artery occlusive disease. Visceral angiography should be part of the work-up in these patients for early diagnosis and prompt management.

Unappreciated causes of ischemia in the leg.

Limb ischemia due to blunt trauma, dissecting hematoma, and cardiac dysfunction jeopardizes limbs and lives more than is generally appreciated. Delay in diagnosis after blunt trauma led to major amputation in 21 percent of our patients. Current principles avoid those hazards. Five patients presented with acute limb ischemia caused by dissecting hematoma of the aorta. Suspicion of that diagnosis is warranted in patients without a history of chronic vascular occlusive disease or cardiac disease, in young white males with Marfan characteristics, and in middle-aged hypertensive black males. Confirmation of the diagnosis requires urgent angiography. In selected cases, treatment with femorofemoral bypass will be limb- and life-saving. Ischemia due to low flow, which portends a dire prognosis, should be suspected in severely ill patients with a history of peripheral vascular disease. Analysis of cardiac and metabolic functions with the Automated Physiologic Profile system identified the cause of the low flow state in 10 patients, permitting precise management with specific therapy. A discernible improvement in circulatory status of the limb coincided with correction of the low flow states. Angiography and surgery were not necessary in 90 percent of this group, and should be avoided during low flow episodes.

Adequacy of central hemodynamics versus restoration of circulation in the survival of patients with acute aortic thrombosis.

Acute aortic thrombosis is an infrequent clinical occurrence, but when it does occur, it is a true cardiovascular catastrophe. Our experience with 34 patients over a 12 year period was reviewed and factors influencing outcome were analyzed. Seventeen women and 17 men had various clinical presentations, although 74 percent of the patients had the classic picture of ischemia. Preoperative assessment of left ventricular function was carried out in all but one patient with intraoperative and perioperative monitoring to guide therapy in addition to revascularization procedures. While extent of the preexisting disease and number of additional operations did influence the outcome, the predominant factor for survival was the left ventricular functional state perioperatively. Fifteen of the 16 patients with adequate left ventricular function survived, whereas 15 of the 17 patients with a failing myocardium died (88 percent). Extraanatomic operations are preferable in patients with demonstrated inadequate left ventricular function. Expeditious restoration of circulation alone does not ensure a favorable outcome. The key to successful therapy is understanding, preventing, and effectively treating the mechanical and metabolic dysfunction of the heart. Review of the literature on acute aortic thrombosis revealed only few isolated case reports except for a recent report of eight patients. Our report of 34 patients over a 12 year period represents the largest experience to date from a single institution. Detailed analysis of hemodynamic parameters and the significance of determination of left ventricular function has not been reported so far in this subset of critically ill patients.

Coexisting carotid stenosis in patients undergoing cardiac surgery: indications and guidelines for simultaneous operations.

The coexistence of critical carotid stenosis with coronary artery or valvular heart disease occurs in a small percentage of patients requiring open heart surgical procedures. Recognition of such combined lesions by noninvasive carotid testing identifies patients at risk for neurologic events. Our experience with 62 patients having combined simultaneous carotid and cardiac operations among 2,400 open heart surgery patients was compared with the results in 110 patients with only carotid endarterectomy operations. The outcomes indicated that carotid endarterectomy can be performed simultaneously with open heart surgical procedures with morbidity and mortality rates similar to those of isolated cervical artery operations. Thus, patients with significant coexisting carotid artery disease defined with specific criteria and coronary artery disease need not be exposed to cerebral ischemic events or to myocardial infarctions that often accompany staged operations.

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.

Malignant renal tumor with extension to the inferior vena cava.

BACKGROUND: Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS: Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS: Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS: An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Agricultural productivity, seasonality and gender bias in rural nutrition: empirical evidence from south India.

This paper analyzes changes in the nutrients intake, intra-household allocation and gender bias due to changes in agricultural productivity among four groups of rural households over six different seasons. The study utilizes household survey data collected from a village in Tamil Nadu, India. While the results are consistent with earlier findings that seasonality influences variation in the intake of nutrients, it is shown that subsistence agricultural households recover faster from poor crop yields than market oriented agricultural households in terms of nutrient intake. Agricultural labour households consumed lowest quantities of energy and protein in all the seasons with the highest degree of gender bias. The gender bias is more in terms of protein intake compared to energy intake for all the households. The non-agricultural households are least affected due to variability in crop yields and seasonality. While nutritional intake of the rural households is positively correlated with crop yields, the variations in yields worsen the gender bias. It is argued that reducing dependency of rural households on agriculture may reduce malnutrition and the gender bias associated with it.

Changing patterns in civilian arterial injuries.

A critical review of 185 patients with 211 arterial injuries over an eleven year period was performed to recognize the changing patterns in clinical findings, management and results. A ten fold increase in multiple arterial injuries as well as higher incidence of associated venous and visceral injuries occurred during the last five years. Despite this, the incidence of hypotension on arrival at hospital was reduced by half due to rapid transportation and resuscitation during transit. Shock in patients with only extremity injuries heralded dual injuries (arterial and venous). Lateral repair of both arterial and venous injuries has given way to end to end anastomoses, vein grafts and patch grafts. A greater tendency to repair all major arteries, most minor arteries, more liberal use of heparin, fasciotomy, intraluminal shunts, repair of venous injuries and extra-anatomic bypass has been noted. Rapid patient retrieval, early resuscitation, improved recognition and management of arterial injuries has not lead to better limb salvage or survival. The apparent lack of benefit in limb salvage is probably due to the higher incidence of multiple arterial injuries and associated venous injuries as well as the willingness to attempt repair all major arterial injuries and reluctance to advise primary amputation. Early patient retrieval, rapid transportation and resuscitation during transit has increased the number of potentially unsalvageable patients (who would otherwise be declared dead on arrival) resulting in an unchanging mortality.

Arterial thrombosis and embolism in malignancy.

In most reviews of arterial embolism or thrombosis the source of emboli or the cause of thrombosis can reasonably be established in over 90% of patients. Still about 10% remain without demonstrable cardiac or intraarterial sources. Although hypercoagulability induced by malignancy has been alluded to as a cause of unexplained intravascular thrombosis reports of arterial thromboembolism with such association are rare. Seven patients with unequivocal thromboembolism are presented. Two distinct clinical patterns are observed, one with in situ thrombosis of small arteries and the other with occlusion of large arteries causing limb ischemia or fatal organ infarction. The various pathogenetic mechanisms of arterial thrombosis or embolism in malignancy include sustained spasm of arteries, precipitation of cryoglobulins or other abnormal proteins in small arteries, direct tumor invasion of arteries, fragmentation and embolization of intracardiac or intraarterial metastases and spontaneous arterial thrombosis due to hypercoagulability. The hypercoagulable state can be recognized by the observation of shortened bleeding and clotting times, partial thromboplastin and prothrombin times, elevation of coagulation factors, platelets and yield stress index and resistance to anticoagulation. Patients presenting with arterial thromboembolic events with out demonstrable source should be investigated for malignancy. Conversely patients with malignancy should be searched for evidence of hypercoagulability in an attempt to prevent arterial thromboembolic complications.

Causes of limb loss in civilian arterial injuries.

Progress in the management of complex vascular injuries of the extremities has not eliminated the necessity for amputation. An analysis of 100 consecutive patients treated at the Lincoln Medical and Mental Health Center during 1974-1980 disclosed that five amputations followed 24 instances of blunt trauma, but only one minor amputation of toes was required in 76 patients after repair of arterial injuries associated with penetrating wounds. Extensive skeletal, muscular and skin loss at the sites of blunt trauma precluded salvage of two limbs. Physicians' failure to suspect arterial injury on admission in three patients with blunt trauma caused delay in the diagnosis and management of occlusive arterial injury that ultimately led to three amputations. In contrast, limited soft tissue damage accompanying penetrating wounds and high index of suspicion resulted in expeditious repair, accounting for the minimal risk of limb loss. Amputation may be obligatory in the presence of extensive skeletal and soft tissue destruction. However, limb loss due to delay in diagnosis is preventable. In every instance of blunt trauma to extremities, we advocate the same suspicion of vascular injuries as in penetrating trauma, with early liberal use of angiography whenever pulses are not absolutely normal, and prompt revascularization of ischemic limbs.

The clinical utility of carotid duplex scanning.

We retrospectively compared the results of duplex scanning (DS) with contrast angiography (CAN) in the evaluation of 119 patients whose 238 carotid arteries were evaluated by both methods within a four-week period. The results of all patients were then categorized by two different definitions of severity of stenosis. Category A classified 1-29% stenosis as mild, 30-69% stenosis as moderate, and 70-99% diameter reduction as severe stenosis. Category B defined mild stenosis as 1-19% lumen diameter reduction, moderate as 20-49% stenosis, and severe as 50-99% stenosis. The findings by each classification were compared in 60 patients with hemispheric symptoms and in 59 patients with nonspecific symptoms. CAN was our "gold standard", and exhibited greater sensitivity, specificity, accuracy, and predictive values than DS. Carotid arteries with 70% stenosis were identified by DS with greater specificity, accuracy, and predictive values than were arteries with 50% stenoses. Only the sensitivity was comparable in categorizations A and B (80% and 83%). All parameters of measurement were superior in patients with hemispheric symptoms. DS alone cannot substitute for CAN in selecting patients for carotid endarterectomy because its error rate exceeded acceptable rates of complications for carotid artery surgery. The false positive rate of DS was 4%. DS failed to diagnose 7 of 19 carotid artery occlusions, 9 of 11 ulcerated plaques, 7 of 119 instances of aortic arch disease, and 13 cases of severe intracranial artery stenosis.

Simultaneous bilateral carotid endarterectomy operations.

Clinical reasoning and sound physiologic data have been the bases for performing bilateral simultaneous carotid endarterectomy operations in 25 patients recently. The results have compared favorably with unilateral carotid endarterectomy operations in 100 patients over the same time span. Thus, there is ample basis for performing operations simultaneously when bilateral carotid endarterectomy operations are indicated.

Socioeconomic impacts of school feeding programmes: empirical evidence from a South Indian village.

PIP: Tamil Nadu a poverty-stricken rural community in South India, funds a school feeding program with about 10% of the state budget. Comparisons of nutrition and literacy show that they are significantly related. No studies have yet been performed to analyse the effect of the feeding programs on aspects of a household's economic and social welfare. The feeding program in Tamil Nadu extends throughout the year, 7 days a week. It provides not only a reason for children to attend school, but also employment opportunities for those who wish to cook. 455 households were surveyed from 1 village using. A Gini coefficient of inequality to determine inequality levels of nutrition, food, and consumption expenditure. Sen's index of poverty was used to calculate the reduction in poverty levels. 3 household groups were defined: the agricultural labor, the silk weaver, and the cultivator. Linear program modelling utilized these 3 groups to study the total effect of nutrition on education. Linear regression was then used to determine the effect of the feeding program on participation in school. At the village level, a reduction of inequality in consumption and intake, an increase in energy intake, and a decrease in poverty level were found. In agricultural labor and silk weaver households, most of the money was spent on cereal food grains and children were mostly uneducated. If modelled to assume that children must be educated and are educated in schools providing food, results suggest that the increase in nutrition helps retain the children in the schools. Cultivator household response to the food programs was poor, since they usually have enough money to meet nutritional needs. Household income and school nutrition, but not adult literacy affect school participation. In general, nutrition offered in school caused a subsequent increase in household purchases of non-cereal items in the first 2 household types.^ieng

Developing decentralized capacity for disaster prevention: lessons from food security and nutrition monitoring in Malawi.

Lack of sufficient analytical capacity in most of the countries of sub-Saharan Africa has been frequently mentioned as a major factor limiting the effectiveness of drought management interventions. In this article we describe an approach used in Malawi for the past three years to develop a decentralized capacity to analyse drought management and disaster prevention programmes. A conceptual framework is presented which identifies the areas in which capacity strengthening is required and lessons from the Malawi experience are presented. Various issues relating to the efficiency of capacity building programmes are discussed. We argue that continuous dialogue between development researchers and decision-makers, and between trainers in academic institutions and donor agencies, is essential for achieving the goals of improved capacity for drought management and disaster prevention.

Doppler diagnosis of partial vertebral/subclavian steals convertible to full steals with physiologic maneuvers.

Subclavian steal syndrome has been classically described as a unidirectional phenomenon in which retrograde flow occurs in the ipsilateral vertebral artery in cases of high-grade proximal subclavian stenosis. Pulsed Doppler examination in cases of subclavian stenosis shows that partial steals with to-and-fro flow do occur. A model based on fluctuating pressure gradients to explain the partial steal phenomenon is discussed. The usefulness of physiologic maneuvers such as ipsilateral arm exercise and postocclusive hyperemia in converting partial steals to full steals is demonstrated. In cases in which surgical bypass to correct partial steals is carried out, a relative steal can be demonstrated by Doppler examination before and after physiologic maneuvers.

Acute aortic occlusion--factors that influence outcome.

PURPOSE: The purpose of this study was to report our experience in the management of acute aortic occlusion and to analyze factors that influenced the outcome. METHODS: This was a retrospective analysis of 48 patients with acute aortic occlusion treated over a 19-year period. Presentation included limb ischemia in 34, acute abdomen in four, spinal cord compression-like symptoms in eight, and sudden onset of hypertension in two patients. Thrombosis was the cause of acute aortic occlusion in 44, and embolus in four patients. Acute thrombosis was associated with underlying atherosclerotic occlusive disease in 36 patients. In these, thrombosis was due to low-flow state caused by cardiac dysfunction or severe volume depletion. Thrombosed aneurysms caused aortic occlusion in two patients. Hypercoagulable state caused thrombosis of relatively normal aorta in six patients. Angiography in 39 patients revealed occlusion to be juxtarenal or infrarenal in 37 and suprarenal in two. Left ventricular function (LVF) was assessed in 42 patients. Circulation was restored in 45 (aortofemoral bypass in 22, axillofemoral bypass in 12, and thromboembolectomy in 11). This was not feasible in three patients. Additional surgical procedures were required in 29 patients (64%). RESULTS: The overall mortality rate was 52% (25 of 48). Of the 20 patients with severely compromised LVF, 17 died (85%). In contrast, only five (23%) deaths occurred among 22 with good LVF. Among 29 patients who required additional operations, 18 died (62%). All four patients with embolic occlusion survived. Patients with normal LVF but hypercoagulable state had dismal outcome--only one of the six survived. CONCLUSIONS: Acute aortic occlusion is infrequent. Presentation may be varied, thus delaying diagnosis. Poor LVF, thrombosis of arteries below the inguinal ligament or of visceral arteries, and "hypercoagulable state" portend ominous prognosis.