Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography.

Peritoneovenous shunts have become an accepted mode of therapy for ascites refractory to medical treatment. However, their use is known to be associated with significant morbidity and mortality. Reported is the case of a patient with a Denver shunt who developed massive intracardiac thrombosis and subsequent shunt malfunction, despite preserved shunt patency.

Early steroid therapy for respiratory failure.

We performed a randomized double-blind trial to determine the usefulness of early methylprednisolone therapy for patients with pulmonary failure. We selected 81 acutely ill, mechanically ventilated patients at high risk for adult respiratory distress syndrome (ARDS). Thirty-nine patients received methylprednisolone, 30 mg/kg, every six hours for 48 hours; 42 patients received mannitol placebo. All patients were given a positive end-expiratory pressure of 5 cm H2O, monitored with pulmonary artery catheters, and treated for their primary disease processes. Twenty-five steroid-treated patients (64%) and 14 placebo-treated patients (33%) developed ARDS. Early infectious complications occurred in 30 steroid-treated patients (77%) and 18 placebo-treated patients (43%). There were no significant differences in factors predisposing to ARDS, ventilatory requirements, or days of intensive care. These results do not support the use of methylprednisolone for ARDS. Steroids failed to improve pulmonary function and were associated with an increased infection rate. Intensive pulmonary and general supportive care remain the preferred therapy for ARDS.

Cholecystectomy after tube cholecystostomy.

Seventy-nine patients with cholecystostomy tubes underwent cholecystectomies. Twenty-nine had cholecystectomies and common bile duct exploration and 50 had cholecystectomies only. The 50 who had cholecystectomies alone were compared with 50 patients who had elective cholecystectomies. The comparison defined any differences in morbidity and mortality between the two groups. Thirty-five (70 percent) of the 50 patients with cholecystostomy cholecystectomies and 34 (68 percent) of the 50 patients having elective cholecystectomies had no operative or postoperative morbidity. The cholecystostomy cholecystectomies did require more operative time, and more patients required blood transfusion. Both these differences were identified as being secondary to a more difficult operative dissection through adhesions. No differences in length of hospitalization, length of postoperative stay, or mortality were present. A cholecystostomy cholecystectomy can be performed with morbidity and mortality rates that are no different than those of an elective cholecystectomy.

Complement and the severity of pulmonary failure.

Complement-induced granulocyte aggregation is suspected as a cause of the adult respiratory distress syndrome. Quantifying the lung damage in these patients is difficult, and complement levels combined with clinical parameters of oxygenation might help define the severity of pulmonary deterioration. Forty-five high-risk patients, selected by arterial blood gas criteria, had their pulmonary insult related to C3a and C5a levels. Patients were stratified by pulmonary shunt, alveolar-arterial oxygen gradient, and radiographic findings into two categories of severity: pulmonary dysfunction, a milder insult, and ARDS, a major aberration in pulmonary function. The clinical assignment of a diagnostic category required at least 96 hours of monitoring. During this 96-hour period, multiple complement levels were obtained. These complement levels were then compared in pulmonary dysfunction and ARDS patients. ARDS patients had significantly higher C3a and C5a values after the patients were selected as high risk. These results suggest that the amount of complement activated in patients with incipient respiratory failure correlates with the severity of eventual pulmonary insult. The use of arterial blood gases and C3a and C5a levels should allow better and earlier definition of patients at risk for ARDS.