The role of hypovolemic stress in the production of fat embolism in rabbits. 2. Changes in arterial blood gas levels and static compliance.

The purpose of this study was to assess the possible role of hypovolemia as a factor in the production of impaired pulmonary function in pulmonary fat embolizaiton. Iv vivo static lung compliance was measured by inflating the lungs with known volumes of air and recording the transpulmonary pressure, monitoring intraesophageal pressure as an index of intrapleural pressure. Arterial blood was drawn from the central artery of the ear. Embolization was produced by the intravenous injection of homologous fat cells either as the sole experimental procedure or in conjunction with hypovolemic shock. Two types of shock were studied. In one, 20 percent of the blood volume was removed, producing hypovolemia associated with hemodilution, and in the other a tourniquet was applied to induce hypovolemia and hemoconcentration. The results indicate that embolization is associated with significantly greater impairment of pulmonary function if it develops on a background of shock than if it occurs in an otherwise healthy animal. These pathophysiologic findings parallel the results of a morphologic study.

The role of hypovolemic stress in the production of fat embolism in rabbits. 1. Morphologic alterations of the lungs.

In rabbits, an experimental model of fat embolism was produced that simulates the course of events in the clinical situation. Small doses of fat-cell suspension (0.075 ml/kg of body weight), prepared by collagenase treatment of homologous adipose tissue, were injected intravenously. Concomitantly, hypovolemia was produced in two animal groups by either withdrawing 20 percent of the estimated blood volume or by application of a hind-limb ischemic tourniquet for 90 minutes. The presence of pathoanatomic characteristics typical of fat embolism was evaluated by recording lung/body weights, macroscopic appearance, and semiquantitative microscopic estimation in the lungs of edema, hemorrhage, atelectasis, intravascular coagulation, and leukocytic thrombi. Mean indices of lung/body weight were higher in all animals receiving injections of fat-cell suspension, as compared to controls. The score for microscopic generalized pulmonary damage was significantly higher in rabbits exposed to both fat-cell injections and hypovolemia than in controls or after fat-cell injections alone. It is concluded that hypovolemia enhances the development of fat embolism in rabbits subjected to small doses of fat-cell suspension.

An investigation of the role of lactic acid production in the causation of metabolic acidosis resulting from raised intracranial pressure in rabbits.

Intracranial pressure (ICP) was acutely raised in anaesthetized rabbits by the injection of saline into the cisterna magna. The raised ICP was maintained at 200 mm Hg for 3 min after which it was allowed to return to baseline values. The profound metabolic acidosis produced (mean base deficit reaching 17.99 +/- SD 4.06 mmol/1 30 min after raised ICP) was found to be in part related to an increase in arterial blood lactate (from mean 7.04 +/- SD 3.26 mmol/l before raised ICP to mean 13.57 +/- SD 5.28 mmol/l 30 min after raised ICP). It would appear that systemic sympathetic nervous system discharge consequent upon raising ICP results in intense vasoconstriction and thus an increase in anaerobic metabolism and inorganic acid production.

Open chest cardiac massage: a review.

Open-chest cardiopulmonary resuscitation (CPR) is physiologically superior to all external CPR methods studied thus far (P. Safer, Ann. Emerg. Med., 13 (1984) 856). Open-chest CPR should again be taught to physicians, and used more often after prolonged cardiac arrest. An extensive review on open cardiac massage is presented herein.

Peroneal arteriovenous fistula. A complication of Fogarty catheter thromboembolectomy.

The Fogarty catheter is an important device used by vascular surgeons to simplify the surgical treatment of thromboembolic disorders. Complications from use of the catheter are rare. This case report is about a patient who developed a peroneal arteriovenous fistula following popliteal thromboembolectomy. The literature regarding this unusual injury is reviewed.

Vein patch angioplasty for brachial arterial occlusion after cardiac catheterization.

Brachial artery thrombosis may be encountered after cardiac catheterization using the Sones technique. Differing opinions have been reported regarding the optimal management of this injury. During the past five years, 20 patients have had surgical repair of the brachial artery after trauma from cardiac catheterization. Satisfactory results have been obtained in the majority of cases with local arterial thrombectomy and debridement with vein patch angioplasty. Arterial resection or vein bypass was needed in unusual cases. This injury should be repaired acutely to avoid long-term functional disability in all patients who present with a pulseless upper extremity.

Crohn's disease of the esophagus.

In 1932 Crohn, Ginzburg, and Oppenheimer described a distinct pathologic and clinical entity characterized by a chronic inflammatory process of unknown etiology involving the terminal ileum. Since then, Crohn's disease has been recognized in all portions of the alimentary canal from mouth to anus. Crohn's disease of the esophagus is a rare process. Such a patient is reported with a review of the literature. A review of the English literature reveals reports of 20 patients with Crohn's disease of the esophagus. One-third of these patients had regional enteritis requiring resection. Esophageal stricture, stenosis, or fistula were frequent complications requiring resection. Regional esophagitis is difficult to distinguish from carcinoma, frequently leads to esophagitis, and is associated with a higher mortality rate than Crohn's disease in other portions of the alimentary tract.

Surgical management of Crohn's disease: experience with 135 patients.

Crohn's disease may involve any portion of the alimentary tract and is being seen with increasing frequency. This report details the results in 135 patients undergoing 214 operations for Crohn's disease. There were 68 males and 67 females ranging in age from 10 to 76 years. Thirty-two per cent of patients underwent multiple operations. The recurrence rate was 53 per cent, with an average follow-up of four years. The common sites of involvement by Crohn's disease were ileocolic (36%), ileum (31%), and perianal (16%). Patients were also managed for Crohn's disease of the esophagus, stomach, and duodenum. Our patient patient with Crohn's disease of the esophagus is very unique, as only 20 such cases have been reported. Primary resection of diseased bowel with re-anastomosis is the preferred operative management. A bypass procedure was done in only four patients. The mortality rate was 2.2 per cent. The incidence of carcinoma is increased in patients with small bowel regional enteritis. A recent literature review reports 36 patients with adenocarcinoma of the small bowel affected with regional enteritis. Three of the patients developed an adenocarcinoma in association with Crohn's disease.

Unusual manifestations of brachiocephalic vascular disease.

Vascular problems involving the brachiocephalic vessels may occur from atherosclerosis, trauma, vasculitis, infection, and procedures for congenital heart disease. A wide variety of symptoms and signs may result from such disorders. This study is a report of five unusual manifestations of brachiocephalic vascular diseases. Diagnosis, management, and previous surgical experience is discussed relating to each case illustrating the complexity and variability of brachiocephalic vascular pathology.

Hematuria from arteriovesical fistula: unusual presentation of ruptured iliac artery aneurysm.

Iliac artery aneurysm rupture can be rapidly fatal if not diagnosed immediately. These aneurysms usually present in patients with other aneurysmal diseases of the aortoiliac arterial system. If not diagnosed and surgically repaired, iliac artery aneurysms can proceed to expand and ultimately rupture, usually presenting with back, flank, or abdominal pain and, possibly, signs of systemic shock. We present an unusual case report of a common iliac artery aneurysm rupture presenting as gross hematuria due to an arteriovesical fistula. Only three other cases of arteriovesical fistulae have been reported previously. Unlike the case presented, all three of these cases involved trauma or surgical instrumentation or manipulation of the bladder.

Unsuccessful control of abdominal aortic aneurysm by bypass and ligation.

Two patients developed abdominal aortic aneurysm rupture following bilateral iliac artery ligation and axillobifemoral bypass. The first patient developed his rupture several weeks after outflow ligation and apparent thrombosis of the aneurysm. At autopsy, the aneurysmal rupture occurred in the left posterior junction between the thrombosed aneurysm and the normal aorta. In the second case, the aneurysm was not completely thrombosed and plans were in progress for thrombosis of the aneurysm when the patient developed frank rupture, necessitating operative intervention. The authors await the published experience of others with bilateral common iliac artery ligation and extra-anatomic bypass for abdominal aortic aneurysm, but these authors do not currently recommend this management plan.

Anesthesia in the Yom Kippur war.

The role of the anesthetist in the treatment of battle casualties is discussed in the light of personal experience in a field hospital and in the rear during the Yom Kippur War of October 1973. Resuscitation and intensive care both before and after evacuation play an important part in reducing mortality, and the importance of providing adequate facilities for these functions in the battle area as well as at the base is emphasized.

Anaesthetic considerations in facial reconstruction for Down's syndrome.

Sixty-three patients with Down's syndrome underwent facial reconstructive surgery under general anaesthesia in order to improve their acceptability and potential for functioning effectively in society. Preoperatively, one-third of the patients had respiratory illnesses, 11 (17.5%) had cardiac anomalies, and 5 (7.9%) had endocrinological abnormalities. Anaesthesia was based on spontaneous ventilation of halothane and N2O in oxygen via an endotracheal tube with appropriate monitoring. Only one patient had an intraoperative complication, an episode of ventricular dysrhythmia, but postoperatively 9 patients required nasopharyngeal airways or endotracheal intubation in order to maintain a patent upper airway. The anaesthetic considerations for facial reconstructive surgery in Down's syndrome are discussed.

Cancer recurrent at stapled colon incision.

Recurrence of colon cancer at a stapled colotomy site separate from the anastomosis was discovered through a rising carcinoembryonic antigen (CEA). Resection resulted in cure. Exfoliation and implantation of cancer cells is discussed.