Reduction of catheter-associated thrombosis in parenteral nutrition by intravenous heparin therapy.

A prospective trial was carried out to test the hypothesis that therapy with intravenous (IV) heparin sodium reduces the incidence of thrombotic complications related to the use of central venous catheters for parenteral nutrition. The patients studied were randomly allocated either to a group given heparin sodium, at a dosage of 5,000 IU/6 hr, or to a control group that received no heparin prophylaxis. The heparin group comprised 23 catheter periods (22 patients), and the control group 26 catheter periods (25 patients). In five of the 23 catheters in te heparin group and 14 of the 26 in the control group, catheter phlebography revealed thrombus formation in association with the catheter when this was removed. The results indicated that the use of IV heparin as prophylaxis against thrombosis reduced the risk of thrombus formation on the central venous catheter.

Lumbosacral epidurography and computed tomography. A preliminary report.

A method for the diagnosis of disc herniation and nerve root compression in the lower lumbar and upper sacral spine is presented. Computed tomography of the spine was carried out after injection of a positive contrast medium into the epidural space. Preliminary results indicate a high diagnostic accuracy.

Photographic subtraction. I. Theory of the subtraction image.

The purpose of subtraction of angiographic images is to demonstrate the vessels free of superimposed, disturbing image noise. With the aid of physical film parameters the theoretic basis for an optimum subtraction technique is presented.

Specific filtration of the primary radiation in computed tomography.

Specific filtration with yttrium of the primary radiation on a Somatom 2 whole body scanner will improve the relationship absorbed dose/information in terms of contrast resolution while spatial resolution will be only marginally affected.

Diagnosis of thrombosis by catheter phlebography after prolonged central venous catheterization.

Sixty central venous catheterizations in 53 patients were prospectively studied with respect to phlebographic findings after prolonged parenteral nutrition. Phlebography was performed by a special technique on completion of the intravenous therapy. Under fluoroscopic control, the central venous catheter was slowly removed, while simultaneously contrast medium was continuously injected through it. Two types of thrombosis were demonstrated--sleeve thrombosis, on 25 occasions (42%), and mural veno-occlusive thrombosis, on five occasions (8%). On removal of the catheter the sleeve thrombosis peeled off the catheter and in several cases it was noticed that parts of the sleeve thrombus or the entire sleeve became detached and were carried away with the blood flow. Although the sleeve thrombus seldom gave rise to any symptoms, this type of thrombosis is of great importance in view of the risk of pulmonary embolism, especially in connection with removal of the catheter. With use of the described phlebographic technique thrombi of this type can be visualized.

Photographic subtraction. II. Technical aspects and method.

Technical aspects of photographic subtraction of original films in black and white and blue and white (Medichrome) under standard development conditions available in any roentgen unit are described. The adjustment necessary to control the gamma-value of the masking film takes advantage of the capacity of some graphic films to respond with different gamma-values on variation of the color of the exposure light.

Bacteriology and phlebography in catheterization for parenteral nutrition. A prospective study.

A total of 42 central venous catheterizations in 32 patients were subjected to a prospective study with respect to bacteriologic and thrombotic complications. Growth of bacteria was found in blood cultures in 3 cases (7%) and in cultures from catheter tips in 15 cases (36%). In 25 cases (59%) phlebography revealed partial or complete thrombosis of the central vein. In 7 cases phlebography could not be performed because of blockage of the catheter (5 cases) or thrombophlebitis (2 cases). There was no relationship between bacteriologic and thrombotic complications. The frequency of bacteraemia is in agreement with earlier observations whereas the frequency of catheter-related thrombosis is much higher. This might be due to the fact that phlebography was performed at the time of catheter removal. The presence of catheter-related thrombosis is potentially hazardous as a source of microembolism. Prophylactic anticoagulant therapy in long-term catheterizations for parenteral nutrition is therefore suggested.

The catecholamine concentration in central veins of hypertensive patients--an aid not without problems in locating phaeochromocytoma.

The concentrations of adrenaline, noradrenaline and cortisol in blood sampled at routine attempts at catheterization of the adrenal and renal veins, the inferior vena cava and the azygos and hepatic veins were measured in six patients with a phaeochromocytoma and six patients with hypertension due to other causes. In the non-tumour patients the adrenaline and noradrenaline concentrations, compared with normal values for peripheral venous blood, were abnormally high in five out of seven samples from the site of the left adrenal vein but in only one out of seven from the right side. In all the adrenal vein samples with an abnormally high catecholamine concentration the cortisol level was also elevated, and it was at least 100 per cent higher than in samples from the inferior vena cava. This suggests that a high catecholamine concentration linked with an elevated cortisol level is merely an indication of correct adrenal vein sampling and is not necessarily evidence of a tumour. In successful attempts of sampling adrenal venous blood (cortisol levels increased), concentrations of adrenaline and noradrenaline of up to 100 and 20 nmol/l, respectively, can be regarded as normal. From a retrospective analysis of catecholamine levels in the six tumour patients it is clear that owing to the variability of venous drainage from the right adrenal gland, the technique of adrenal venous blood sampling may be unreliable and even misleading in attempts to locate a phaeochromocytoma. This is also true in patients with generally elevated catecholamine levels.

Angiography and scintigraphy of human pancreatic allografts.

Serial graft angiographies and scintigraphies were obtained in 4 human pancreatic allograft recipients. Important information was obtained both of graft morphology and function. Graft rejection was accompanied by characteristic abnormalities, including arterial irregularities and prolonged contrast medium passage time. On scintigraphy, rejection was associated with reduced isotope uptake.

Pancreatic transplantation for diabetes mellitus. Discussion of indications and surgical technique with reference to 3 cases.

Three patients reveived segmental pancreatic transplants. In two the main indication was hyperlabile diabetes, and in the third progressive loss of vision. Vascular anastomoses were to the iliac vessels, the graft being placed extraperitoneally. The pancreatic duct was ligated in the first case, while the other two, the transected end of the pancreatic graft was implanted into a jejunal Roux-Y loop. Two of the patients had normal blood glucose levels without insulin administration for 40 and 35 days, respectively. The grafts then underwent rejection and were removed. In both cases the postoperative course was complicated by pancreatic fistulae. In the 3rd patient the graft failed on the day after operation, due to venous trombosis.

Rejection of isolated pancreatic allografts in patients with with diabetes.

Four patients with diabetes mellitus of juvenile onset but without uremia have been treated with segmental transplantation of the body and tail of pancreas. The indications were hyperlabile diabetes or progressive loss of vision. The grafts were procured from cadaveric donors four to 16 minutes after circulary arrest and were subsequently stored in the cold for approximately four hours. In one patient, the pancreatic duct was ligated, while in the other three, drainage was attained by suturing the transected end of the pancreas into a jejunal Roux-en-Y loop. Three of the grafts failed within six weeks as a result of irreversible refection, and one graft failed because of the early onset of venous thrombosis. The first sign of graft rejection was an increase in the postprandial blood sugar level, an increase in the fasting blood sugar level occurring several days later. Neither hyperamylasemia nor fever was observed. Radioisotope scans and angiograms were of great value in establishing the diagnosis of graft rejection. All of the patients survived after graft removal.