Pulmonary dysfunction associated with streptokinase therapy.

A 66-year-old lower-extremity amputee with an acute femoral artery occlusion was treated with low-dose (10000 units/h) percutaneous constant-infusion streptokinase. At 48 hours after initiation of therapy, the patient experienced adult respiratory distress syndrome and died. A postmortem examination confirmed the diagnosis; laboratory studies reflected an increased level of fibrinolytic split products, thrombocytopenia, and a low level of fibrinogen.

Traumatic arterial injuries of the upper extremity: determinants of disability.

Of 233 patients who sustained vascular injuries during a 13 year period, 99 had involvement of the upper extremity. The primary site of upper extremity injuries was the brachial artery (43 patients), and the primary cause of injury was gunshot wounds. The majority of the vascular injuries were repaired primarily. Nerve injuries occurred in 56 of the patients, and they were the primary cause of disability. Edema and infection were not significant determinants of limitations in function. Gunshot wounds to the brachial artery resulted in the highest incidence of disability and limb loss.

Lymphocele around aortic femoral grafts simulating a false aneurysm.

A 64-year-old female treated with a Dacron aortobifemoral graft for atherosclerotic vascular disease sought medical evaluation for abdominal pain 6 months later. Studies including ultrasound, radionuclide, angiography, and CT scan suggested a diagnosis of false aneurysm. Surgical intervention subsequently confirmed the diagnosis of lymphocele.

Inhibition of beta-lactamase-induced resistance in soft-tissue infections.

Sulbactam ([CP45,899] penicillanic acid sulfone) inhibits many of the beta-lactamases commonly found to be the cause of penicillin resistance. This agent was combined with either penicillin G potassium or ampicillin sodium in the treatment of 97 patients admitted with serious soft-tissue infections. Fifty-one of the infections were caused by at least one bacteria resistant to the antibiotic alone. Staphylococcus aureus was the most common pathogen (48 isolations) followed by the coliforms (30 isolations). Ninety percent of the isolates that were tested produced beta-lactamase. Susceptibility studies showed a high degree of resistance to the penicillin alone that was significantly lowered by the addition of sulbactam. The overall clinical results showed 81% of the infections to be either well controlled or cured. Three patients failed to show improvement. Thirteen patients showed transitory increases relatively safe and efficacious in the treatment of soft-tissue infection caused by penicillin-resistant and penicillin-susceptible organisms.

Risk of infection after penetrating abdominal trauma.

To identify the risk factors for the development of postoperative septic complications in patients with intestinal perforation after abdominal trauma, and to compare the efficacies of single-drug and dual-drug prophylactic antibiotic therapy, we studied 145 patients who presented with abdominal trauma and intestinal perforation at two hospitals between July 1979 and June 1982. Logistic-regression analysis showed that a higher risk of infection (P less than 0.05) was associated with increased age, injury to the left colon necessitating colostomy, a larger number of units of blood or blood products administered at surgery, and a larger number of injured organs. The presence of shock on arrival, which was found to increase the risk of infection when this factor was analyzed individually, did not add predictive power. Patients with postoperative sepsis were hospitalized significantly longer than were patients without infection (13.8 vs. 7.7 days, P less than 0.0001). Both treatment regimens--cefoxitin given alone and clindamycin and gentamicin given together--resulted in similar infection rates, drug toxicity, duration of hospitalization, and costs.

Barbiturate therapy in the postoperative endarterectomy patient with a neurologic deficit.

Three patients awoke in the operating theater with a neurologic deficit after carotid endarterectomy with shunt under general anesthesia with either upper or lower extremity paralysis or both and evidence of a patent carotid artery confirmed by Doppler ultrasonography, B-mode real-time ultrasonography, or surgery. After confirmation of patency of the carotid artery, patients were anesthetized with thiopental (3 to 4 mg/kg) for 48 hours, with respiratory maintenance by ventilator. The therapeutic effect of barbiturates was monitored by prevention of spontaneous respiration without hypotension. All patients awoke approximately 36 to 48 hours after discontinuing the thiopental without the previously noted postoperative neurologic deficit or any adverse neurologic sequelae. At last follow-up more than 1 year postoperatively they were asymptomatic. Results of this study indicate that patients who undergo carotid endarterectomy and awake with a neurologic deficit and a patent operated vessel should be considered for barbiturate induced coma as a therapeutic modality.

Amputations after vascular trauma in civilians.

In a ten-year retrospective study of 233 patients who sustained a vascular injury to an extremity, eight (3.4%) extremities were amputated. Factors that affect the incidence of amputation after peripheral vascular trauma include early operation, fasciotomy, preoperative antibiotics, appropriate vascular reconstruction with adequate tissue coverage, use of arteriography during and after reconstruction, and early reoperation for postoperative complications. Some patients benefit psychologically and physically from early definitive amputation.

Aortic erosion by duodenal diverticulum: an unusual aortoenteric fistula.

Primary aortoduodenal fistula presenting as a diverticulum of the distal duodenum with GI bleeding may be a difficult diagnostic entity with nondiagnostic endoscopy and angiography. We have described a patient in whom diagnosis was established at laparotomy, with treatment including debridement, repair, and extra-anatomic bypass.

Severe systemic sepsis resulting from neglected perineal infections.

Eleven patients with severe necrotizing fasciitis involving the soft tissues and muscles of the perineum, abdominal wall, buttocks, and thighs were treated on the Tulane Surgical Service in New Orleans between 1979 and 1981. The etiologic factor in ten of these patients was a neglected or inadequately drained perirectal abscess. Three of the 11 patients died of the disease and ensuing multiple organ failure, for a mortality of 27%. All of the patients had signs of systemic sepsis. Initial radical debridement of all involved tissues, diverting colostomy, and aggressive medical support of the multisystem failure that ensues from sepsis are essential for successful management. To decrease the prohibitive mortality, early treatment is essential. A preventive measure appears to be operative drainage under adequate anesthesia of all perirectal abscesses.

Management of traumatic peripheral vein injuries. Primary repair or vein ligation.

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.