Retrospective analysis of the efficacy of open lung biopsy in acquired immunodeficiency syndrome.

Open lung biopsy (OLB) was performed on 66 patients with acquired immunodeficiency syndrome from November 1981 through December 1987. Twenty-two patients with severe respiratory failure died within a month, 3 during operation. Fourteen patients with negative transbronchial biopsy and 19 with failure of treatment based on transbronchial biopsy died within a year. Six were alive and 5 were lost to follow-up. The most common organism found in patients with severe respiratory failure was Pneumocystis carinii alone or with other pathogens. Successful therapeutic change based on OLB findings was possible in only 1 (1.5%) of the 66 patients. Open lung biopsy has limited application in the management of acquired immunodeficiency syndrome. In patients with overt pulmonary failure, OLB is invariably fatal. Those seen with suspicious lung infiltrates without risk factors or with known risk factors and negative transbronchial biopsy results might benefit from OLB. In our institution, 18 of 64 acquired immunodeficiency syndrome admissions underwent OLB in 1983, whereas in 1987, only 2 of 302 patients admitted with acquired immunodeficiency syndrome had OLB.

Aggressive management of potential penetrating cardiac injuries.

Since 1970 all patients admitted with penetrating injuries near the cardiac silhouette are transferred immediately to the operating room for resuscitation and evaluation for immediate thoracotomy. The clinical courses of 10 patients with penetrating cardiac injuries treated between 1962 and 1969 were analyzed and compared with those of 33 patients who presented between 1970 and 1977 and were managed more aggressively. Since the institution of this more aggressive policy, overall survival has improved from 20% to 67%. In patients arriving in the emergency room with signs of viability, survival increased from 29% to 76%. Of 53 patients with injuries in the area of the cardiac silhouette, 33 (62%) actually sustained cardiac injury. The high probability of cardiac injury in patients with external wounds in the silhouette and the improved survival rate seen with aggressive surgical therapy justifies the change to this policy.

Autologous blood in the treatment of intraoperative hemorrhage.

Severe hemorrhage associated with major trauma and vascular procedures is seen frequently in our operating rooms. Immediate autotransfusion has enabled us to safely and adquately correct blood losses without placing overwhelming demands on our blood bank. Since October 1973, a device capable of retrieving, filtering and reinfusing blood lost during operation has been used on 51 patients (major trauma, 20; ectopic pregnancy, 2; portacaval shunt, 9; peripheral vascular surgery, 20). From 700 to 20,000 cc's of blood were reinfused. Platelets, hematocrit, fibrinogen, free plasma hemoglobin, bilirubin, and creatinine showed no significant changes as compared to preoperative values in 39 survivors. There were 12 deaths. Eight died postoperatively as a result of their injuries, 3 of uncontrollable bleeding and one of renal failure. This study shows that autotransfusion, when used with proper operating technique, is a most satisfactory technique for restoring blood volume in severe trauma cases and elective vascular operations. This method provides a rapid, simple way of reinfusing fresh blood, free of hepatitis contamination with minimal derangement in cellular and plasma coagulation parameters.

Constant-pressure coronary artery perfusion during aortic valve operations.

We considered the theoretical differences between the normal relationships of coronary blood flow and perfusion pressure in the working heart and those obtained with continuous, steady-flow perfusion by a roller pump during aortic valve replacement. Steady pump perfusion should deliver less blood flow to the endocardium because: 1. For the same mean artery perfusion pressure, the average coronary blood flow is less with constant-flow pump perfusion. 2. With constant pump perfusion, pressure would be excessively high during systole, and during diastole it would be significantly lower than the mean perfusion pressure. Instantaneous pressure and flow were measured in the left coronary artery in 8 patients undergoing aortic valve replacement, employing either roller pump perfusion or a gravity flow system to provide a steady pressure source. Although we did not attempt to demonstrate improved endocardial flow, the mean left coronary flow was always greater with gravity perfusion (297 versus 153 ml/min), lending support to the theoretically proposed differences between the two perfusion methods.

Myocardial contractile reserve and indices of contractility.

A close examiniation of several indices of contractility derived from the ventricular pressure was made using an isolated canine heart preparation. The repsonses to single intracoronary injections of calcium chloride as well as to increasing doses of this agent were tested. From the latter, calcium dose-transient-response curves intended to reveal the extent of myocardial/contractile reserve were constructed. Indices included various extrapolations to maximal velocity of shortening at zero load, maximal value of the quotient of the first derivative and ventricular pressure, time-tension index, energy averaged power density, and power averaged rate of generation of power density. Indices were compared over the same cardiac cycles before and after administration of calcium. Most indices showed increments from 10 to 20%, except power density functions which had increments of 40 and 70%, respectively. Calcium dose-response curves were linear for most indices, but, again, the power density functions showed the steepest slopes. After severe coronary occlusion, the curves for most indices flattened and lost linearity and, presumably, this was due to loss of myocardial contractile reserve. For milder occlusions, only the power density functions showed significant flattening. The conceptual framework of a contractile myocardial reserve appears supported by these results.

Balloon catheter for endoscopic removal of foreign bodies.

A method for endoscopic removal of foreign bodies in the bronchial tree and esophagus using a balloon catheter is described.