Management of vascular prosthetic infections: results of long-term follow-up.

An infected vascular prosthesis is a risk to life and limb, with many of the infections insidious in nature. A retrospective analysis with a minimum 49-month follow-up identified 18 patients (mean age, 61.3 years) with culture-positive infections and exposed prosthetic grafts in the infrainguinal region. All patients were managed with muscle flaps. Mean follow-up was 59 months, with a long-term salvage of infected prosthetic grafts in 16 of 18 patients; there was no loss of life or limb. Early, aggressive reconstruction of infected prosthetic grafts using a muscle flap technique saves graft, leg, and patient.

Sociology of care in patients with severe peripheral vascular disease.

Peripheral vascular disease (PVD) remains a leading cause of limb amputation, resulting in a significant morbidity and disability. This study was undertaken to evaluate whether earlier referral of the patients with severe limb-threatening PVD to a vascular surgeon could result in a higher limb-salvage rate. Seventy-one consecutive patients, 48 men and 23 women, with mean ages of 67.1 and 70.4 years, respectively, were studied; there were 64 blacks (42 men, 22 women). Risk factors included smoking (39 men, 20 women) and diabetes mellitus (31 men, 11 women). The delay in seeking medical attention in patients with rest pain was 9 to 24 weeks (mean, 14.2), and with nonhealing ulcers the delay was 4 to 20 weeks (mean, 6.7). An additional delay of 11.7 weeks was noted if the patient was seen by a primary-care physician, and only 4 weeks if the patient was seen in the Emergency Department. Ten primary amputations were performed; 61 patients underwent limb-salvaging revascularization procedures, with a success rate of 87 per cent; 8 patients had below-the-knee amputation as a result of failed bypass. Delay in referral of patients with severe PVD can cause an increase in limb loss.

Pathophysiologic plasma levels of leukotriene C4 in relation to the hemodynamic dysfunction and mediator release of graded bacteremia.

This study was undertaken to identify those events of bacteremic shock that pathophysiologic levels of leukotriene C4 (LTC4) alone were sufficient to cause. Sixteen adult swine were studied for 4 h in three groups: ANES (n = 6) received anesthesia only; Septic (n = 6) received Aeromonas hydrophila, 10(9)/mL, intravenously, increased incrementally from .2 to 4.0 mL/kg/h; LTC4 (n = 4) received LTC4 infused intravenously, at rates that approximated LTC4 levels of Septic animals. Measurements included mean arterial pressure and arterial PO2, mmHg, pulmonary and systemic (SVRI) vascular resistance indexes, cardiac index (CI), oxygen extraction ratio, hematocrit; thromboxane B2 (TxB2), prostaglandin 6 keto F1 alpha (6 keto), leukotrienes B4 and C4D4E4, and tumor necrosis factor were measured in pg/mL by ELISA. Statistical analysis was performed by ANOVA and general linear model). Mean arterial pressure increased from 100 +/- 5 to 141 +/- 9 in the LTC4 group, but decreased in the Septic group from 90 +/- 7 at baseline to 62 +/- 6 at 3 h. In the LTC4 group, SVRI did not differ from ANES, and pulmonary vascular resistance, PO2, and CI did not change from baseline. In the LTC4 group, TxB2 and 6 keto levels decreased from 149 +/- 26 to 87 +/- 18 and 58 +/- 10 to 44 +/- 12, respectively; in the Septic group, TxB2 increased 140-fold and 6 keto increased 60-fold. Pathophysiologic LTC4 is not sufficient alone to cause the derangements in CI and SVRI, and tissue metabolism induced by graded bacteremia. Significantly increased systemic blood pressure suggests that endogenous pathophysiologic LTC4 may be involved. LTC4 does not increase plasma eicosanoids and tumor necrosis factor, but may down-regulate prostaglandin and leukotriene release.

Is the incidence of hemorrhagic stress ulceration in surgical critically ill patients affected by modern antacid prophylaxis?

Hemorrhagic stress ulceration (HSU), a known complication in the Surgical Intensive Care Unit (SICU) patient population, has a reported incidence rate of 25 to 75 per cent. The goal of this study was to evaluate whether the use of prophylactic antacid agents significantly reduced the frequency of HSU in critically ill patients, or whether improved care reflected the decrease in HSU. A total of 425 consecutive patients were reviewed for occurrence of HSU; of these, 304 were eligible for the study. Admitting diagnoses were trauma including head injury, postoperative patients, and patients with surgical complications. Inclusion criteria were length of stay in the SICU for at least 48 hours; antral gastric pH subsequently measured every 6 to 8 hours and maintained at > or = 4; and absence of the history of peptic ulcer disease or gastrointestinal bleeding. One group included 251 (83%) patients who were started on prophylactic agents (H2 blockers with or without antacids); the second group of 53 (17%) patients had no prophylaxis. The Injury Severity Score on admission to the SICU was 27.5 +/- 7.5, Apache II score was 26.4 +/- 6.4, and Revised Trauma Score was 4.3 +/- 2.3, with no difference in severity (P < 0.05). Thirteen (4%) patients were found to have evidence of HSU: 11 of 251 (4%) in the first group and 2 of 53 (4%) in the second. No statistically significant difference was found in the incidence of HSU between the two groups (P = 0.86). Results of this study suggest that modern prophylaxis for HSU did not significantly alter the incidence of stress ulceration in SICU patients.

Nd:YAG laser scalpel compared with conventional techniques in head and neck cancer surgery.

Many theoretical advantages over conventional surgical techniques have been attributed to the Nd:YAG contact laser. Clinically significant differences in perioperative results between the Nd:YAG contact laser and standard surgery, however, are not well defined. The present study was undertaken to evaluate the Nd:YAG contact laser compared with standard scalpel and/or electrocautery in curative operations for head and neck cancer. Clinical records of 36 patients undergoing head and neck cancer surgery were reviewed retrospectively. Patients were studied in three groups: 9 previously irradiated patients operated upon using the Nd:YAG laser (Nd:YAG); 9 previously irradiated patients operated upon using conventional techniques (conventional/RT); 18 nonirradiated patients operated upon using conventional techniques (conventional/no RT). These groups underwent 14, 14, and 25 procedures, respectively. Differences between the Nd:YAG, conventional/RT, and conventional/no RT groups regarding cancer staging, age, procedures performed, operative time, intraoperative blood loss, and hospital and ICU stay were not statistically significant. Preoperative radiotherapy dosages in the Nd:YAG and conventional/RT groups were similar (5,127 +/- 842 vs. 604 +/- 2,373 cGy). Postoperative morbidity in Nd:YAG patients (11%) was similar to that of the conventional/no RT group (17%) and was significantly reduced compared to conventional/RT (11% vs. 56%, P < 0.05). Clinical outcome, including operative time, blood loss, and hospital and ICU stay using the Nd:YAG contact laser in curative operations on previously irradiated patients with head and neck cancer, is equal to that of conventional surgical techniques, with or without preoperative radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)