Correlation of arterial PaCO2 to end tidal CO2 in children undergoing laparoscopic abdominal surgery: An observational study.

Background and Aims: The reliability of end tidal carbon dioxide (ETCO2) as a measure of arterial carbon dioxide (PaCO2) in pediatric laparoscopy is unclear. We evaluated the correlation of arterial to end tidal P(a-ET) CO2 during pediatric laparoscopy at two hours of pneumoperitoneum as the primary objective. We also compared P(a-ET) CO2 and alveolar to arterial oxygen gradient P(A-a) O2 and haemodynamics at fixed time points during surgery. Material and Methods: A cross-sectional study was conducted in 25 children undergoing laparoscopic abdominal surgery. Arterial blood gases were drawn at T0, baseline, T10: ten minutes, T1h: 1 hour, T2h: 2 hours of pnuemoperitoneum and T 10d: 10 mins after deflation. The P(a-ET) CO2, P(A-a) O2, were measured from the blood gas and ETCO2 and FiO2 values on the monitor. The Pearson's correlation coefficient, the Wilcoxon rank test and Chi square test were used for statistical analysis. Results: At T2h moderate correlation of P(a-ET) CO2 (r = 0.605, P = 0.001) with 40% children documenting accurate P(a-ET) CO2, -1 to +1 mm Hg was seen. Moderate correlation was also seen at T0, T10, T 10d but poor correlation at T 1h. The P(A-a) O2 increased progressively with surgery and did not correlate with P(a-ET) CO2. Heart rate was stable, but systolic blood pressures at T 10 and diastolic at T10, T 1h, T 2h were higher than baseline. Conclusion: Moderate correlation was seen between PaCO2 and ETCO2 at 2 h of pnuemoperitoneum and at T0, T 10, and T 10d. P(A-a) O2 increased with surgery but did not correlate with P(a-ET) CO2.

Malignant renal tumor with extension to the inferior vena cava.

BACKGROUND: Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS: Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS: Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS: An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Livedo reticularis, rhabdomyolysis, massive intestinal infarction, and death after carbon dioxide arteriography.

In patients with renal insufficiency or hypersensitivity to iodinated contrast material, carbon dioxide gas (CO2) is generally considered a safe alternative contrast media for digital subtraction angiography. However, we herein report a previously undescribed fatal complication of CO2 angiography in a patient with acute renal dysfunction and congestive heart failure. The possible pathogenetic mechanisms of this complication are discussed.

Changing patterns of atheroembolism.

Among 1011 patients undergoing infrarenal aortic and infrainguinal vascular surgery in a 90-month period (1986-1993), 29 patients (2.9%) with clinical, angiographic and pathologic evidence of atheroembolism were identified. Over one-third (44.8%) of atheroemboli were iatrogenic and the rest spontaneous. All iatrogenic atheroemboli were precipitated by angiographic (n = 11; 84.6%) or operative manipulation (n = 2; 15.4%). The sources of emboli were in the abdominal arota (16), iliac (seven) and femoropopliteal (six) arteries. 'Trash foot' occurred in 19 patients (seven bilateral) and occlusions of tibioperoneal/digital arteries were seen in seven, renal and dermal microcirculation in two each, and calf muscles in one. Larger conduits were affected in three instances (common femoral, popliteal and in situ saphenous vein graft). The management consisted of 54 (43 surgical and 11 endovascular) procedures concurrently with thrombolytic, anticoagulant and antiplatelet therapy. Three early (10.3%) and two late (6.9%) deaths (overall mortality rate 17.2%), eight major (27.6%) and five minor (17.2%) amputations, and four (13.8%) instances of renal failure occurred in 17 patients resulting in a 58.6% complication rate. Besides initial angiography, 53 invasive procedures were required in 25 patients. Among these, 12 patients could be managed with a single definitive procedure in contrast to a group of 13 patients that required 41 (average 3.2 per patient) procedures. The incidence of foot ischemia, reoperation and amputation was higher in the spontaneous group, whereas, the iatrogenic group incurred a higher incidence of endovascular interventions, greater mortality and new onset renal failure. The high morbidity and mortality of atheroemboli demand prompt recognition and treatment, as well as attempts at prevention to achieve good results.

Preconditioning with ischemia or adenosine protects skeletal muscle from ischemic tissue reperfusion injury.

Prolonged tissue ischemia and subsequent reperfusion results in significant tissue injury due to the ischemic-reperfusion (IR) syndrome. Ischemic preconditioning (IPC) or adenosine (ADO) pretreatment are known to protect IR injury in cardiac muscle. Our aim was to determine whether IPC or ADO pretreatment attenuates and protects against ischemic tissue reperfusion injury in skeletal muscle. Rats were anesthetized and global hindlimb ischemia was induced by 60 min of suprarenal aortic clamping followed by 30 min of reperfusion period. The degree of skeletal muscle dysfunction was determined by decreases in maximum contractile force, and adenosine triphosphate (ATP) and creatine phosphate (CP) levels of extensor digitorum longus (EDL) muscle. The distal tendon of the EDL was attached to a force transducer for maximum isometric force measurement. Samples were taken from the EDL for measurement of ATP and CP levels. The following were protective protocols prior to the IR challenge: (1) four consecutive 5-min periods of ischemia separated by 5-min reperfusion periods (PC/I) or (2) i.v. adenosine infusion (350 microg/kg/min x 10 min, PC/A). Our data suggest that pretreatment with brief periods of ischemia or systemic ADO infusion attenuates ischemic tissue reperfusion injury in skeletal muscle. [Table: see text]

Popliteal vein compression due to popliteal artery aneurysm: effects of aneurysm size.

Unlike the venous compression associated with larger popliteal artery aneurysms, which frequently is associated with deep vein thrombosis, the venous compression caused by the moderate sized (greater than 2 cm and less than 3 cm) aneurysms in the reported cases is not associated with thrombosis. The extrinsic compressive effect of these moderate sized popliteal artery aneurysms on the adjacent vein is shown to vary with the patient's leg position. Three of the four patients with unilateral leg swelling discussed here had bilateral popliteal artery aneurysms. In these cases, the contralateral leg had a small popliteal aneurysm (less than 2 cm) and no leg swelling was present. The cases suggest that popliteal artery aneurysm size is an important factor in determining the type of venous obstruction that results from the extrinsic compression of the ipsilateral popliteal vein. The described phenomenon of a popliteal artery aneurysm having the effect of restricting flow in the ipsilateral popliteal vein must be included as a differential diagnosis among the causes of unilateral leg swelling in the absence of deep vein thrombosis.

Developing decentralized capacity for disaster prevention: lessons from food security and nutrition monitoring in Malawi.

Lack of sufficient analytical capacity in most of the countries of sub-Saharan Africa has been frequently mentioned as a major factor limiting the effectiveness of drought management interventions. In this article we describe an approach used in Malawi for the past three years to develop a decentralized capacity to analyse drought management and disaster prevention programmes. A conceptual framework is presented which identifies the areas in which capacity strengthening is required and lessons from the Malawi experience are presented. Various issues relating to the efficiency of capacity building programmes are discussed. We argue that continuous dialogue between development researchers and decision-makers, and between trainers in academic institutions and donor agencies, is essential for achieving the goals of improved capacity for drought management and disaster prevention.

Acute aortic occlusion--factors that influence outcome.

PURPOSE: The purpose of this study was to report our experience in the management of acute aortic occlusion and to analyze factors that influenced the outcome. METHODS: This was a retrospective analysis of 48 patients with acute aortic occlusion treated over a 19-year period. Presentation included limb ischemia in 34, acute abdomen in four, spinal cord compression-like symptoms in eight, and sudden onset of hypertension in two patients. Thrombosis was the cause of acute aortic occlusion in 44, and embolus in four patients. Acute thrombosis was associated with underlying atherosclerotic occlusive disease in 36 patients. In these, thrombosis was due to low-flow state caused by cardiac dysfunction or severe volume depletion. Thrombosed aneurysms caused aortic occlusion in two patients. Hypercoagulable state caused thrombosis of relatively normal aorta in six patients. Angiography in 39 patients revealed occlusion to be juxtarenal or infrarenal in 37 and suprarenal in two. Left ventricular function (LVF) was assessed in 42 patients. Circulation was restored in 45 (aortofemoral bypass in 22, axillofemoral bypass in 12, and thromboembolectomy in 11). This was not feasible in three patients. Additional surgical procedures were required in 29 patients (64%). RESULTS: The overall mortality rate was 52% (25 of 48). Of the 20 patients with severely compromised LVF, 17 died (85%). In contrast, only five (23%) deaths occurred among 22 with good LVF. Among 29 patients who required additional operations, 18 died (62%). All four patients with embolic occlusion survived. Patients with normal LVF but hypercoagulable state had dismal outcome--only one of the six survived. CONCLUSIONS: Acute aortic occlusion is infrequent. Presentation may be varied, thus delaying diagnosis. Poor LVF, thrombosis of arteries below the inguinal ligament or of visceral arteries, and "hypercoagulable state" portend ominous prognosis.

Agricultural productivity, seasonality and gender bias in rural nutrition: empirical evidence from south India.

This paper analyzes changes in the nutrients intake, intra-household allocation and gender bias due to changes in agricultural productivity among four groups of rural households over six different seasons. The study utilizes household survey data collected from a village in Tamil Nadu, India. While the results are consistent with earlier findings that seasonality influences variation in the intake of nutrients, it is shown that subsistence agricultural households recover faster from poor crop yields than market oriented agricultural households in terms of nutrient intake. Agricultural labour households consumed lowest quantities of energy and protein in all the seasons with the highest degree of gender bias. The gender bias is more in terms of protein intake compared to energy intake for all the households. The non-agricultural households are least affected due to variability in crop yields and seasonality. While nutritional intake of the rural households is positively correlated with crop yields, the variations in yields worsen the gender bias. It is argued that reducing dependency of rural households on agriculture may reduce malnutrition and the gender bias associated with it.

Celiac territory ischemic syndrome in visceral artery occlusion.

Abdominal angina that is characterized by postprandial pain, and often associated with weight loss, is a well-recognized symptom complex of mesenteric artery insufficiency (mesenteric territory symptoms). In the past 5 years, we have observed six patients with atypical symptoms who had mesenteric artery occlusion combined with stenosis or occlusion of the celiac artery. Atypical symptoms included severe nausea and vomiting at the sight or smell of food, anorexia, weight loss, and right upper quadrant or epigastric discomfort (celiac territory symptoms). An extensive work-up to rule out gastric, pancreatic, biliary, or colonic pathology was undertaken in these patients. The findings included gallbladder dysfunction, diffuse micro-ulceration of gastric mucosa, and colonic mucosal ulceration. The diagnosis of visceral artery occlusion was initially missed in all six patients. Four patients had cholecystectomy. Visceral angiography confirmed occlusion of the celiac, superior, and inferior mesenteric arteries. Five patients had dramatic resolution of symptoms after restoration of visceral circulation. One patient who developed intestinal infarction before revascularization died. Symptoms suggesting upper abdominal visceral pathology may be a manifestation of celiac artery stenosis/occlusion coexisting with mesenteric artery occlusive disease. Visceral angiography should be part of the work-up in these patients for early diagnosis and prompt management.

The clinical utility of carotid duplex scanning.

We retrospectively compared the results of duplex scanning (DS) with contrast angiography (CAN) in the evaluation of 119 patients whose 238 carotid arteries were evaluated by both methods within a four-week period. The results of all patients were then categorized by two different definitions of severity of stenosis. Category A classified 1-29% stenosis as mild, 30-69% stenosis as moderate, and 70-99% diameter reduction as severe stenosis. Category B defined mild stenosis as 1-19% lumen diameter reduction, moderate as 20-49% stenosis, and severe as 50-99% stenosis. The findings by each classification were compared in 60 patients with hemispheric symptoms and in 59 patients with nonspecific symptoms. CAN was our "gold standard", and exhibited greater sensitivity, specificity, accuracy, and predictive values than DS. Carotid arteries with 70% stenosis were identified by DS with greater specificity, accuracy, and predictive values than were arteries with 50% stenoses. Only the sensitivity was comparable in categorizations A and B (80% and 83%). All parameters of measurement were superior in patients with hemispheric symptoms. DS alone cannot substitute for CAN in selecting patients for carotid endarterectomy because its error rate exceeded acceptable rates of complications for carotid artery surgery. The false positive rate of DS was 4%. DS failed to diagnose 7 of 19 carotid artery occlusions, 9 of 11 ulcerated plaques, 7 of 119 instances of aortic arch disease, and 13 cases of severe intracranial artery stenosis.

Use of the centrifugal flow pump for vena caval shunting.

We have used the Bio-Medicus centrifugal flow pump for vena cava shunting during surgical resection of renal cell carcinoma with extension of the tumor into the inferior vena cava. The active shunt can provide optimal blood return to the heart to promote hemodynamic stability, help provide an isolated field for resection of the involved kidney and its tumor extension into the vena cava, and avoid use of full-dose heparin to minimize blood loss in this extensive operation.

Doppler sonographic demonstration of the progressive spontaneous thrombosis of pseudoaneurysms.

In three patients with diagnosed pseudoaneurysms, surgical intervention was delayed because of the patients' clinical condition. In successive follow-up examinations in one patient, development of a new lobe to the previously single-lobed pseudoaneurysm was noted with progressive centripetal thrombus formation in each lobe leading to the eventual complete thrombosis of the pseudoaneurysm without surgical intervention. The sequence of steps leading to the complete thrombosis of the pseudoaneurysm as seen by color Doppler and pulsed Doppler examination is described. In two other patients with a single-lobed and a multilobed pseudoaneurysm, respectively, follow-up examinations without surgical management revealed complete thrombosis of the pseudoaneurysms. Whereas traditional teaching holds that pseudoaneurysms require surgical repair, this short series of cases suggests that, when progressive centripetal thrombus formation is observed, the pseudoaneurysms can go on to complete thrombosis. Follow-up for up to 4 months reveals no sonographic evidence of rebleeding or other evidence of weakness in the arterial wall at the site of the previous pseudoaneurysms.

Doppler diagnosis of partial vertebral/subclavian steals convertible to full steals with physiologic maneuvers.

Subclavian steal syndrome has been classically described as a unidirectional phenomenon in which retrograde flow occurs in the ipsilateral vertebral artery in cases of high-grade proximal subclavian stenosis. Pulsed Doppler examination in cases of subclavian stenosis shows that partial steals with to-and-fro flow do occur. A model based on fluctuating pressure gradients to explain the partial steal phenomenon is discussed. The usefulness of physiologic maneuvers such as ipsilateral arm exercise and postocclusive hyperemia in converting partial steals to full steals is demonstrated. In cases in which surgical bypass to correct partial steals is carried out, a relative steal can be demonstrated by Doppler examination before and after physiologic maneuvers.

Incidence and results of arterial complications among 16,350 patients undergoing cardiac catheterization.

A total of 16,350 patients underwent cardiac catheterization from January 1981 to December 1987. The brachial artery was used in 10,500 patients (group I), and the femoral artery was used in 5850 patients (group II). Surgical intervention for complications was necessary in 60 (0.57%) of the group I patients and in 14 (0.23%) of the group II patients. Hand ischemia in group I and bleeding in group II were the most frequent indications for operation. Procedures performed were segmental resection, vein interposition, and long bypass in group I, and simple suture and angioplasty were performed in group II. Fifty-six patients of the total of 74 underwent early repair (within 48 hours), and 18 patients underwent delayed intervention. Only one (1.7%) of the 56 patients who had early repair had a complication. Five of the 18 patients (28%) with delayed intervention suffered significant complications. Cardiac catheterization by the brachial or femoral route has a low incidence of complications. Delayed intervention is associated with high morbidity despite adequate restoration of circulation. Although there were fewer complications in the femoral group, they were far more serious with respect to life- or limb-threatening events.

Liver abscess following superior mesenteric artery revascularization for acute mesenteric ischemia.

A case of pyogenic liver abscess following successful mesenteric artery revascularization is described in a patient with acute mesenteric ischemia. Prior to revascularization, arteriography confirmed celiac and superior mesenteric artery occlusion. Occurrence of liver abscess is explained on the basis of ischemia impairing the barrier function of the intestinal mucosa, contributing to portal bacteremia that seeds ischemic or necrotic liver. In patients with acute mesenteric ischemia, sequential sonographic examination of the liver following mesenteric revascularization is advocated for early diagnosis of liver abscess if there is clinical evidence of the sepsis.

Socioeconomic impacts of school feeding programmes: empirical evidence from a South Indian village.

PIP: Tamil Nadu a poverty-stricken rural community in South India, funds a school feeding program with about 10% of the state budget. Comparisons of nutrition and literacy show that they are significantly related. No studies have yet been performed to analyse the effect of the feeding programs on aspects of a household's economic and social welfare. The feeding program in Tamil Nadu extends throughout the year, 7 days a week. It provides not only a reason for children to attend school, but also employment opportunities for those who wish to cook. 455 households were surveyed from 1 village using. A Gini coefficient of inequality to determine inequality levels of nutrition, food, and consumption expenditure. Sen's index of poverty was used to calculate the reduction in poverty levels. 3 household groups were defined: the agricultural labor, the silk weaver, and the cultivator. Linear program modelling utilized these 3 groups to study the total effect of nutrition on education. Linear regression was then used to determine the effect of the feeding program on participation in school. At the village level, a reduction of inequality in consumption and intake, an increase in energy intake, and a decrease in poverty level were found. In agricultural labor and silk weaver households, most of the money was spent on cereal food grains and children were mostly uneducated. If modelled to assume that children must be educated and are educated in schools providing food, results suggest that the increase in nutrition helps retain the children in the schools. Cultivator household response to the food programs was poor, since they usually have enough money to meet nutritional needs. Household income and school nutrition, but not adult literacy affect school participation. In general, nutrition offered in school caused a subsequent increase in household purchases of non-cereal items in the first 2 household types.^ieng

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.