Intractable obstructive shock as a result of isolated cardiac metastases: a case report.

Cardiac metastases are uncommon and difficult to diagnose clinically; thus, they are most often found only at autopsy. Here we present a case of isolated right atrial cardiac metastasis found 7 weeks after the resection of the primary tumor, which was an adenocarcinoma of the lung. The patient presented with intractable obstructive shock, caused by a ball-valve effect of the atrial lesion that prevented forward blood flow from the right atrium. Computed tomography (CT) scans and echocardiograms failed to detect the lesion, and the patient died 2 weeks later. An autopsy revealed a large, isolated right atrial metastatic adenocarcinoma.

The duration of antibiotic administration in penetrating abdominal trauma.

BACKGROUND: The epidemiology of penetrating abdominal trauma is changing to reflect an increasing incidence of multiple injuries. Not only do multiple injuries increase the risk of infection, a very high risk of serious infection is conferred by immunosuppression from hemorrhage and transfusion and the high likelihood of intestinal injury, especially to the colon. Optimal timing and choice of presumptive antibiotic therapy has been established for penetrating trauma, but duration has not been studied extensively in such seriously injured patients. The purpose of this study was to test the hypothesis that 24 hours of antibiotic therapy remains sufficient to reduce the incidence of infection in penetrating abdominal trauma. METHODS: Three hundred fourteen consecutive patients with penetrating abdominal trauma were prospectively randomized into two groups: Group I received 24 hours of intravenous cefoxitin (1 g q6h) and group II received 5 days of intravenous cefoxitin. The development of a deep surgical site (intra-abdominal) infection as well as any type of nosocomial infection, as defined by the Centers for Disease Control and Prevention, (ie, surgical site infections, catheter-related infections, urinary tract, pneumonia), was recorded. Hospital length of stay was a secondary endpoint. Statistical analysis included chi-square tests for coordinate variables and two-tailed unpaired t tests for continuous variables. The independence of risk factors for the development of infection was assessed by multivariate analysis of variance. Significance was determined when P <0.05. RESULTS: Three hundred patients were evaluable. There was no postoperative mortality, and no differences in overall length of hospitalization between groups. The duration of antibiotic treatment had no influence on the development of any infection (P = 0.136) or an intraabdominal infection (P = 0.336). Only colon injury was an independent predictor of the development of an intraabdominal infection (P = 0.0031). However, the overall infection incidence was affected by preoperative shock (P = 0.003), colon (P = 0.0004), central nervous system (CNS) injuries (P = 0.031), and the number of injured organs (P = 0.026). Several factors, including intraoperative shock (P = 0.021) and injuries to the colon (P = 0.0008), CNS (P = 0.0001), and chest (P = 0.0006), were independent contributors to prolongation of the hospital stay. CONCLUSIONS: Twenty-four hours of presumptive intravenous cefoxitin versus 5 days of therapy made no difference in the prevention of postoperative infection or length of hospitalization. Infection was associated with shock on admission to the emergency department, the number of intra-abdominal organs injured, colon injury specifically, and injury to the central nervous system. Intra-abdominal infection was predicted only by colon injury. Prolonged hospitalization was associated with intraoperative shock and injuries to the chest, colon, or central nervous system.

Educational needs among pediatricians regarding caring for terminally ill children.

BACKGROUND: According to the Accreditation Council on Graduate Medical Education and the Ambulatory Pediatrics Association, pediatricians need to be instructed in caring for terminally ill children as a part of residency training. However, a systematic approach to education in end-of-life care is lacking in most residency programs. OBJECTIVES: To assess pediatricians' self-perception of their coping skills regarding death and dying at The New York Hospital-Cornell Medical Center, New York City, NY, if they felt further support and education were needed in this area, and which modes of instruction respondents thought would be most useful. METHODS: Data based on a questionnaire distributed to pediatricians at The New York Hospital are presented. RESULTS: The following topics are discussed: (1) existing level of education and support in caring for terminally ill patients; (2) attitudes of pediatricians regarding discussions of diagnosis and prognosis with dying children and their families; (3) pediatricians' perceived need to limit emotional involvement with terminally ill children; (4) attendance of funeral or memorial services of patients by pediatricians; (5) experience of patient death as a failure; and (6) expressed need for support and instruction in death and dying based on level of training. CONCLUSION: Educational interventions and support in this area are needed.

Management of penetrating juxtahepatic inferior vena cava injuries under total vascular occlusion.

BACKGROUND: Juxtahepatic inferior vena cava injuries are often lethal. Various operative strategies have been used to improve outcome, but the mortality rate reported in the literature is 80 percent or more. The atriocaval shunt has been advocated for isolation of bleeding retrohepatic vena cava, but recent reports suggest that mortality might be even higher in patients selected for shunting, perhaps owing to ongoing hemorrhage because of indecision and delay prior to insertion, or to technical difficulty with insertion. A series of patients with juxtahepatic inferior vena cava injuries treated successfully with total vascular isolation and occlusion were studied. STUDY DESIGN: Consecutive series of 10 patients with penetrating injuries to the juxtahepatic inferior vena cava were treated at an urban, university-affiliated Level I trauma center. A rapid and direct approach was used along with isolation techniques similar to those used in liver transplantation and elective resection for neoplasm. As resuscitation continued, repair of the inferior vena cava was accomplished in a bloodless field, created by manual compression of the liver, wide exposure, portal inflow occlusion, and proximal and distal control of the inferior vena cava. Aggressive fluid resuscitation and transient aortic cross-clamping controlled resulting systemic hypotension. RESULTS: Mean injury severity score was 26 and mean penetrating abdominal trauma index score was 28. After exposure, three patients had tangential injuries controlled by undersewing a partially occluding clamp. Subdiaphragmatic aortic cross-clamping was performed if total occlusion of the inferior vena cava reduced systolic blood pressure to 60 mm Hg, which was necessary in the remaining seven patients. Nine patients survived surgery, and seven of nine survived to hospital discharge. One postoperative death was a result of multiple organ dysfunction syndrome, and the other of necrotizing bacterial pneumonia. CONCLUSIONS: Total vascular occlusion with selective use of aortic cross-clamping yielded 70 percent survival in an injury that historically has been associated with survival of 20 percent or less. Minimization of visceral ischemia is accomplished by occluding the aorta only after complete isolation of the inferior vena cava.

Hepatic duct transection during laparoscopic cholecystectomy.

A rare anatomical variation was encountered during a laparoscopic cholecystectomy. The right hepatic duct emptied into the infundibulum of the gallbladder. This confluence then joined the left hepatic duct to form the common bile duct. The right hepatic duct was transected between the gallbladder and the common bile duct as a normal cystic duct would have been isolated and divided laparoscopicaly. This anatomic variant was recognized after further mobilization of the gallbladder from the liver bed. A laparotomy was performed to create a right hepatic duct enteric anastomosis. The case illustrates one possible pitfall that may be encountered during laparoscopic cholecystectomy.

The role of intra-aortic balloon occlusion in penetrating abdominal trauma.

Intra-aortic balloon occlusion (IABO) of the thoracic aorta was attempted in 21 consecutive hemodynamically unstable patients with missile injuries of the abdomen. Retrospectively, the patients fell into three groups. Group One consisted of five patients with a cardiac rhythm but no recordable blood pressure (BP). Group Two were six patients with refractory hypotension, that is, BP of 80 torr systolic or less. Group Three comprised ten patients who had hemodynamic deterioration to a BP of 80 torr systolic or less during preparation for or in the course of celiotomy. IABO was successful in occluding the thoracic aorta in 20 patients with a resultant rise of BP; one patient required thoracotomy for aortic clamping. Operative control of hemorrhage was accomplished in 11 patients; seven patients survived and were discharged in a functional status. There were no survivors in Group One, three in Group Two, and four in Group Three.

Multiple granular cel tumors of the gallbladder and biliary tree. Report of a case.

Granular cell tumors are benign lesions that usually appear in the skin, oral activity, and mucous membrane. Occasionally, they will appear in visceral organs, and cause signs and symptoms similar to those of other organ-related diseases. We studied a patient with granular cell tumors of the common bile duct whose clinical appearance mimicked that of cholecystitis with cholelithiasis. Recognition of granular cell tumors on frozen section will allow surgical resection with probable cure.

Open diagnostic peritoneal lavage in blunt trauma victims.

Open diagnostic peritoneal lavage was 97.8 per cent accurate for diagnosis of intra-abdominal injury in 2,072 blunt trauma victims. The only significant injuries missed were in certain patients with a ruptured hemidiaphragm, renal trauma and extraperitoneal bladder rupture. However, these injuries were identified by other means. False-postive lavage results are generally a consequence of technical error and can be minimized by careful surgical technique. Hemoperitoneum must be explained for all patients to prevent needless morbidity and mortality. Only diagnostic tests of proved value in blunt abdominal trauma should be used and risk to the patient must be minimized. We currently rely upon diagnostic laparotomy to evaluate hemoperitoneum in patients with a weakly positive lavage result confirmed by a second infusion. With this policy, approximately one of every four to five laparotomies was for injuries not requiring surgical therapy; and, the over-all morbidity rate and mortality was 12 and 3.5 per cent, respectively, in this group. By using open diagnostic peritoneal lavage in essentially all blunt trauma victims, we have had no deaths from either unrecognized intra-abdominal injury or delayed treatment.

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula: complications of delayed treatment of a penetrating abdominal injury (case report).

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula complicated delayed treatment of an abdominal gunshot wound. Gastric and duodenal decompression, external drainage of the duodenal repair, and caval ligation are preferred for delayed treatment of combined duodenal and infrarenal vena caval injuries.

Acute cholecystitis complicating trauma.

Twelve patients developed acute cholecystitis complicating trauma. Acute acalculus cholecystitis was present in 11 patients. Nine patients died. A review of 20 reports comprising 98 patients shows 86.7% had acute acalculus cholelithiasis, and 61.1% had necrosis, gangrene, and/or perforation of the gallbladder. The overall mortality was 33.3% and only 16.1% of patients treated by cholecystectomy died. The etiology of acute cholecystitis complicating trauma is multifactorial. Gallstones are present infrequently whereas shock, increased bile pigment load, drugs, surgery, and (other) trauma are common precursors. Diagnosis is difficult and depends upon clinical suspicion and the physical examination. Immediate surgical intervention is required. Cholecystectomy is the procedure of choice. We recommend cholecystectomy at initial laparotomy whenever there is evidence of trauma to the gallbladder, or if the right or common hepatic artery is ligated for hepatic bleeding.

Transcatheter embolization of autologous clot in the management of bleeding associated with fractures of the pelvis.

Extraperitoneal hemorrhage, associated with a fracture of the pelvis, is a major cause of death in pedestrian accidents. Transfusion alone may be unsatisfactory. Direct control of bleeding may be required. Surgically, this may be technically difficult or inadequate. Transcatheter embolization of autologous clot was used to control hemorrhage in three patients with such a fracture. If laparotomy is required immediately, arteriography of the pelvic area may be done postoperatively, If laparotomy is not performed, arteriography may define pelvic bleeding sites. Transcatheter embolization of autologous clot controls hemorrhage from branches of the hypogastric artery.

The repair of extracranial carotid artery aneurysms.

Aneurysm of the internal carotid artery was repaired in three instances by a combination of gas endarterectomy and aneurysmorrhaphy. No shunt was used during cross clamping. The occlusion was uncomplicated. Both patients (in one the procedure was bilateral) have been well for two years. Because of its simplicity and effectiveness, the method is recommended.