[Efficacy of metoprolol in prevention of supraventricular arrhythmias after coronary artery bypass grafting]. / Wirksamkeit der Metoprolol-Therapie in der Prävention supraventrikulärer Arrhythmien nach koronarer Bypass-Operation.

Atrial fibrillation is in 20-50% the most frequent dysrhythmia after coronary artery bypass grafting (CABG) and a possible cause for hemodynamical complications and prolongation off the medical treatment in patients. Therefore, the effect of beta-blocking with metoprolol for prevention of supraventricular arrhythmias (SVA) was investigated in a prospective and randomized trial. 200 patients after CABG were randomized in a drug and control group (average age 63.2 years, 154 male, 46 female). Patients of the drug group (n=100) were treated with metoprolol (1mg/kg/BW) beginning on day one after operation, whereas patients of the control group (n=100) received therapy only in case of occurrence of atrial fibrillation. ECG, blood pressure, and electrolyte concentrations were measured regularly until the tenth day after surgery. Reasons for exclusion were an ejection fraction (< 30%, SA- and AV-block or simultaneous application of epinephrine and metoprolol. There were no significant differences between the patients of drug and control group with respect to age, sex ejection fraction, previous medication, number and type of bypass grafts, cardiopulmonary bypass time, and perioperative ischemic events. However, a statistically significant difference was seen in the occurrence of supraventricular arrhythmias in both groups, 4 patients of the therapy group (4%) in contrast to 37 patients of the control (37%) developed supraventricular arrhythmias during the postoperative observation period (p<0.0001). Both groups differed in total time of hospital stay by 1.5 days (control group: 9.83+/-2.88 days; drug group: 8.42+/-2.81 days), which was statistically significant (p<0.05). All patients of the drug group could be discharged with a stable sinus rhythm, whereas 7 patients of the control group were discharged with persistent atrial fibrillation. The difference was statistically significant as well (p<0.01). Neither typical side effects of metoprolol, nor AV-blocks, bradycardia (f<60/min) or symptoms of low blood pressure could be observed. The conclusion of this trial is a recommendation for a preventive application of 50mg metoprolol/day after coronary artery bypass surgery, which can reduce the incidence of SVA as well as the hospital stay statistically significant.

Pneumatic antishock garment-associated compartment syndrome in uninjured lower extremities.

Pneumatic antishock garment-associated compartment syndrome is a rare and yet underrecognized complication that when it occurs, frequently results in myonecrosis and loss of limb function, and occasionally loss of a limb or even death. We report a case of pneumatic antishock garment-associated compartment syndrome in a trauma patient without lower extremity injury and review similar published reports. It is only with a high index of suspicion, early recognition, and prompt treatment of this complication by fasciotomy and proper wound care that associated morbidity and potential mortality of this complication can be prevented or minimized.

Management of stab wounds to the thoracoabdominal region. A clinical approach.

We studied 324 patients admitted to Harlem Hospital Center from July 1981 to June 1986 with stab wounds of the thoracoabdominal region (area limited by a coronal circle through the fifth interspaces anteriorly and seventh interspaces posteriorly from above to a subcostal circle 5 cm caudad to the costal margins and 12th ribs from below). We divided this region into 12 zones (six symmetrical zones on each side) using the above upper and lower limits and the costal margins, the midlines, and the anterior and posterior axillary lines. This study was conducted to determine the incidence of transdiaphragmatic penetration for the thoracoabdominal region stab wounds in each of the 12 zones identified for the first time and applied in this study, and the reliability and safety of surgical management based mainly on physical examination. The highest incidence of transdiaphragmatic penetration occurred in stab wounds of the left anterior lower thoracic zone (21.7%). The lowest incidence was 0% and the overall incidence was 11%. Physical examination was accurate in making the diagnosis in 95.4% of all cases and no mortality was associated with a delay in diagnosis that may have resulted from the serial physical examinations. We conclude that this method of selective operative management based on physical examinations is accurate and safe.

Central venous access in critically ill patients in the emergency department.

Several techniques of percutaneous venipuncture and cut-downs for insertion of intravenous catheters and the respective clinical results are described. We believe that puncture of the subclavian vein from above the clavicle in the segment of the veins over the first rib is the safest anatomic approach to the vein. The first rib under the vein shields the pleural dome and the apex of the lung against the needle puncture, and the tip of the needle is directed away from the apex of the lung. Insertion of double and multiple IV catheters in one vein, adjacent veins, or even veins located away from each other is safe and much less costly than the double- and triple-lumen catheters. The special and unconventional venous cut-downs for providing IV access described here in patients with difficult access may be life saving. The experience with vascular access in our institution indicates that supervised training in vascular access and the personal experience of each physician with these techniques and teamwork help to reduce potential complications.

Penetrating neck wounds. Mandatory versus selective exploration.

We reviewed the records of 257 patients (ages, 16-83 years) with penetrating neck wounds (119 gunshot and 138 stab) managed at Harlem Hospital Center. Among the first 148 patients, 134 were managed by mandatory neck exploration; 42 had injuries (31%), and 92 (69%) had no injury. There were four deaths (3%) and seven (5%) morbidities. Because of the high rate of unnecessary operations, the following 109 patients were managed selectively, 40 by exploration, and nine of the 40 (22%) had no injury; 69 were observed and did not require subsequent operative intervention. There were six deaths (5.5%) and six morbidities (5.5%) among the second group. Morbidity and mortality were unrelated to the method of management but related to the type and severity of injuries, associated injuries, preexisting illnesses, and age of the patients. The frequency of operations for penetrating neck wounds without structural injuries was minimized in the selective exploration group.

Establishment of intravenous lines for long-term intravenous therapy and monitoring.

Our experience at this institution indicates that the greater the individual and the institutional experience, the lower the complications of central venous lines. The techniques of double catheter insertions in one vein or region, as described, are safe, cost-effective, and useful. These catheters can remain in place for up to 8 weeks. Insertion of double catheters is ideal for intravenous feeding to avoid premixing amino acids and glucose, thus minimizing the hazards of contamination as well as saving time and cost for mixing. Special unconventional techniques for vascular access when indicated in patients who have limited accessible sites may be lifesaving. Except for fibrinous clots around the catheters, the complications in our series have diminished as our experience has grown. Vascular access techniques and long-term care should be formally taught to committed individuals. Well-trained, concerned, experienced personnel available 24 hours a day, 7 days a week is the most important factor in the reduction of complications of vascular access technique and the long-term maintenance of intravenous lines.

Rectovaginal fistula: management by intravenous feeding and surgical repair.

Two patients, each with a large rectovaginal fistula, were managed successfully by intravenous feeding and surgical repair of their fistulae. Intravenous feeding eliminated the need for food from the gastrointestinal tract, thus minimizing the fecal flow. Both fistulae healed following surgical repair. Neither patient required a diverting colostomy.