Esophageal perforation following use of esophageal airway.

The esophageal airway has gained increasing acceptance in airway management during cardiopulmonary resuscitation, and its enthusiastic advocates are urging expansion of its use. A fatal case of esophageal perforation following the use of an esophageal airway is presented. Possible contributing factors are discussed. A modified esophageal airway which seems safer and more versatile, effective, and economic is described.

Effects of hypertension and propranolol upon aneurysm expansion in the Anidjar/Dobrin aneurysm model.

Propranolol has been suggested to slow aortic aneurysm (AAA) expansion by a mechanism independent of simple blood pressure (BP) reduction. To investigate this hypothesis, we designed a series of experiments to examine the effects of hypertension and propranolol upon AAA expansion. Using an established animal model, we induced AAA in normotensive and genetically hypertensive rats by perfusion of the isolated infrarenal aorta with elastase for two hours. Systolic tail BP was monitored with a plethysmograph. AAA size was measured directly with a micrometer on postoperative days 7 and 14. All data are expressed as the mean +/- standard deviation (SD). BP (mmHg) was significantly higher in hypertensive rats: 164 +/- 15 versus 119 +/- 7 (p < 0.001). AAA were also significantly larger in hypertensive rats with a mean expansion rate (mm/day) nearly twice that of normotensive animals: 0.13 +/- 0.09 versus 0.07 +/- 0.03. In a second series of animals, propranolol treatment was compared to placebo. In those animals, hypertensive propranolol-treated rats had significantly smaller AAA than placebo-treated controls (p < 0.05). There was no difference in normotensive animals but these rats had an unexplained paradoxical rise in BP with treatment. In this model, hypertension increases the expansion rate of AAA. Propranolol reduced the size of AAA in hypertensive animals, at least in part because of a decrease in BP. Other possible mechanisms of propranolol's action may be operative and require further study.

A simplified instrument for noninvasive vascular assessment.

A simple, inexpensive pulse wave recording device was tested in large (25- to 40-kg) dogs. Femoral arterial flow, prestenotic and poststenotic arterial waveforms, and pressures were monitored as stenosis was induced with a constricting silk loop. The recording device tested was placed around the distal leg. The pulse wave recorder accurately reproduced the arterial pulse waveform. The amplitude of the device's waveform was linearly proportional to the arterial pulse pressure. The instrument was sensitive in detecing a flow-limiting stenosis. The cuff represents an advance in noninvasive vascular assessment because it is quite inexpensive, portable, and durable, as well as precise and sensitive.

Intestinal intubation in acute, mechanical small-bowel obstruction.

A review of 100 consecutive patients admitted with simple, mechanical small-bowel obstruction secondary to adhesions and treated for at least 24 hours with nonoperative intestinal intubation showed that of 76 patients admitted with partial small-bowel obstruction, 49 (65%) were successfully treated without operation. Of those with complete small-bowel obstruction (CSBO), 18 of 24 (75%) subsequently required surgical intervention; however, six of 24 (25%) were safely treated by nonoperative intubation. The 24-hour delay in surgery for CSBO did not increase morbidity or mortality in the 18 requiring operations. Major indications for surgical intervention were suspected strangulated obstruction or persistent obstruction, which frequently was associated with unsuccessful tube passage. Administration of antibiotics preoperatively was associated with a significant reduction in wound infections in patients requiring resection or enterotomy.

Five-year follow-up of prophylactic vena cava filters in high-risk trauma patients.

OBJECTIVE: To assess the short- and long-term outcomes of vena cava filter (VCF) placement for prophylaxis against pulmonary embolism in patients at high risk due to trauma. DESIGN AND SETTING: Case series at a level I trauma center. PATIENTS: Patients were considered for prophylactic VCF placement if they met 1 of the injury criteria--spinal cord injuries with neurologic deficit, severe fractures of the pelvis or long bone (or both), and severe head injury--and had a contraindication to anticoagulation. INTERVENTION: Vena cava filters were placed percutaneously by the interventional radiologists when the acute trauma condition was stabilized following admission. MAIN OUTCOME MEASURES: Filter tilt of 14 degrees or more, strut malposition, insertion-related deep vein thrombosis, pulmonary embolism, or inferior vena cava patency. RESULTS: There were 132 prophylactic VCFs placed. A 3.1% rate of insertion-related deep vein thrombosis occurred, all of which were asymptomatic. Filter tilt occurred in 5.5% of patients and strut malposition in 38%. Three cases of pulmonary embolism (1 fatal) occurred in a prophylactic VCF, and all patients had either filter tilt or strut malposition. The risk of pulmonary embolism developing was higher in those patients with filter tilt or strut malposition than in those who did not have these complications (6.3% vs 0%; P=.05; Fisher exact test). The 1-, 2-, and 3-year inferior vena cava patency rates (+/-SD) were 97%+/-3%. CONCLUSIONS: Prophylactic VCF can be placed safely with an acceptable rate of insertion-related deep vein thrombosis and long-term inferior vena cava patency. Patients with prophylactic VCF remain at risk for pulmonary embolism if the filter is tilted 14 degrees or more or has strut malposition. In such patients, consideration should be given to placing a second filter.

Vascular complications of cardiac catheterization.

Peripheral vascular complications after cardiac catheterization constitute an increasing portion of traumatic vascular injuries. To determine the incidence of these complications and the sequelae of their treatment, we reviewed 7,690 catheterizations performed over a 40-month period. One hundred eleven vascular complications were detected (1%), 41 of which required surgical repair (0.5%). Pseudoaneurysm (10), arteriovenous fistula (4), thromboembolism (9), infection (5), and other bleeding complications (83) were all found. Significantly more complications occurred in patients who were older than 60 years of age or female (P < 0.0009). In addition, the likelihood of a vascular injury after coronary angioplasty was significantly higher than after angiography alone (3% versus 1%, P < 0.00001). Secondary local and systemic complications after surgical repair were more frequent compared with those injuries that were managed nonoperatively (32% versus 11%; P = 0.015). Vascular complications continue to be a significant problem after cardiac catheterization, especially when coronary angioplasty is performed. The sequelae of surgical repair are significant, adding to their morbidity. Periodic review of these complications may identify factors that might be modified to reduce complications.

Vascular ultrasound.

Surgeon-interpreted diagnostic ultrasound has become the preferred screening test and often the definitive test for the diagnosis of arterial stenosis, aneurysm, and venous thrombosis. As a modality for surveillance, its noninvasive quality makes it particularly appealing as the test of choice to screen patients for abdominal aortic aneurysms or to perform follow-up examinations on those patients with a carotid endartectomy or in situ bypass grafts. The increasing reliance on intraoperative duplex imaging of vascular procedures demands that the surgeon learn the skills to perform the studies without a technologist or radiologist to interpret the examination.

Hydroxychloroquine sulfate in prevention of thromboembolic phenomena in surgical patients.

Hydroxychloroquine sulfate appears to be a safe drug with no apparent hemorrhagic or other complications when used pre- and postoperatively in the manner described. With the criteria for thromboembolism of abnormal impedance plethysmography and confirmatory clinical signs, protection seems to have been afforded by hydroxychloroquine sulfate. Since these studies support prior extremely favorable results, further clinical trial with parenteral hydroxychloroquine sulfate seems indicated.

Carotid body tumors.

A review of seven carotid body tumors less than 5 cm in diameter confirms the thesis of other recent reports that such tumors can be resected with minimal morbidity. In two of our cases, initial exploration and biopsy were performed not suspecting the nature of the neck mass; in one of these, hypoglossal and facial nerve deficits resulted. Angiography was diagnostic in six of our seven cases and should be used to establish the diagnosis preoperatively in any neck mass of doubtful origin where carotid body tumor is a part of the differential diagnosis.