Reduced or absent serum anion gap as a marker of severe lithium carbonate intoxication.

Two patients with life-threatening lithium carbonate intoxication (serum levels, greater than 4 mEq/L [greater than 4 mmol/L]) presented with a reduced or absent serum anion gap. In both subjects, hemodialysis simultaneously removed the excess lithium ion and normalized the anion gap. Conversely, the anion gap was normal in subjects with therapeutic serum lithium ion levels. Severe lithium carbonate intoxication should be added to the category of illnesses (multiple myeloma, bromide intoxication) causing a marked reduction in the anion gap. In the comatose patient, a reduced anion gap may serve as an important clinical clue to the presence of this drug intoxication.

Penetration of clindamycin into the human appendix.

Clindamycin penetrated extremely well into inflamed (19) and normal (one) appendices. Average levels in appendiceal tissue taken 26 to 300 minutes after a single intravenous dose were 154% of the simultaneous serum concentration.

Monitor-guided responses. Operability with safety is increased in patients with peripheral vascular diseases.

Poor cardiopulmonary reserve was demonstrated in a group of 75 elderly patients undergoing elective vascular reconstruction when cardiovascular hemodynamics were analyzed with the automated physiologic profile (APP) preoperatively. Only 25 patients (33.3%) had normal left ventricular function (LVF) and did not need any corrective therapy before surgery. Increment in preload was necessary in 20 patients (26.7%) to improve myocardial function; 30 patients (40%) revealed abnormal LVF and hence required pharmacologic modulation and preload adjustment, inotropic support, and afterload reduction to enhance the ventricular performance. Conventional methods of clinical evaluation did not reveal the degree of compromised ventricular function and potential high risk of surgical morbidity and mortality in many of these patients. The APP disclosed subtle and important physiologic aberrations indicating modification of anesthetic and operative procedures and precise modulation of physiologic factors. Optimization was achieved in all except two patients, and only one was denied the benefits of vascular reconstruction.

The role of physiologic monitoring in patients with fractures of the hip.

Mortality rates for elderly patients with hip fractures have been reported to be as high as 37%. This study evaluated 70 patients of whom 35 were evaluated preoperatively by conventional diagnostic means, and 35 in whom hemodynamic, respiratory, and metabolic status was assessed using a Swan-Ganz balloon-tipped catheter. The derived variables were then calculated by a minicomputer and automatically plotted on a printed graphic display in a bar graph format. This diagnostic modality permitted appreciation of occult physiologic aberrations not detected by conventional methods, enabling correction of these abnormalities preoperatively and postoperatively. The study demonstrated a mortality rate of 2.9% in the monitored group compared to a 29% mortality in the nonmonitored group. The intrinsic assumption that patients should undergo surgery within 24 hours (3) was also modified. The appropriate time for surgery should be accurately determined and chosen on the basis of optimal physiologic balance.

Arterial shunt with pump infusion line for the treatment of chronic thoracic aortic aneurysms: the "modified shunt of Gott".

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.