Among the factors involved in the early complications of lung transplantation is the ischemiareperfusion syndrome related to a warm reperfusion in ischemic lungs.
Using an isolated rabbit lung ...preparation perfused with whole blood, we studied the effects of cold ischemia followed by a warm reperfusion on pulmonary vascular responses to reproduce experimentally the conditions encountered during lung transplantation.
Pulmonary vascular responses to acetylcholine were rapidly altered by warm ischemia (relaxation of 7% versus 60% in controls). Conversely, relaxation was maintained even after a prolonged cold ischemic storage (maximal relaxation of 57% at 48 hours). Warm reperfusion in ischemic lungs induced major alteration of endothelium-dependent relaxation (maximal relaxation of 13% at 4 hours). The addition of l-arginine or pentoxifylline during reperfusion prevented the pulmonary endothelial alteration resulting from warm reperfusion.
These data suggest that treatments aimed at maintaining intact functional endothelium reduce ischemia-reperfusion injury in transplanted lungs.
Objective:
Pulsed Doppler measurement of pulmonary venous flow (PVF) in the left superior pulmonary vein has been suggested as a noninvasive method to evaluate pulmonary capillary wedge pressure ...(PCWP). In previous studies, PVF was measured at end-expiration, and it is unknown to what extent PVF is affected by the respiratory cycle. It is hypothesized that phasic variations of PVF during mechanical ventilation may be used to estimate PCWP.
Design:
Prospective clinical study.
Setting:
Tertiary care university hospital.
Participants:
Thirty patients undergoing elective cardiac surgery.
Interventions:
At multiple intervals during the surgery, the PVF was measured with transesophageal pulsed Doppler echocardiography, and measurements of PCWP and airway pressure were simultaneously obtained.
Measurements and Results:
Components of PVF evaluated were the systolic (X), diastolic (Y), and atrial (Z) waves with their velocity-time integrals (VTI). The systolic fraction (SF = VTI X/VTI X + VTI Y) and respiratory variations of each component of PVF were determined and compared with PCWP. There was a greater respiratory variation of the X wave (X expiratory-X inspiratory/X expiratory) in patients with PCWP <18 mmHg than in patients with PCWP ≥ 18 mmHg (0.19 ± 0.19
v 0.14 ± 0.13, respectively,
p < 0.01). PVF components measured at end-expiration that related best with PCWP were the X/Y peak velocities (
r = − 0.53), VTI X/VTI Y ratio (
r = −0.42), and the SF (
r = −0.49). When measured during end-inspiration, the relation of the X/Y ratio, VTI X/VTI Y, and SF with the PCWP were
r = −0.54,
r = −0.41, and
r = −0.50, respectively.
Conclusions:
It has been documented that PVF velocity is influenced by the respiratory cycle during mechanical ventilation in patients undergoing cardiac surgery, and the magnitude of this variation is influenced by PCWP. However, it is not actually possible to predict PCWP accurately using these findings. Further studies are needed in which preload is varied acutely to confirm the usefulness of the results.
Among the factors involved in the early complications of lung transplantation is the ischemia-reperfusion syndrome related to a warm reperfusion in ischemic lungs.
Using an isolated rabbit lung ...preparation perfused with whole blood, we studied the effects of cold ischemia followed by a warm reperfusion on pulmonary vascular responses to reproduce experimentally the conditions encountered during lung transplantation.
Pulmonary vascular responses to acetylcholine were rapidly altered by warm ischemia (relaxation of 7% versus 60% in controls). Conversely, relaxation was maintained even after a prolonged cold ischemic storage (maximal relaxation of 57% at 48 hours). Warm reperfusion in ischemic lungs induced major alteration of endothelium-dependent relaxation (maximal relaxation of 13% at 4 hours). The addition of L-arginine or pentoxifylline during reperfusion prevented the pulmonary endothelial alteration resulting from warm reperfusion.
These data suggest that treatments aimed at maintaining intact functional endothelium reduce ischemia-reperfusion injury in transplanted lungs.
Results of cardiac surgery in renal transplant patients are not well documented. Immunosuppression as well as associated conditions in these patients, and the increased susceptibility of the renal ...allograft to the extracorporeal circulation (ECC) may alter the prognosis of renal transplant patients submitted to cardiac surgery. To evaluate this hypothesis, we reviewed the files of 24 patients (18 Male, 6 Female; age: 49 +/- 12 years) operated under ECC between 1978 and 1997. Twenty patients underwent coronary artery bypass surgery, 5 patients a valve replacement procedure (aortic and/or mitral), and one patient necessitated a Cabrol procedure for an ascending aorta aneurysm. Preoperatively, the majority of patients were in functional class (NYHA) IV (16 patients), and ejection fraction was > 50% in 18 patients. Two operative deaths secondary to cardiogenic shock were encountered. Five patients (23%) were reoperated for bleeding; 5 patients (23%) sustained a major infection (2 pneumonias, 2 mediastinitis and one wound infection) resulting in death in one patient; 5 patients (23%) were treated for arythmia; and 2 patients (9%) suffered a perioperative myocardial infarction. Serum creatinine levels did not increase significantly during hospitalization (p = 0.41 between extreme values). Mean follow-up (41 +/- 28 months) of the 20 survivors revealed recurrent angina in 5 patients and late death in 4 patients, cardiac-related in 3 cases.
Cardiac surgery in renal transplant patients is subjected to a high morbidity and mortality. Mid-term prognosis is reserved especially in presence of associated conditions.
La démarche générale d’élaboration du rapport final qui suit, repose d’une part, sur les objectifs fixés lors de la signature du projet et, d’autre part, sur la base de réflexion généralement ...utilisée pour réaliser des études de processus décisionnels en univers incertain et qui n’est pas spécifique à notre problématique. C’est par une combinaison de ces deux aspects qu’a été construit le rapport suivant. De plus, ce dernier regroupe, d’une part, une synthèse des différents travaux de recherche réalisés au cours de son projet et, d’autre part, les différentes études effectuées répertoriées.
La démarche générale d’élaboration du rapport final qui suit, repose d’une part, sur les objectifs fixés lors de la signature du projet et, d’autre part, sur la base de réflexion généralement ...utilisée pour réaliser des études de processus décisionnels en univers incertain et qui n’est pas spécifique à notre problématique. C’est par une combinaison de ces deux aspects qu’a été construit le rapport suivant. De plus, ce dernier regroupe, d’une part, une synthèse des différents travaux de recherche réalisés au cours de son projet et, d’autre part, les différentes études effectuées répertoriées.
Old people living alone and in poverty are most at risk for developing scurvy, but the diagnosis may be missed unless the physician is aware of it. A 42-year-old immigrant living in poverty was ...treated surgically at the Hôtel-Dieu Hospital in Montreal for a compartment syndrome of the leg. She had ecchymoses on the skin of the leg and an interstitial hematoma in both posterior compartments. Three weeks later, she was readmitted with more swelling in the leg, gingivitis, hemorrhagic folliculitis, petechiae and gastrointestinal hemorrhage. Her response to vitamin C was remarkable and confirmed the diagnosis of scurvy.
Between December 1984 and September 1991, a total of 68 palliative esophageal intubations were performed in 57 patients. The mean age was 64 years, there were 40 males and 17 females. The more ...frequent causes of esophageal obstruction were malignant tumors of the esophagus (49%), lung (23%) and cardia (19%). Total dysphagia (24.5%), dysphagia to liquids (47%) and esophagotracheal aspiration (14%) were present in these patients. In 65% of patients insertion of the prosthesis was the first attempt at palliation, in the remaining patients it followed the failure of another type of palliation. The decision to palliate esophageal obstruction was established preoperatively in 86% of patients, in the remaining 14% it was decided at the time of surgery. The intubation by pulsion (Atkinson) 1 was successful in 57% of patients and by traction (Celestin) 2 in 86% of patients. The associated morbidity was 36% for the Atkinson prosthesis and 13% for the Celestin prosthesis, although the latter required a laparotomy. The in hospital mortality was 12.5%. The mean survival was 85 days. A normal or semi-solid diet was tolerated by over 60% of patients following intubation. Palliation of esophageal obstruction by intubation improves the quality of life but is associated with a high morbidity.
Thoracotomy with muscle sparing Normandin, L; Pagé, A; Verdant, A
Annales de chirurgie,
1991, Letnik:
45, Številka:
9
Journal Article
Recenzirano
Muscle sparing thoracotomy is suggested more frequently in recent literature. From March 1988 to February 1990, a muscle sparing technique was used in 77 (58%) of 132 consecutive thoracotomies. There ...were 50 men and 27 women, age varied from 23 to 81 years, with a mean of 58 years. Forty-four lobectomies, 10 pneumonectomies, 9 lung biopsies, 6 wedge resections, 6 bullectomies and 2 segmentectomies were performed. A horizontal incision was used in 47 (61%) patients and a vertical mid-axillary incision in 30 (39%). For optimal exposure, transection of the latissimus dorsi muscle was needed in 14 (30%) of the horizontal incisions. Inadvertent rib fracture occurred in 10 (13%) cases. Continuous epidural analgesia was added in 46 (60%) patients for an average of 40 hours. Mechanical ventilation in 14 (18%) patients for a mean duration of 22 hours and an average stay of 2 days in the ICU and 7 days in the hospital, were required. There was 1 (1.3%) hospital mortality, 4 (5%) patients developed a seroma that required aspiration. Muscle sparing thoracotomy can be used safely for most thoracic procedures and we believe it permits easier pain control and early preservation of full shoulder motion. However the operative field is more restricted. A horizontal incision, permitting section of the latissimus dorsi for better exposure should be used for hilar or invasive lesions.
