Hepatic and vena cava resection using cardiopulmonary bypass with hypothermic circulatory arrest.

When large hepatic or retroperitoneal tumors encroach upon hepatic veins or vena cava and make conventional resection hazardous, the most commonly used method of hepatic resection or vena cava reconstruction includes hepatic vascular exclusion, at times with venovenous bypass or aortic occlusion. These techniques result in warm liver ischemia, and may be accompanied by significant systemic hypotension, despite aggressive central venous preloading. Hepatic lobe (two patients) and retroperitoneal sarcoma (one patient) resections were done in a cold, bloodless field without significant complications. Standard cardiopulmonary bypass techniques with heparin and cardioplegia were used. Systemic circulatory arrest was done at 15 degrees C with isolated retrograde perfusion of the brain through the jugular veins. Hepatic vein and vena cava reconstructions were performed with arrest times of between 30 and 78 minutes. Blood loss was gradual and easily controlled, occurring during the rewarming phase when clot formation was inhibited by cold and heparin.

Emergency department treatment of hand burns.

The hand burn, although small, can cause significant loss for the patient. Therefore, decisive attention to preserve the skin and the function of the fingers is required. This article reviews assessment of burn injuries, types of burn injuries, and treatment. Pain management information is provided along with recommended antibiotic regimens. Criteria on admission versus outpatient treatment, which is particularly relevant for the emergency physician, is also presented.

Proximal renal tubular dysfunction in severe burns.

Proximal renal tubular function was studied in 11 patients with severe burn injury. Creatinine clearance was normal or increased in ten patients. Fractional excretion of sodium was less than 1% in ten. Fractional excretion of uric acid and amylase were increased in all but four and two cases, respectively, while absolute clearances of lysozyme and beta 2-microglobulin were increased in all but one patient. Renal threshold phosphate concentration was reduced in four patients. Twenty-four-hour urine glucose excretion exceeded 1 g in five patients, aminoaciduria was noted in eight, and proteinuria, predominantly globulinuria, was present consistently. Metabolic acidosis was seen in one patient, and transient hypokalemia occurred in two. Abnormalities of proximal tubular function were more marked in the five patients with the greatest extent of third-degree burns who died. The cause of proximal tubular dysfunction is not clear and may be related to an adaptive response to severe injury.

Control of upper gastrointestinal bleeding with a microcrystalline collagen hemostat.

A microcrystalline collagen hemostat (MCH) widely used in general surgery was tested in the control of bleeding from experimentally produced gastric ulcers. Five dogs had a gastrotomy and were given heparin. Using the standard "ulcer maker," three sets of three ulcers were made in the gastric mucosa of each animal. Blood from each ulcer was collected for a 5-min period to allow for stabilization of bleeding. MCH powder or slurry or no MCH was placed directly on one ulcer of each set in random order. The bleeding rate for the next 10 min was measured. Mean decrements in the bleeding rate for slurry MCH and dry MCH-treated ulcers were 87% and 81%, respectively, compared with 51% for controls, P less than 0.05. Twelve MCH-treated ulcers, but no control ulcer, stopped bleeding completely, P less than 0.01. Preliminary observations show that MCH slurry can be applied through an endoscope and may be hemostatically effective in man. MCH may have a role in the endoscopic control of gastrointestinal bleeding.

Fatal iron intoxication in an adult.

An 18-year-old male accidentally fell into a vat of saturated ferrous chloride in a dilute solution of hydrochloric acid. He aspirated the iron solution to his lungs, ingested it into his stomach, and absorbed it through the burned skin. His clinical course paralleled acute iron intoxication with GI bleeding, acidosis, and transient improvement before his demise. In addition, he developed a severe disseminated intravascular coagulopathy which was temporarily ameliorated with heparin and clotting factors.

Hemodynamic analysis of septic shock in thermal injury: treatment with dopamine.

Eleven burn patients were studied while in septic shock and during dopamine infusion. There was only one survivor. The shock state in septic burn patients is hyperdynamic with a marked increase in cardiac index but a significant loss of systemic vascular resistance. Dopamine infusion in low doses stimulated the heart by increasing the cardiac index but caused further vasodilation and exerted little beneficial effect on blood pressure. High doses of dopamine increased the systemic vascular resistance and the blood pressure to levels which more adequately perfused the kidney. Dopamine infusion in high doses will improve the septic patient's hemodynamic status. This may permit surgical treatment of the septic process to remove the cause of the shock state.