Cell saver autologous transfusion: metabolic consequences of washing blood with normal saline.

OBJECTIVE: To evaluate acid-base and electrolyte changes in high volume cell saver autologous blood transfusion when normal saline (0.9% NaCl) is used as the wash solution. DESIGN: Open-label study. MATERIALS AND METHODS: Nine anesthetized and anticoagulated mongrel dogs underwent 15 cycles of cell saver autologous blood transfusion. Eight percent of the circulating blood volume (125 mL) was withdrawn, washed with normal saline, and retransfused for each cycle. MEASUREMENTS AND MAIN RESULTS: Analyses of acid-base, electrolyte, and hematologic parameters were performed on both systemic and the washed blood. The washed blood had increased levels of sodium and chloride. There were decreased levels in pH, Pco2, total CO2 (bicarbonate), lactic acid, potassium, total and ionized calcium, magnesium, inorganic phosphorus, total protein, and albumin. Systemically, in the animals, by the end of the study, there were significant increases in the levels of chloride, inorganic phosphorus, hemoglobin, and hematocrit and significant decreases in the levels of pH, total CO2, total and ionized calcium, magnesium, total protein, and albumin. CONCLUSIONS: Acid-base, electrolyte, and hematologic changes occur when normal saline is used as the wash solution in high volume cell saver autologous blood transfusion. The washed blood with its elevation of sodium and chloride appears to reflect the constituents of the wash solution, normal saline. The depletion in the washed blood of PCO2, total CO2, potassium, total calcium, ionized calcium, magnesium, phosphorus, total protein, and albumin we feel is because of the absence of these electrolytes in the wash solution and their physical removal during salvaged blood separation and washing. The systemic acid-base and electrolyte changes primarily reflect the electrolyte pattern of the reinfused washed blood except for inorganic phosphorus. Inorganic phosphorus was maintained systemically, despite its wash out in the cell salvage process. This paradoxical finding may be caused by intracellular to extracellular inorganic phosphorus flux caused by the progressive systemic metabolic acidosis.

Extramedullary hematopoiesis simulating posterior mediastinal tumors.

We report the case of a patient with intrathoracic extramedullary hematopoiesis presenting as a posterior mediastinal tumor in response to chronic hemolytic anemia. Noninvasive studies including chest roentgenograms, computed tomographic scans, magnetic resonance images, and nuclear scans can establish the diagnosis in most cases. In equivocal cases, transthoracic needle biopsy and open biopsy should be considered. Surgical resection is recommended only for patients with symptoms of compression.

Cholecystokinin upregulation during intestinal repair.

To determine whether cholecystokinin (CCK), a small intestinal hormone, may have autocrine or paracrine functions, gene regulation in the rat stomach and duodenum has been evaluated following cytotoxic injury. We quantified total RNA, CCK messenger RNA (mRNA), total protein, small and large forms of CCK peptides and gastrin. The stomach and the intestine respond differently. Following cytotoxic injury duodenal total RNA falls (1.5 +/- 0.1 vs 0.18 +/- 0.04 mg/g P less than or equal to 0.0001), and CCK mRNA content is depleted (260 +/- 23 vs 41 +/- 8 pg CCK mRNA/duodenum P less than or equal to 0.0001), yet there is a paradoxical increase in CCK mRNA concentration (176 +/- 20 vs 303 +/- 38 pg CCK mRNA/mg total RNA P less than or equal to 0.01). Increases occurred in both molecular species of CCK peptides evaluated: CCK8 (8 +/- 7 vs 26 +/- 2 pmole/g P less than or equal to 0.0001), large forms of CCK (42 +/- 4 vs 250 +/- 27 pmole/g P less than or equal to 0.0001). By contrast, in the stomach, only decreases were observed. These data identify sites of anatomical and biosynthetic upregulation during gastrointestinal repair. Changes are dependent upon the length of the period of recovery, differ between stomach and duodenum, and may be age related. Intestinal CCK may have para- and or autocrine roles in addition to its hormone function.

Postoperative sepsis: reexplore or observe? Accurate indication from diagnostic abdominal paracentesis.

OBJECTIVE: To determine if postoperative diagnostic abdominal paracentesis is a useful clinical tool in the abdominal evaluation of the critically ill septic patient. DESIGN: Retrospective review. SETTING: Surgical ICU patients in a Veterans Administration medical center. PATIENTS: Ten patients were studied from a total of 1,053 patients admitted to the surgical ICU between September 1985 and May 1989. INTERVENTIONS: Diagnostic abdominal paracentesis performed by the open or closed approaches. MEASUREMENTS AND MAIN RESULTS: Results are presented in three patient groups (A, B, and C): Group A (n = 4) had positive diagnostic abdominal paracentesis. Abdominal causes for the sepsis were found at reexploration. One of these four patients survived. Group B (n = 3) had negative diagnostic abdominal paracentesis. No abdominal septic source was found at reexploration; all three patients died. In group C (n = 3), diagnostic abdominal paracentesis was negative, patients were not reexplored, and all survived. Diagnostic accuracy correlated with three variables: a) the gross appearance and smell of the fluid, b) WBC count greater than 5000 or less than 500/mm3, and c) Gram stain demonstrating bacterial organisms. CONCLUSIONS: Diagnostic abdominal paracentesis proved accurate, reliable, simple, safe, and rapid in evaluating the abdomen in the postoperative septic patient. The use of this procedure should be considered in postoperative septic patients in whom an abdominal source for the sepsis needs to be excluded.

Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax. Results of a Department of Veterans Affairs cooperative study.

This prospective, multicenter, randomized, "unblinded," controlled clinical trial was designed to determine if the intrapleural instillation of 1500 mg of tetracycline hydrochloride would be effective in diminishing the ipsilateral rate of recurrence for spontaneous pneumothorax. During the 4-year enrollment period, 113 patients were assigned to the tetracycline group; 116 patients were assigned to the control group. During the 5-year study period, the recurrence rate in the tetracycline group (25%) was significantly less than that in the control group (41%). Use of tetracycline seemed to reduce the recurrence rates for patients with either primary or secondary spontaneous pneumothorax and for patients with either an initial or a recurrent pneumothorax. We conclude that the intrapleural administration of tetracycline in patients with spontaneous pneumothorax significantly reduces the rate of ipsilateral recurrence but is associated with intense chest pain. Intrapleural tetracycline therapy is indicated for patients with a spontaneous pneumothorax who are hospitalized and are treated with tube thoracostomy.

Segmental intestinal absorption of ranitidine: investigative and therapeutic implications.

The absorption of ranitidine from different segments of the intestinal tract was studied in a subject who had an anatomically divided small intestine. The results indicate that the drug is maximally absorbed from the small bowel rather than the stomach. Subsequent animal studies have shown that absorption of ranitidine in dogs is primarily duodenal followed by jejunal and ileal. The lack of gastric absorption, with predominantly small bowel absorption, may have investigational and therapeutic implications in a variety of gastrointestinal diseases.

Avoidance of injury to the left hepatic duct during parenchymal dissection for hepatic trisegmentectomy.

A simplified and safe technique is described herein for the dissection of the feedback structures to the medial segment of the left lobe, while preserving the integrity of the remaining left hepatic bile duct during the dissection for right hepatic trisegmentectomy. This is accomplished by passing a biliary probe into the main left hepatic duct from the stump of the right hepatic duct. Use of this technique during the performance of a hepatic trisegmentectomy expedites the hepatic dissection and decreases the potential for intraoperative injuries of the remaining bile duct to the lateral segment of the left lobe of the liver. In addition, irrigation of the left hepatic bile duct through the open right duct stump may demonstrate leakages of bile that may be repaired, leading to a decreased over-all morbidity in the subsequent postoperative period.

The effect of various postphlebotomy storage conditions on drug levels.

Monitoring drug levels in patients is standard practice in presentday critical care medicine. Clinical laboratories, however, are often unable to assay drug levels immediately following phlebotomy. This may result in blood samples being kept under a variety of storage conditions for nonuniform periods of time. The current study evaluated the stability of eight frequently monitored medications and one of their metabolities, in whole blood and plasma, at 4 degrees C or 25 degrees C, for up to 72 hours. The drugs included antibiotics, a bronchodilator, antiarrhythmics, and an anticonvulsant. Significant changes in drug levels were not identified at the time points studied. Our data suggests that meticulous postphlebotomy handling of blood samples may not be essential to obtain accurate levels of the drugs studied.

Exclusion of small bowel from pelvis for postoperative radiotherapy for rectal cancer.

The pelvis is the preferential site of disease when recurrence occurs after curative resection of rectal cancer. Postoperative adjuvant radiotherapy decreases local recurrence rates for Dukes stages B and C; however, after abdominoperineal or anterior resections, the small bowel descends into the lower pelvis, and, due to its low tolerance to radiation, optimal doses cannot be safely delivered unless the small bowel can be excluded from the pelvis. This can be achieved by cystopexy and/or by creating a pelvic sling with a knitted polypropylene mesh. Three cases are presented in which radiotherapy was satisfactorily delivered with these techniques.

Colonic vascular ectasias and aortic stenosis: coincidence or causal relationship?

Eleven patients with vascular ectasias of the colon and associated gastrointestinal hemorrhage were evaluated. All had the clinical features associated with aortic stenosis. In two patients, the configuration of the pulse wave in the mesenteric vessel was studied. In both, the abnormal peripheral pulse wave pattern associated with aortic stenosis was also transmitted to the ileocolic artery, where it differed quite clearly from the pattern in control patients. In a parallel study, the computer records of 3,623 patients with aortic or mitral stenosis admitted to the Mount Sinai Hospital over a 10 year period were reviewed for the presence of cryptogenic gastrointestinal hemorrhage. Twenty-one of 1,811 patients with aortic stenosis but only 1 of 1,812 patients with mitral stenosis had concomitant gastrointestinal hemorrhage (chi-square = 18, p less than 0.001). These data suggest that the cause of colonic vascular ectasias should be attributed to pathologic abnormalities of the arterial inflow pulse wave, rather than to chronic intermittent submucosal venous outflow obstruction.

Infected false aneurysms of the subclavian artery: a complication in drug addicts.

Two cases of infected false aneurysms of the subclavian artery in drug addicts are described. The clinical findings related to the location of these rare lesions are presented, together with an attempt to explain their pathophysiology. The signs and symptoms include a tender supraclavicular mass in an obviously septic patient associated with brachial plexus palsy, a swollen edematous arm, Horner's syndrome, and hemoptysis. Because of the complexity of symptoms, delay in diagnosis is common. It is emphasized that the recognition of this constellation of symptoms should prompt the physician to perform emergency angiography followed by immediate surgery.

A technique for preservation of spinal accessory nerve function in radical neck dissection.

A new technique is described that preserves trapezius muscle function in radical neck surgery while cutting that part of the spinal accessory nerve which courses through the sternocleidomastoid muscle. The technique takes advantage of the little-know fact that, in humans, the trapezius muscle has dual innervation. The C2-3-4 motor root is joined to the distal portion of the spinal accessory nerve to give motor function to the trapezius muscle. This procedure will save shoulder mobility in the majority of patients who undergo radical neck dissection. The technique is accomplished rapidly with the use of the gastrointestinal stapler in the scalene fat pad.

Ultrasonic partial splenectomy.

We describe use of the ultrasonic scalpel to perform three partial splenectomies expeditiously, with control, and with excellent hemostasis. This new powered instrument has a tip that vibrates at ultrasonic frequencies and cuts through mesenchymal tissue, sparing blood vessels. On the basis of experience in the laboratory and the cases presented, we believe that the technique of ultrasonic partial splenectomy may overcome problems inherent in methods now used.