Post cholecystectomy admission to the intensive care unit. Comparison between open, mini-lap and laparoscopic techniques.

Admissions to the intensive care unit following techniques for cholecystectomy, the open, mini-lap and laparoscopic methods, were studied over an 18-month period. Of 1078 cases of operative cholecystectomy performed during that period, 28 cases (2.6%) from all groups were admitted to the intensive care unit. Cases in the open and mini-lap cholecystectomy groups were admitted for postoperative monitoring because of pre-existing medical diseases and were discharged after an average period of stay of 2.4 and 4.7 days respectively. In contrast, the average stay of patients in the laparoscopic group was 14.8 days and the majority were admitted as a result of complications related to the procedure. In this group, one patient died on the first day of admission to the unit (mortality of 8.3%). This study has shown that laparoscopic surgery, from the intensive care point of view, is a very costly surgical procedure.

The anesthetic and intensive care management of pulmonary hemosiderosis in a child--case report.

Pulmonary hemosiderosis represents challenges during anesthesia and intensive care management. This is a report of a case of idiopathic pulmonary hemosiderosis in a child which was successfully managed during anesthesia and in the intensive care unit with total remission of the disease. The management of this and similar cases are discussed.

Cannulation of the internal jugular vein. The very high approach.

A new approach to internal jugular vein catheterisation in the neck (the 'very high' approach) was used in 335 patients over a 12-month period. The success rate was 100% and there were no complications. It proved to be an easy technique to learn and may be particularly useful in difficult and emergency situations.

Postintubation tracheal damage. A four-year prospective study.

A 4-year prospective study was undertaken to estimate the incidence and identify the pathogenesis of cuff-induced major tracheal damage. All tracheal tubes were implantation tested and the cuffs were of the high-volume low-pressure type. The cuff pressure was continuously monitored and maintained below 3kPa. During the period of the study, 684 patients were intubated. Their average age was 33.6 years (range 14-296). The average intubation period was 9.3 days (range 1-256). At first, the damage was diagnosed clinically, radiologically and then confirmed by computed tomography. Three patients (0.4%) developed lesions that were not related to excessive (CP). In this study CP control seems to have eliminated a known major cause of intubation-associated tracheal injury. To date, there is no alternative to tracheal intubation. However the laryngeal mask seems ideal if invasion of the trachea is to be avoided altogether.

Incidence of pulmonary embolism in total knee arthroplasty.

The end-tidal carbon dioxide concentration (ETCO2) of 47 patients undergoing prosthetic knee operations was monitored to detect pulmonary embolism during the anthroplasties. The ETCO2 of one patient dropped suddenly following the release of the tourniquet and insertion of the bone cement. Intracardiac aspiration did not reveal any air. At autopsy there was massive pulmonary thromboembolism and the deep veins of the right leg contained old formed thrombi. Patients undergoing such procedures should be investigated to exclude the presence of deep vein thrombosis so that measures to prevent pulmonary thromboembolism must be taken well in advance. As regards the occurrence of air embolism it is believed that insertion of the bone cement is the most important single factor in the prevention of air embolism during knee arthroplasty.

Disseminated intravascular coagulopathy diagnosed by computed tomography.

A 24-year-old man was brought to casualty after a fall. He suffered from head injury and multiple fractures. On arrival he was apneic and the heart was at a standstill. Resuscitation was successful and the patient was taken to the CT room to assess the extent of his head trauma. At the end of the procedure, maintaining adequate ventilation proved to be very difficult; the blood pressure was rapidly falling and the ECG showed severe bradycardia. Asystole followed and resuscitation was unsuccessful. Postmortem CT scanning of the chest revealed that the tracheobronchial tree was flooded with blood and coagulation profile showed the picture of disseminated intravascular coagulopathy. CT may be useful in the diagnosis of some pathological conditions when autopsy is difficult to perform.

Mortality in the surgical intensive care unit--the role of sepsis and organ failure.

Study of admissions to the surgical intensive care unit (SICU) at King Khalid University Hospital in Riyadh was carried out from 1982 to 1987. There were 1149 surgical admissions, of whom 96 patients died (mortality rate 8.3%). Eighty-six patients died of multisystem and organ failure (MSOF). Sepsis appeared to be the ultimate cause of death in 54 patients of the organ failure group (62.8%). Twenty four percent of this group had positive blood cultures, and 57% had more than one positive culture site. Gram-negative bacilli and gram-positive cocci were the predominant organisms with only two positive anaerobic cultures. In this study the risk for developing sepsis starts at the age of 50, otherwise our data confirm previous studies on the influence of sepsis and MSOF on mortality in SICU. Recommendations for future improvement in patient's care and investment in antibiotic research are made.

Tracheal dilatation followed by stenosis in Mounier-Kuhn syndrome. A case report.

A patient with previously undiagnosed Mounier-Kuhn syndrome (tracheobronchomegaly) was admitted with a head injury after a fall. The trachea was intubated with an oral tracheal tube with high-volume low-pressure cuff. The intracuff pressure was within the normal safe range recommended by the manufacturer. However, the patient developed tracheal dilatation on the second day after intubation. The trachea was extubated on the 15th day, and it was noticed 48 hours later that the patient was developing a tracheal stenosis at the site of the previous dilatation. The stenosis was so severe that the patient underwent resection-anastomosis surgery of his stenotic tracheal segment 2 months after extubation. It may be preferable in patients with Mounier-Kuhn syndrome who require mechanical ventilation to intubate the trachea with an uncuffed tube and to pack the throat to decrease the chances of gas leak and inhalation.

Evaluation of epidural needles.

Eight different epidural needles (Tuohy Everett, Pitkin, Braun Perifix and Portex in 16-gauge, and Becton Dickinson Crawford, Becton Dickinson B-D, Monoject and Portex in 18-gauge) were evaluated using a scanning electron microscope and spectral x-ray analysis. Differences were noted in the metal composition, between disposable and reusable needles with respect to molybdenum content. The inner surface of the 18-gauge Crawford needle was found to be the smoothest and it also had the best clearance between the needle and stilette. The Portex 16-gauge had the best needle/stilette fit at its bevel. The hardness of the metal was found to be satisfactory in all the needles.