Ruptured Giant Coronary Artery Aneurysm With Coronary Artery to Pulmonary Artery Fistula Presenting as Cardiac Tamponade Diagnosed by Intraoperative Transesophageal Echocardiography: A Case Report.

A 63-year-old woman presented with cardiac tamponade because of a ruptured giant left anterior descending coronary artery aneurysm with a fistula to the main pulmonary artery. The diagnosis was made intraoperatively during an emergent subxiphoid pericardial window using transesophageal echocardiography and confirmed by intraoperative coronary angiography. Because of this prompt diagnosis, the patient was successfully managed with immediate surgical repair of the aneurysm and fistula.

Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score.

Early allograft dysfunction (EAD) is a serious complication after liver transplantation (LT). There is no uniform definition of EAD, and most definitions are based on arbitrary laboratory values. The aim of this study was to devise a definition of EAD that maximizes the predictive power for early death and graft failure. In this single-center, retrospective study, the ability of the international normalized ratio (INR), total bilirubin, aspartate aminotransferase (AST), physiological Model for End-Stage Liver Disease (MELD) score, and serum albumin levels within 7 days after LT to predict 90-day mortality or graft loss was compared with 2 previously used definitions of EAD: (1) peak total bilirubin level >10 mg/dL on days 2 to 7 and (2) either a total bilirubin level >10 mg/dL or an INR >1.6 on day 7 or an AST or alanine aminotransferase level >2000 IU/L within the first 7 days. Of 572 enrolled LT patients 38 died or required retransplantation within 90 days. Peak INR, total bilirubin level, AST levels, and MELD scores were predictors of 90-day graft failure. MELD score on postoperative day 5 was the best predictor with an area under the curve of the receiver operating characteristic curve of 0.812 (95% CI: 0.739-0.886, P < 0.001). The best cutoff of MELD score on day 5 for predicting 90-day mortality or graft loss was 18.9. A MELD score >18.9 on postoperative day 5 was a better predictor than any other laboratory value or definition of EAD. This study has demonstrated that the MELD score can be a useful tool not only for pretransplant graft allocation but also for postoperative risk stratification.

External blood loss estimation using the MAR Method.

BACKGROUND: An element lacking in medical education is training to estimate blood volumes. Therefore, health care workers currently use visual estimation as their only means of determining blood volumes, which has shown to be highly inaccurate. This study proposes and tests a new method using one's fist to determine external blood loss. METHODS: Increments of human whole blood were measured and used to compare fist size to surface area of blood present. A formula was created averaging blood per fist, hereafter known as the MAR Method. Two scenarios were staged using set quantities of blood (75 and 750 mL). Participants estimated blood volumes before and after being taught the MAR Method in a 1-minute session. Errors in estimation before and after using the MAR Method were compared. RESULTS: The MAR Method was created using a fist to cover a surface area of blood that equals 20 mL. A total of 74 participants had errors of 120% and 73% for visualization of the small and large pools, respectively. For the smaller volume, the average error from the mean decreased by 76% (P < .0001), and the interquartile range of errors decreased by 60%. For the larger volume, the average error from the mean reduced by 40% (P < .0001), and the interquartile range of errors reduced by 45%. CONCLUSION: Use of the MAR Method improves blood volume estimations. After less than 1 minute of instruction, participants were able to determine blood volumes with improved accuracy and precision.