Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study.

PURPOSE: Ventricular-arterial (V-A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV). METHODS: After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol. RESULTS: Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l(-1)), arterial dP/dt max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms(-1)), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg(-1) min(-1), p < 0.05). CONCLUSIONS: HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V-A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

Linear stapling device in partial resection of abdominal parenchymatous organs.

The use of the linear stapling device (LSD) is well-established in hollow-organ gastro-intestinal surgery. Its use in operations performed on parenchymatous viscera is less common. We present our experiences with the LSD in partial resection of the spleen (2 cases), pancreas (5 cases), liver (2 cases) and kidney (2 cases). To the best of our knowledge the use of the LSD for partial nephrectomy and resectional debridement of the liver has not been previously described. We suggest that LSDs are useful aids in the resection of parenchymatous organs, and allow rapid resection if applied to healthy tissues and in regions with an intact capsule.

'Missed stabbed hearts'--pitfalls in the diagnosis of penetrating cardiac injuries. Report of 4 cases.

Classically, penetrating injuries of the heart present with clinical signs of an ongoing massive haemorrhage or cardiac tamponade. In a few patients, however, none of these signs are present and the diagnosis is overlooked. Diagnostic aids, such as ultrasonography or angiography, are occasionally misleading. Four cases of penetrating cardiac injuries that were not diagnosed on initial presentation, but which subsequently manifested with a secondary and sometimes fatal haemorrhage, are presented. Recommendations are made for preventing diagnostic delays.

Large-vein, thrombotic, hepatic venous outflow obstruction (Budd-Chiari syndrome). A case report.

A patient with Budd-Chiari syndrome caused by large-vein, thrombotic, hepatic venous outflow obstruction, who was initially treated conservatively, is presented. The hazards of this approach are emphasised. Accurate classification of Budd-Chiari syndrome and active treatment tailored to the site and nature of the hepatic venous outflow obstruction are indicated to prevent progressive hepatic damage leading to chronic liver failure, portal hypertension and eventual death.

Percutaneous drainage of pancreatic pseudocysts: a prospective study.

We classify pancreatic pseudocysts in 3 types: post-necrotic type I, related to acute pancreatitis; post-necrotic type II, related to an acute attack superimposed on chronic pancreatitis; and retention type III, due to chronic pancreatitis with ductal stricture. A prospective study on percutaneous catheter drainage of post-necrotic pseudocysts (type I and II) was undertaken from 1987 to 1990. Twenty-three pseudocysts in 21 patients were drained. Overall recurrence rate was 4%; 2 patients had fistulization of the catheter into bowel; no deaths occurred. The procedure was successful in all type I cysts; in type II cysts it was associated with prolonged drainage and increased risk of complications when cyst-duct communication was present. Percutaneous drainage has no role to play in type III retention cysts. Guidelines regarding indications for treatment and the techniques employed are described.

Intestinal presentation of phaeochromocytoma. A case report.

An unusual case of a patient with a phaeochromocytoma presenting with colitis is reported. A review of published reports showed a high mortality rate in patients with phaeochromocytoma complicated by intestinal disease. The importance of pre-operative preparation with alpha-adrenergic blockers and removal of the tumour for the disappearance of intestinal symptoms is emphasised.

Pancreatic pseudocysts: a proposed classification and its management implications.

Pancreatic pseudocysts in 83 patients were classified according to clinical and radiographic criteria. Group I (45 patients) had acute, 'post-necrotic' pseudocysts with normal pancreatic duct anatomy and rarely duct-pseudocyst communication. Percutaneous drainage was curative in all patients in whom it was used. Group II (26 patients) included 'post-necrotic' pseudocysts developing in patients already suffering from chronic pancreatitis. The pancreatic duct was diseased but not strictured, and duct-pseudocyst communication was often present. Percutaneous drainage is possible for such patients but it may have to be prolonged; surgical internal drainage was usually successful. Group III (12 patients) had chronic 'retention' pseudocysts. The pancreatic duct was grossly diseased and strictured and duct-pseudocyst communication was present in all cases. Percutaneous drainage is contraindicated and surgical internal drainage has a high recurrence rate. Operative procedures in this group should address the specific ductal pathology. An improved classification of pseudocysts could help the surgeon to choose the most appropriate form of treatment.

Pancreatic necrosis and infection--an update on management.

The mortality rate for acute pancreatitis complicated by necrosis and infection has remained high in spite of progress made in supportive care. This is mostly related to development of multi-organ failure and overwhelming sepsis. Early diagnosis of necrosis and infection followed by correct management are essential for improving survival. Contrast-enhanced computed tomography with the adjunct of fine-needle aspiration is reliable in detecting necrosis and infection. Several surgical treatment modalities are discussed in the literature; however, the cornerstone for improved survival in patients with infected necrosis is adequate debridement and wide drainage. This can be achieved with any modality, provided that the patients are re-explored promptly if the septic status persists.

Surgical strategies in the treatment of pancreatic necrosis and infection.

Controversy still surrounds the management of necrotic and septic complications of acute pancreatitis. A review of the literature of the past decade dealing with the surgical treatment of pancreatic necrosis, pancreatic abscess and infected pancreatic necrosis has been undertaken. Three main patterns of management could be identified: (1) 'conventional treatment', consisting of pancreatic resection or necrosectomy with drainage; (2) 'local lavage', consisting of necrosectomy followed by regional lavage; and (3) 'open management', with resection or necrosectomy followed by planned multiple re-explorations. From this review it appears that local lavage and open management offer better survival prospects than conventional treatment. Open abdomen techniques, however, are associated with an increased risk of complications, such as colonic necrosis, intestinal fistula, and intra-abdominal bleeding. Excellent results can be achieved in specialized centres with any of the three methods, provided adequate debridement and prompt reoperations are undertaken if the septic state persists.

Percutaneous drainage of immature pancreatic pseudocyst. A preliminary study of 4 cases.

The management of immature pancreatic pseudocysts is controversial because surgical external drainage is associated with a high morbidity and mortality rate. A study was conducted during which immature pseudocysts that were enlarging, causing pain or giving respiratory distress were selected for percutaneous drainage and placement of a pigtail drainage catheter under ultrasonographic guidance. This preliminary study of 4 cases demonstrated that this procedure is safe and does not cause morbidity or mortality. It is suggested that there will be no recurrence provided the catheter is well secured and that no communication between the cyst and the pancreatic duct can be seen on sinography and endoscopic retrograde cholangiopancreatography.