Fatal respiratory distress in burned patients.

Of 167 patients with major burns, fatal respiratory distress developed in ten. Fluid overload caused fatal respiratory failure within 48 hours of admission in five patients with anuria, whereas late deaths were due to fluid overload and pulmonary sepsis. Three of the four patients who had a tracheostomy died of pulmonary sepsis, whereas all ten patients who had endotracheal intubation survived, p less than 0.05. Preventable causes of fatal respiratory distress were found in all ten patients. The use of colloid infusions during burn shock resuscitation and serial monitoring of pulmonary extravascular water was suggested for prophylaxis of fluid overload and respiratory distress syndrome. Aspiration pneumonia prophylaxis and avoidance of an early tracheostomy were suggested for prophylaxis of pulmonary sepsis. It is suggested that the concept of idiopathic burn lung syndrome be abandoned, and instead, a vigorous etiologic search to be instituted in order to prevent, to identify and to treat correctable causes of respiratory failure.

Short-term femoral vein catheterization. A safe alternative venous access?

Results of femoral vein catheterization were compared with those of subclavian and antecubital vein catheterization in 2,345 combat casualties during treatment of hypovolemic shock. Femoral vein catheterization was successful in 95.5 per cent of cases. Accidental arterial puncture occurred in 6.3 per cent, hematomas in 1.3 per cent, and infection in 1.4 per cent. Subclavian vein catheterization was successful in 92.4 per cent. Arterial puncture occurred in 0.4 per cent, hematomas in 0.3 per cent, infection in 1.1 per cent, pneumothorax in 1.4 per cent, and hydrothorax in 0.4 per cent. Antecubital vein catheterization was successful in 77.6 per cent, infection developed in 3.3 per cent, and phlebitis occurred in 5.6 per cent. No clinically detectable phlebitis occurred after either femoral or subclavian vein catheterization. The low morbidity of femoral vein catheterization in this series suggests that this approach be considered when short-term massive intravenous fluid administration is indicated in the treatment of circulatory collapse or cardiac arrest.

Inflammatory carcinoma of the breast. A therapeutic approach followed by improved survival.

Disappointing results of radical mastectomy for treatment of inflammatory breast carcinoma led to its abandonment and the use of alternative therapeutic methods without improvement of survival rates. Results of radical mastectomy combined with other therapeutic modalities have not been fully evaluated so far. In a series of nine patients with proven inflammatory breast carcinoma and no distant metastases, two underwent radiotherapy, oophorectomy, and adrenalectomy (group A) and seven underwent preoperative irradiation, radical mastectomy, postoperative irradiation, and chemotherapy (group B). There were no local recurrences in either group. Group A patients survived five and eight months (mean, 6.6+/-2.1) and patients of group B survived 45.5+/-26.2 months (p less than 0.05). Results show no rational basis for withholding radical mastectomy, but suggest that improved survival may be obtained when radical mastectomy is an integral part of a rational sequential therapeutic schedule.

The effect of fluid infusions upon serum protein concentrations during hemorrhagic shock.

Of 24 dogs subjected to hemorrhagic shock, 12 resuscitated with intravenous infusions containing 2.5 per cent human serum albumin maintained significantly higher, p less than 0.05, serum albumin levels than did 12 others treated with Ringer's lactate solution, with or without 50 per cent dog plasma. These differences persisted for as long as six weeks after hemorrhage. Dogs resuscitated with Ringer's lactate solution and 50 per cent dog plasma had significantly higher serum globulin levels than did the dogs receiving 2.5 per cent albumin containing infusion during the first three days after hemorrhage. The simultaneous addition of 5 per cent glucose, potassium chloride and hydrocortisone sodium succinate to the infusion of dogs receiving 2.5 per cent albumin in Ringer's lactate solution did not provide significant alterations in the serum concentration of protein and protein fractions when compared with those of dogs receiving only 2.5 per cent albumin in Ringer's lactate solution. These findings corroborate the suggestion of a capillary leak of serum albumin into the interstitial space during hemorrhagic shock that persists for at least one week after hemorrhage. The administration of albumin containing solutions during the initial stages of hemorrhagic shock counteracts this albumin loss.

Survival following infusion of Pitressin into the superior mesenteric artery to control bleeding esophageal varices in cirrhotic patients.

Morbidity and mortality data from patients with bleeding esophagogastric varices treated with portosystemic shunts relate to the clinical status of the patient and to control of hemorrhage both in the immediate postoperative period as well as later. To obtain comparable data following selective infusion of pitressin into the superior mesenteric artery (SMA), records of 23 consecutive patients with cirrhosis, diagnosed by endoscopy as bleeding from varices and treated with SMA pitressin infusions, were reviewed. Twenty-four infusions were performed and hemorrhage was controlled in 12. Fourteen of the 23 patients subsequently underwent portosystemic shunts. Pitressin infusion controlled hemorrhage preoperatively in seven of these, and five survived one year or longer. The remaining seven, in whom bleeding was not controlled by pitressin, died postoperatively. One of the nine patients not undergoing a portosystemic shunt survived more than eight weeks after pitressin infusion. Vascular complications occurred in seven of 17 who died. These complications and the delay between institution of pitressin and operative therapy to control variceal hemorrhage appears to be a factor in the high mortality rate. Portosystemic shunt remains the best therapy for uncontrolled hemorrhage and to prevent recurrent bleeding from esophageal varices.

Abdominoperineal resection in the treatment of devascularizing rectal injuries.

Local debridement, drainage, and diverting colostomy, with or without primary repair of the rectum, have been considered to be the standard treatment for most rectal injuries, but they are not sufficient for those patients sustaining uncontrollable bleeding or extensive rectal devascularization. This report assessed the indications and results of abdominoperineal resection of the rectum in these patients. Ten patients who were victims of explosive trauma presented with massive perineal injuries and extensive rectal devascularization. Six of these were treated with local debridement of necrotic tissue, pararectal drainage, antibiotics, and colostomy. Five of the six patients initially treated by colostomy died after operation from hemorrhage or sepsis. The sixth patients, who survived, had an abdominal resection of the rectum performed 5 days after the colostomy for removal of a gangrenous rectum. All five of those who underwent abdominoperineal resection survived (p less than 0.01). Increasing violence in the life patterns of modern society enhances the possibility of occurrence of this type of lesion, previously limited to military practice. The need for careful investigation of rectal viability is emphasized. Primary abdominoperineal resection of the rectum is advised when extensive devascularization has occurred.

Serum protein concentration during hemorrhagic shock.

Early changes in serum protein concentration during hemorrhagic shock were evaluated in a series of 20 dogs, following massive bleeding. The serum protein concentration fell faster than did the hematocrit value, with significant changes becoming apparent 15 minutes after hemorrhage, p less than 0.05. After this initial fall, a less marked descent occurred. The most remarkable changes were in the serum albumin fraction. Changes of the globulin levels were less evident. These findings of an early albumin loss, occurring within 15 minutes following acute massive hemorrhage in the dog, probably are due to a leakage of albumin into the interstitial space, secondary to increased capillary membrane permeability. Larger molecules, such as the globulin fraction, did not consistently decrease during the first 45 minutes following shock, a possible indication that loss of this protein into the interstitial space did not occur in a consistent manner. The aforementioned findings support the early use of intravenous infusions containing macromolecules, larger than albumin, during hemorrhagic shock, to re-establish an oncotic gradient, which is diminished due to a loss of albumin from the circulation.