The "stable" ruptured abdominal aortic aneurysm gives a false sense of security.

BACKGROUND: Operative mortality for ruptured abdominal aortic aneurysms (rAAA) has not changed over the past 4 decades. Previous studies have attempted to identify preoperative risk factors that impact upon survival. METHOD: A retrospective review of 25 patients with rAAA treated during a 2-year period was performed. Patients were divided into groups based upon the presence (GpI), absence (GpIIa), or subsequent development of preoperative hypotension (GpIIb). Time intervals from initial presentation to arrival in the operating room (IP-OR), to cross clamp application (IP-XC), and from observed hypotension to cross clamp (HYPO-XC) were recorded. RESULTS: Average time intervals for IP-OR and IP-XC were significantly shorter for GpI compared with GpIIa and GpIIb. No difference in HYPO-XC was noted between GpI and GpIIb. Mortality was 33% for GpI, 25% for GpIIa, and 87.5% for GpIIb. CONCLUSIONS: Normal admission blood pressure led to a decreased sense of urgency, creating avoidable delays and missed opportunities for salvage.

Toothpick perforation of the intestine diagnosed by a small bowel series.

We report the case of a 50-yr-old man who unknowingly swallowed a double-pointed toothpick that ultimately perforated the distal small bowel over a period of several weeks. Appendicitis and ileitis were sequentially considered as diagnosis. A foreign body was diagnosed on a second small bowel series and removed. It has been noted that, because toothpicks are not radiopaque, radiographic studies are not useful in the diagnostic workup. In the case reported, the toothpick was seen on the contrast radiograph of the small bowel and the correct diagnosis ultimately made.

Severe acute metabolic acidosis (acute beriberi): an avoidable complication of total parenteral nutrition.

Total parenteral nutrition is one of the most important recent advances in medicine. The delivery of total parenteral nutrition, however, can be associated with a broad spectrum of complications ranging from mechanical (catheter related) to metabolic. We have recently seen a previously unreported complication of total parenteral nutrition - three patients maintained on total parenteral nutrition, who did not receive vitamins and experienced the acute onset of life-threatening metabolic acidosis with pH values as low as 6.70. All responded promptly and completely to the administration of intravenous thiamine, and thus were probably examples of acute beriberi. Acute beriberi is a well-documented syndrome which usually occurs in nutritionally compromised individuals outside the hospital setting who lack thiamine in their diet. Without thiamine, glucose cannot enter the Krebs cycle in order to be completely oxidized for energy production and therefore, accumulates as lactic acid. This lactic acidosis is refractory to any treatment except thiamine and will result in cardiovascular collapse if the vitamin is not administered.

The fluorescence camera: how to use fluorescein dye in a normally illuminated room.

The Polaroid SX 70 Sonar camera has been modified so that it will produce instant photographs of the fluorescence of fluorescein in illuminated rooms. The camera was used to record the dye pattern in 40 rats and 65 patients. The photographic method proved to be as good as--but no better than--the visual one in predicting the viability of skin flaps. The camera eliminates the need to totally darken the room and use an ultraviolet lamp; it provides useful information to the surgeon and a permanent record for the chart.