Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest.

In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims.

Extracorporeal membrane oxygenation (ECMO) as lung or heart assist.

Extracorporeal membrane oxygenation (ECMO) may serve as extracorporeal lung assist (ECLA) in patients with acute respiratory failure (ARF) or as extracorporeal heart assist (ECHA) in patients with low output syndrome (LOS) after open heart surgery. From 1988 to 1992 seven patients underwent ECMO in our hospital; four suffered from ARF and three from LOS. Various bypass techniques were employed. Two ARF patients, aged 58 and 18 years, had veno-venous bypass; in the latter, ECMO was reinstituted as a veno-arterial bypass one week after weaning. In a three-year-old boy, the ECMO outflow tubing was primarily connected to the pulmonary artery, and shortly afterwards relocated to the common carotid artery. In a 31-year-old man with ARF, and three LOS patients, a 56-year-old woman, and two men aged 68 and 70 years, ECMO was veno-arterial with direct access to the ascending aorta. A heparin-coated system was used, and all but one patient, who was treated with warfarin, received a daily low dose of heparin, which was withdrawn after from one to nine days. Six patients were weaned off ECMO after 4.5 to 21 days. Three ARF patients recovered completely; the child died. In one LOS patient, ECMO was withdrawn due to a poor general condition. Two others were weaned off ECMO and the intra-aortic balloon pump, and the inotropic support was significantly reduced, but both died of multiple system organ failure. Although no firm conclusions can be drawn from these few case reports, the heparin-coated system used as ECLA appears promising, whereas ECHA seems to imply a poor prognosis in patients who are not candidates for cardiac transplantation.

[Extracorporeal membrane oxygenation. A therapeutic alternative in acute heart and/or pulmonary failure?]. / Ekstrakorporal membranoksygenering. Et behandlingsalternativ ved akutt hjerte- og/eller lungesvikt?

Extracorporeal membrane oxygenation was introduced as a supplement ot mechanical ventilation in the treatment of two patients with severe acute respiratory failure and as heart assist in one patient with acute refractory cardiac failure after open heart surgery. The system includes a membrane oxygenator and a roller pump. The whole circuit is coated with partially degraded heparin covalently bound to the surface (Carmeda Bioactive Surface), reducing the need of systemic heparinization to a minimum. In the first case of acute respiratory failure a veno-venous bypass was employed, with cannulas in the right atrium and the femoral vein. Given a blood flow through the circuit of 2.5 l/min, ventilator settings could be favourably reduced. The patient was weaned off the bypass system after six days, off the ventilator after 120 days, and recovered completely. In two cases the system served as partial venoarterial bypass, and blood was returned to the ascending aorta. A 31 year-old male victim of a smoke inhalation lung injury was on bypass for four and a half days. He recovered completely after another 17 days of mechanical ventilation. A 68 year-old man with pump failure after cardiac surgery needed extracorporeal support as heart assist for seven days. On the eighth day he was weaned off intra-aortic balloon-pumping as well. Unfortunately, he died of septicemia, with multiple organ failure, 13 days later. The heparin-coated extracorporeal membrane oxygenation system may represent a major advancement in the treatment of critically ill patients in need of cardiopulmonary assist.

An outpatient approach to female sterilization with methylcyanoacrylate.

MCA is a tissue adhesive which can be delivered transcervically to the Fallopian tubes by means of the FEMCEPT device. In the patients treated with this system, both prior to hysterectomy and on an ambulatory basis, there have been no significant complications or side effects. In the most recent series of ambulatory patients treated with the REMCEPT-MCA system, the bilateral tubal closure rate was 78%.

PIP: Clinical trials of methylcyanoacrylate (MCA), a tissue adhesive injected to occlude fallopian tubes for tubal sterilization, were conducted in ambulatory patients and are presented. 3 small series of patients are described; most received .4-ml injections, but 23 of the 131 total subjects received .6-ml injections. Outcome was determined by hysterosalpingography. Bilateral closure rate after 1 treatment in series 1 (n=28) was 64%. In the 2nd series the bilateral closure rate was 54% after 1 injection; after a 2nd injection in the 2nd series, the rate was 78%, but overall the closure rate for this group after 2 injections was 65% (n=102). In the 3rd series, bilateral closure rate was 78% after 1 injection; this series used .6-ml injections and represents a dramatic improvement over the preceding series. Complications include pain at site of injection, mild to moderate cramping, and transient vagal reaction. The procedure takes 5 minutes or less. 2 uterine pregnancies have occurred to date, and no ectopic pregnancies were reported. MCA is a low-viscosity fluid in a monomeric form which rapidly polymerizes when placed in contact with body fluids.

[Hemorrhages in abnormal production of gonadotropins]. / Blødninger ved unormal produksjon av gonadehormoner

PIP: A review of the organic and hormonal causes of irregular menstrual bleeding is presented. Menstrual bleeding irregularities are the most frequent gynecological ailment. Oligomenorrhea is most often caused by a prolonged proliferation phase in the menstrual cycle. In younger women this may be due to insufficient hormonal secretion of the pituitary gland; in older women it may be due to late follicular development in spite of normal glandular secretion. Polymenorrhea is usually caused in younger women by a shortening of the proliferation phase, usually because the ovaries are hypersensitive to pituitary hormones, which causes an aceleration of follicular development. Polymenorrhea in older women is usually due to a shortened secretory phase caused by early degeneration of the corpus luteum, and later may develop into oligomenorrhea or amenorrhea. Irregular corpus luteum function after ovulation can cause bleeding irregularities. When the corpus luteum fails to produce progesterone, the endometrium develops irregularly, causing premenstural spotting or increased volume of menstrual bleeding. Slow degeneration of the corpus luteum causes increased progesterone production and irregular discharge of the endometrium. Anovulation is the most frequent cause of bleeding irregularities, because there is no progesterone secretion. A quick increase in estrogen production in the proliferation phase in conjunction with anovulation causes an irregular discharging of the endometrium with prolonged or increased bleeding. A slow increase in estrogen production during the proliferation phase in conjunction with anovulation causes hyperplasia. In a few patients, anovulation in conjunction with a secretion of estrogen insufficient to maintain the endometrium can cause endometrial atrophy. Irregular bleeding is usually functional in younger women and organic in older women. To diagnose the cause of irregular menstrual bleeding, organic reasons should be explored 1st. A complete history should be taken, then abrasio, recording the basal temperature, and hematological, and hormonal analysis should be used to pinpoint the causes of irregular bleeding. Abrasio is the most common treatment for bleeding irregularities, and hormone treatment is the 2nd most common. Hysterectomy should be used only in extreme cases for treatment of bleeding irregularities.^ieng

Study of the suppression of lactation and the influence on blood clotting with bromocriptine (CB 154) (Parlodel): a double blind comparison with diethylstilboestrol.

Inhibition of lactation was studied in 38 puerperal women in a double blind trial to assess the effect of bromocriptine in comparison with diethylstilboestrol (DS). Simultaneously the influence of both compounds on blood clotting was studied, along with a control group of 20 women not receiving any medication. Bromocriptine was given in a daily dose of 5 mg for 14 days and DS in a daily dose of 20 mg for 7 days followed by a placebo for a further 7 days. The first doses were not later than 8 hours after delivery. Both compounds showed an inhibitory effect on the onset of lactation and mammary congestion. This inhibitory effect on both parameters was significantly in favour of bromocriptine during the last days of the treatment due to rebound in the DS group. The bromocriptine doses used (5 mg daily for 2 weeks) caused no objective side effects and no subjective restraint. Treatment with bromocriptine caused no untoward effect on the blood clotting, while in the DS group a slower return to normal antithrombin III could be observed. Also in this group one case of thrombophlebitis occurred. Bromocriptine can be administered to puerperal women for the suppression of lactation.

Tubal sterilization. With special reference to electrocoagulation through the laparoscope.

In the past 5 years 1 168 tubal sterilizations have been performed. One thousand and twelve of these were performed by dividing the tube by diathermy through the laparoscope. Since the first cases, and with increasing experience, complications have been infrequent, at the most a slight bleeding from the mesosalpinx. So far we have had ten failures, probably due to lack of experience. In every failure it was found at re-examination that the tube had not been divided-at least at one side. The method is quick and simple. The patient suffers little inconvenience, has a very small scar and is in hospital only a short time. It has been used in post-partum cases, but is not suitable for patients who have had several abdominal operations.