Post-operative respiratory failure due to bilateral phrenic nerve palsy.

A 65 year old female patient developed a large left pleural effusion and a sternal split dehiscence following aorto-coronary artery bypass grafting. A second operation was performed to investigate and drain the pleural effusion and to repair the sternum. Subsequent to this operation the patient was in acute respiratory failure due to bilateral phrenic palsy. It is probable that the left phrenic nerve was damaged in the initial operation and the right nerve in the second. The patient's subsequent progress is described.

Effects of preoperative glucose-insulin-potassium on myocardial glycogen levels and on complications of mitral valve replacement.

Myocardial glycogen content was increased from a mean of 25.8 +/- 3.7 to 40.3 +/- 4.2 mumol/gm (p less than 0.0001) by an infusion of glucose, insulin, and potassium before mitral valve replacement. Patients who had received such an infusion and who had a higher myocardial glycogen content had a lower incidence of postoperative hypotension, less serious postoperative arrhythmias, and fewer serious complications after elective mitral valve replacement.

Septicaemia as a hospital hazard.

In 1 year there were 135 episodes of septicaemia in a large referral hospital serving a population of 400,000 people. Of these, 52 were hospital-acquired giving a nosocomial septicaemia rate of 2.08 per 1000 admissions. The mortality rate rose with the number of antibiotics used; from 15% in those receiving one drug to 50% in those receiving three. A wide variety of organisms were encountered, the largest group being Staphylococcus aureus, 12 episodes; and Escherichia coli, nine episodes. Staphylococcus epidermis was pathogenic in seven patients with one death. A review of possible aetiological factors showed that 28 episodes occurred postoperatively with surgery considered directly responsible in 20. Intravenous cannulae were in place in 39 patients at the time of development of infection; they were causal in at least five; with two deaths. Urinary catheters were in situ in 14 patients and causal in at least six, with two deaths. Immunosuppression by drugs carried a worse prognosis than when infection occurred in patients with immunosuppressive disease.

Constrictive pericarditis following myocardial revascularization. A case report.

The occurrence of constrictive pericarditis after coronary bypass surgery is rare and clinical manifestations may appear at variable intervals after surgery. Three possible causes have been postulated, all of which were probably involved in the case which we describe. The clinical diagnosis of postoperative constriction is difficult and not often considered. It is best confirmed by means of cardiac catheterization, which shows typical haemodynamic features. Surgical treatment is both difficult and a threat to the coronary bypass grafts, when present. Conservative management with diuretics is preferred unless constriction is severe.

Technique, complications, and clinical value of endomyocardial biopsy in patients with heterotopic heart transplants.

A review of 157 consecutive biopsies of donor endomyocardium in patients with heterotopic heart transplants is reported. The technique of percutaneous transvenous endomyocardial biopsy after this operation is described; manipulation of the catheter and bioptome into the junction of the donor superior vena cava and right atrium can be difficult when this anastomotic junction is small, as a result either of operative surgical technique or of subsequent contraction. The complication rate was 4%, but one patient may have died from infection resulting from biopsy when the bioptome had to be introduced at the groin. The histopathological changes seen in the biopsy specimens have been graded according to a scoring system to give the clinician a guide to the severity of rejection. Histopathological assessment was of clinical value in 96% of cases, but was inaccurate on two occasions, once because an opinion was given on what was in retrospect an inadequate sample. In patients undergoing persistent low-grade acute or chronic rejection there was difficulty in detecting or appreciating the true extent of myocardial fibrosis; this led to inadequate immunosuppressive treatment in two patients. Attention is drawn to the fact that ischaemic fibrosis resulting from the vascular changes of chronic rejection may spare the endomyocardium, which is kept viable by intracavitary blood, and that this may lead to a misleading histopathological report.

Septicaemia in a general hospital.

Over a three-year period, 6102 blood cultures were performed in a large general hospital. Each year, septicaemia was diagnosed in about 0.5% of patients. Detailed examination of one-year records showed that the largest proportion was from the surgical wards, followed by the emergency admitting ward, with smaller numbers from the adult medical, renal and paediatric areas. The organism most frequently responsible was Staphylococcus aureus followed by Escherichia coli. The mortality rate rose from 16% in those treated with one antibiotic, to 58% in those given three or more. Nosocomial infections accounted for 39% of all episodes, with a mortality rate of 29%. At least five cases of these, with two deaths, were attributable to intravenous cannulae. Neutropenia and concurrent immunosuppressive drug therapy were associated with a worse prognosis, but the body temperature and leucocyte count had no prognostic significance.