Preoperative cardiac assessment of the candidate for major resective pancreatic surgery.

The risk of perioperative cardiac morbidity and mortality can be predicted based on clinical assessment and noninvasive testing for the detection of myocardial ischemia. Appropriate preoperative interventions in high-risk patients are indicated. Medical intervention with beta blockade is particularly effective.

Postoperative care of the pancreatic surgical patient: the role of the intensivist.

Improved patient selection and intraoperative techniques have reduced the need for an intensivist in the care of the pancreaticoduodenectomy patient. Perioperative hemodynamic fine-tuning and the precise management of postoperative complications, however, are areas in which an intensivist can offer expert help. An approach to hemodynamic management and the use of mechanical ventilation is offered. Meticulous detail in each organ system is stressed.

Peripheral vascular trauma: a civilian experience.

A detailed review of 106 vascular injuries seen at the Mt. Sinai Hospital of Cleveland in a period of six-and-a-half years is presented. The type and location of the vascular injuries, the concomitant injuries, the preoperative evaluation, operative and post operative management, the complications and their management are discussed. The overall amputation rate in our cases was 4.7%, and for popliteal artery injuries 20%. The mortality rate was 5.6%.

Transfusion-associated cytomegalovirus mononucleosis.

Transfusion-associated cytomegalovirus mononucleosis is generally considered only as a complication of extracorporeal circulation following cardiac surgery. Three cases following trauma were recognized in less than one year. Both massive and limited volume blood transfusions were involved. Hectic fever was a characteristic feature in these otherwise remarkably asymptomatic individuals, without the classic features of heterophile-positive infectious mononucleosis. Since the illness developed several weeks into the post-operative period after extensive thoracic or abdominal trauma surgery, the presence of an undrained abscess was naturally the major diagnostic concern. Atypical lymphocytosis, markers of altered immunity (cold agglutinins, rheumatoid factor) and moderate hepatic dysfunction were important laboratory clues. In one case, focal isotope defects in the spleen scan misleadingly suggested a septic complication. A false-positive monospot test initially obscured the correct serologic diagnosis in the same patient. Failure to consider this selflimited viral infection may be a critical factor leading to unnecessary surgery. Other viral agents capable of eliciting a similar syndrome are cited.

Small-bowel obstruction due to congenital anomaly of the falciform ligament.

A patient who initially had a small-bowel obstruction was found, at laparotomy, to have an internal hernia through a defect of the falciform ligament. Simple resection of the round ligament was curative. The defect is presumed to have been congenital in origin. No previous report could be found in our review of the literature.

Gastrointestinal bleeding: treatment with intra-arterial vasopressin.

Seventeen patients with upper and lower gastrointestinal hemorrhage were treated with selective intra-arterial continuous vasopressin infusion. 62.5 per cent of variceal and 60 per cent of nonvariceal episodes of hemorrhages were permanently controlled by vasopressin. The initial total success rate was 76.5 per cent. No major complications occurred. Early success with this technique has encouraged its continued use under a controlled setting for indications for its use to be evaluated.