Coronary artery bypass graft surgery trends in New South Wales, Australia.

OBJECTIVE: The main objective of this study was to assess the trends in coronary artery bypass graft (CABG) rates in New South Wales (NSW), Australia over a 12-year period beginning in mid-1990. These rates were examined in relation to the patients' age, gender, complications and length of stay in the hospital. METHODS: Data pertaining to the CABG surgeries performed among 72668 patients were extracted from the hospital inpatient statistics of the NSW Department of Health. The study covered all public and private hospitals in NSW. The indirect standardization technique and logistic regression modelling were used to analyse the data. RESULTS: CABG rates increased with age, peaked in the age range 65-79 years and then declined with age. The median age of the patients showed an increasing trend. While women were less likely to have a CABG, they were substantially older than men at the time of surgery. The predictors of extended post-surgery length of stay were age, insulin-dependent diabetes, acute and chronic renal failure, congestive heart failure, pulmonary disease and having more than three vein grafts. CONCLUSION: An increasing trend in older patients indicates the improvements in skills of cardiothoracic surgeons and the advancement in technology, which have enabled the doctors to treat those patients who were unable to have the surgery previously.

Survivor of a stingray injury to the heart.

Injuries to the extremities from stingray barbs are not uncommon along the Australian seaboard. Cardiac injuries from stingray barbs are rare, even worldwide, and all but one have been fatal. We report a survivor of a cardiac injury caused by a stingray barb. Penetration of a body cavity by a stingray barb requires early surgical referral and management.

Subcutaneous emphysema associated with chest tube drainage.

BACKGROUND: Subcutaneous emphysema may complicate a pneumothorax, but may also occur as a consequence of its treatment by chest tube drainage. The aim of this study was to evaluate the factors involved in the association between subcutaneous emphysema and chest tube drainage, and the clinical outcomes in these cases. METHODOLOGY: One hundred and sixty-seven patients undergoing chest tube drainage within a 12-month period were evaluated retrospectively. There were 30 reported cases of subcutaneous emphysema (SE). Comparisons were made between those with subcutaneous emphysema and those who did not develop this complication. RESULTS: A total of 134 patient notes were evaluated (25 SE and 109 non-SE). Subcutaneous emphysema was more commonly associated with trauma, bronchopleural fistulae, large and bilateral pneumothoraces, and mechanical ventilation. Subcutaneous emphysema was also associated with prolonged drainage, poor tube placement, tube blockage, side-port migration, and a greater number of chest tubes. Importantly, those with SE had a longer length of stay and increased mortality. CONCLUSION: Subcutaneous emphysema can be spontaneous or traumatic, but is associated with avoidable causes such as inadequate chest tube drainage, particularly due to poor tube placement, anchorage and blockage, and also with side-port migration into the subcutaneous tissue. It is associated with an increased morbidity and mortality, and may indicate the need for urgent chest tube replacement.

Ultra-low dose aprotinin decreases transfusion requirements and is cost effective in coronary operations.

BACKGROUND: The recommended dose of aprotinin has been shown to reduce blood loss and need for blood transfusions, but the cost precludes its routine use. This study was designed to determine whether a less expensive, ultra-low dose of aprotinin is effective when used in coronary artery bypass grafting with left internal mammary artery. METHODS: Patients (n = 202) were randomized to receive either placebo or aprotinin, 0.5 million KIU before incision and 0.5 million KIU during initiation of cardiopulmonary bypass. Differences in quantity of blood transfused were analyzed. Further groups were analyzed to account for the effect of aspirin. Multivariable analysis was performed to determine risk factors for transfusion. Direct costs of blood products and aprotinin were tabulated for each group. RESULTS: There was an important reduction in the proportion of patients transfused, and number of blood units transfused when aprotinin was given before coronary artery bypass grafting. These differences were even more important in patients on aspirin preoperatively. Independent predictors for increased number of transfusions were aspirin continued before operation, smaller body surface area, and the use of placebo instead of ultra-low dose aprotinin. There was no difference in morbidity between treatment groups. There was a reduction in direct costs associated with the use of aprotinin. CONCLUSIONS: These data support the routine use of aprotinin 1 million KIU in coronary artery bypass grafting with left internal mammary artery to reduce cost and transfusion requirements.

Gunshot wounds and stabbings: experience with 124 cases.

A retrospective study was undertaken of 124 patients admitted with gunshot and stab wounds between January 1980 and the end of June 1985. The present series found an almost equal number of gunshot wounds (65) and stabbings (59), with an increasing incidence. The patients fell heavily into the categories of being male (88.7%), in their twenties (42%) and having consumed alcohol (52% when documented). There were 77 cases of assault, with 50 of these being caused by persons known to the victim, whilst violent crimes and prison riots accounted for the rest. The majority of injuries occurred outside normal working hours, with 62% arriving at the hospital between 8 pm and 8 am. There were 14 deaths (11.3%), usually within the first 4 h, with all but one occurring in the first 24 h. Gunshot wounds resulted in a higher mortality rate (16.9% cf. 5%) and longer hospital stay.