Challenges in the development of chronic pulmonary hypertension models in large animals
2017; 7 (1): 156-166
Vascular histomolecular analysis by sequential endoarterial biopsy in a shunt model of pulmonary hypertension.
2013; 3 (1): 50-57
Pulmonary hypertension (PH) results in significant morbidity and mortality. Chronic PH animal models may advance the study of PH's mechanisms, evolution, and therapy. In this report, we describe the challenges and successes in developing three models of chronic PH in large animals: two models (one canine and one swine) utilized repeated infusions of ceramic microspheres into the pulmonary vascular bed, and the third model employed a surgical aorto-pulmonary shunt. In the canine model, seven dogs underwent microsphere infusions that resulted in progressive elevation of pulmonary arterial pressure over a few months. In this model, pulmonary endoarterial tissue was obtained for histology. In the aorto-pulmonary shunt swine model, 17 pigs developed systemic level pulmonary pressures after 2-3 months. In this model, pulmonary endoarterial tissue was sequentially obtained to assess for changes in gene and microRNA expression. In the swine microsphere infusion model, three pigs developed only a modest chronic increase in pulmonary arterial pressure, despite repeated infusions of microspheres (up to 40 in one animal). The main purpose of this model was for vasodilator testing, which was performed successfully immediately after acute microsphere infusions. Chronic PH in large animal models can be successfully created; however, a model's characteristics need to match the investigational goals.
View details for DOI 10.1086/690099
View details for Web of Science ID 000399052900015
View details for PubMedCentralID PMC5448539
Hemodynamic and Histologic Characterization of a Swine (Sus scrofa domestica) Model of Chronic Pulmonary Arterial Hypertension
2011; 61 (3): 258-262
The molecular mechanisms of pulmonary arterial hypertension (PAH) remain ill-defined. The aims of this study were to obtain sequential endoarterial biopsy samples in a surgical porcine model of PAH and assess changes in histology and mRNA expression during the disease progression. Differentially expressed genes were then analyzed as potential pharmacological targets. Four Yucatan micro-pigs underwent surgical anastomosis of the left pulmonary artery to the descending aorta. Endovascular samples were obtained with a biopsy catheter at baseline (before surgery) and from the left lung 7, 60, and 180 days after surgery. RNA was isolated from biopsy samples, amplified and analyzed. Dysregulated genes were linked to drugs with potential to treat or prevent PAH. With the development of PAH in our model, we identified changes in histology and in the expression of several genes with known or investigational inhibitors and several novel genes for PAH. Gene dysregulation displayed time-related variations during disease progression. Endoarterial biopsy provides a new method of assessing pulmonary vascular histology and gene expression in PAH. This analysis could identify novel applications for existing and new PAH drugs. The detection of stage- and disease-specific variation in gene expression could lead to individualized therapies.
View details for DOI 10.4103/2045-8932.109913
View details for PubMedID 23662174
View details for PubMedCentralID PMC3641740
All Cardiac Right Ventricular Outpouches Are Not Created Equal
2009; 30 (7): 954-957
The purpose of this work was to develop and characterize an aortopulmonary shunt model of chronic pulmonary hypertension in swine and provide sequential hemodynamic, angiographic, and histologic data by using an experimental endoarterial biopsy catheter. Nine Yucatan female microswine (Sus scrofa domestica) underwent surgical anastomosis of the left pulmonary artery to the descending aorta. Sequential hemodynamic, angiographic, and pulmonary vascular samples were obtained. Six pigs (mean weight, 22.4±5.3 kg; mean age, 7.3±2.7 mo at surgery) survived long-term (6 mo) and consistently developed marked pulmonary arterial hypertension. Angiography showed characteristic central pulmonary arterial enlargement and peripheral tortuosity and pruning. The biopsy catheter was safe and effective in obtaining pulmonary endoarterial samples for histologic studies, which showed neointimal and medial changes. Autopsy confirmed severe pulmonary vascular changes, including concentric obstructive neointimal and plexiform-like lesions. This swine model showed hemodynamic, angiographic, and histologic characteristics of chronic pulmonary arterial hypertension that mimicked the arterial pulmonary hypertension of systemic-to-pulmonary arterial shunts in humans. Experimental data obtained using this and other models and application of an in vivo endoarterial biopsy technique may aid in understanding mechanisms and developing therapies for experimental and human pulmonary arterial hypertension.
View details for Web of Science ID 000302042900010
View details for PubMedID 21819696
View details for PubMedCentralID PMC3123759
RECURRENT PULMONARY INFECTION IN AN INFANT
1993; 28 (9): 138-?
PERCUTANEOUS DENVER PERITONEOVENOUS SHUNT INSERTION
AMERICAN JOURNAL OF SURGERY
1990; 159 (6): 600-601
Congenital right ventricular diverticula and aneurysms are rare. Clinically, a diverticulum is difficult to distinguish from an aneurysm. Four diverse right ventricular cameral defects or right ventricular outpouches (RVOs) are described together with the management of each. Surgery may be necessary if an RVO has thin walls. However, if an RVO is composed of uniform thick contractile walls, conservative follow-up care likely is appropriate.
View details for DOI 10.1007/s00246-009-9474-6
View details for Web of Science ID 000270186200013
View details for PubMedID 19488803
FACTORS AFFECTING MORTALITY-RATE WITH ILIAC VEIN INJURIES
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1990; 30 (3): 320-323
A simplified technique for insertion of a peritoneovenous shunt is described. By using a "peel-away" sheath at both ends of the shunt, the insertion is much quicker and less traumatic to the patient.
View details for Web of Science ID A1990DH16900016
View details for PubMedID 2349990
MANAGEMENT OF THE INJURED COLON - EVOLVING PRACTICE AT AN URBAN TRAUMA CENTER
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1990; 30 (3): 247-253
Over an 8-year period, 49 patients were treated for iliac vein injuries with 25 (51%) deaths. The iliac vein injuries and their mortality rates (MR) were: common iliac vein--40% (6/15), internal iliac vein--65% (9/14), external iliac vein--29% (4/14), and two or more iliac veins--100% (6/6). This MR (51%) was much higher than those (18% to 38%) found in other series. The factors associated with this significantly increased MR were: Trauma Score less than 11 (MR = 71% or 24/35), initial OR systolic BP less than 70 mm Hg (MR = 89% or 15/17), ISS greater than 28 (MR = 65% or 24/37), 10 or more units of blood in the first 24 hours (MR = 65% or 22/34), and no obtainable BP on admission to the ED (MR = 65% or 15/22). Although the overall calculated probability of survival (Ps) by TRISS methodology was 0.43, several deaths might have been prevented by more complete resuscitation including restoration of core temperature above 34 degrees or 35 degrees C, and by packing the pelvis and closing rather than allowing three or more separate additional hypotensive episodes to occur while attempting definitive control of bleeding vessels.
View details for Web of Science ID A1990CW83900010
View details for PubMedID 2313751
PREDICTING AND PREVENTING INFECTION AFTER ABDOMINAL VASCULAR INJURIES
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1989; 29 (10): 1371-1375
The records of 239 patients surviving more than 24 hours with full-thickness intraperitoneal colonic injuries over a 7-year period were reviewed. During the first 3 years, 29% (31/106) of the patients were managed by primary repair without colostomy. In the next 4 years, almost twice as many patients, 56% (75/133), with similar colonic trauma were treated without fecal diversion (p less than 0.05). Although there was no difference in the mean Trauma Score in the patients with primary repair in the two time periods, the Injury Severity Score (mean +/- sd) in the patients without colostomy in the later periods was significantly higher (17.8 +/- 2.1 vs. 20.2 +/- 5.1) (p less than 0.001). No patient suffered because of the increased incidence of primary repairs. These patients had five abdominal abscesses and only one leak, whereas the patients with colostomy had 15 intraperitoneal abscesses. Because of the safety when primary repair is performed, more liberal use of primary colonic repair following penetrating trauma is warranted.
View details for Web of Science ID A1990CW83900001
View details for PubMedID 2313743
VASCULAR INJURY ABOUT THE KNEE - IMPROVED OUTCOME
1989; 55 (6): 370-377
Of 210 patients with major intra-abdominal vascular injuries, 111 (53%) survived more than 48 hours. Of these, 41 (37%) developed serious infections resulting in death or a hospital stay exceeding 14 days (mean, 55 +/- 49) in the 33 who survived. The most frequent serious infections were intraperitoneal and resulted in a 35% mortality rate (8/23). The 111 patients surviving 48+ hours were divided into two groups based on their initial E.D. BP and injuries. The "high-risk" patients (with no obtainable blood pressure on admission, five or more injuries or a colon injury with a systolic BP of 40 to 89 mm Hg) had a serious infection rate of 63% (25/40). This was significantly higher than the serious infection rate of 23% (16/71) in the remaining 71 "low-risk" patients (p less than 0.001). The patients were then evaluated for factors which surgeons might control. In the high-risk group, resuscitation adequate to produce an initial operating room (O.R.) systolic BP greater than 70 mm Hg and early control of bleeding so that less than 10 units of blood were used resulted in a serious infection rate of only 20% (2/10) versus 77% (23/30) in the other high-risk patients (p less than 0.01). In the low-risk patients, having an initial O.R. systolic BP greater than 70 mm Hg and using less than 10 units of blood resulted in a serious infection rate of 13% (6/48) versus 43% (10/23) in the others (p less than 0.05). High-risk patients failing to meet these resuscitation goals must be watched particularly carefully for development of infections.
View details for Web of Science ID A1989AW86000014
View details for PubMedID 2810413
OUTCOME OF TRAUMA PATIENTS WHO PRESENT TO THE OPERATING-ROOM WITH HYPOTENSION
1989; 55 (6): 338-342
The records of 41 patients with 43 vascular injuries about the knee (34 popliteal artery, five tibial-peroneal trunk, one proximal anterior tibial artery, and three isolated popliteal veins) were analyzed. The etiology of the injuries were gunshot wounds (22), blunt trauma (11), shotgun wounds (4), and stab wounds (4). Associated injuries included fractures (67%), popliteal vein (54%), and nerves (32%). Arterial repairs consisted of primary repair (19), lateral repair (1), saphenous vein grafts (13), and saphenous vein patching (1). Five patients received polytetrafluoroethylene (PTFE) grafts. Fasciotomy was performed in 27 limbs. The associated venous injuries (21) and isolated venous injuries (3) were managed with ligation (14), primary repair (9), and vein patch (1). The amputation rate was 11 per cent for popliteal artery injuries (4/34). No other amputations were required. All four amputations were associated with massive limb injury (3) or diagnostic delay (1). One patient died during hemodialysis for renal failure resulting from prolonged shock and myoglobinuria. Successful management correlates best with prompt repair of both popliteal arterial and venous injuries and early fasciotomy. Vein repair (vs ligation) is associated with better long-term results.
View details for Web of Science ID A1989U969400011
View details for PubMedID 2658706
CENTRAL LUNG INJURIES - A NEED FOR EARLY VASCULAR CONTROL
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1988; 28 (10): 1418-1424
The case records of 101 patients with trauma who presented to the operating room (OR) for emergency surgery and had a systolic blood pressure (sBP) less than 90 mm Hg over a period of 3 years were reviewed. The sBP was 70-89 mm Hg in 47 patients, 50-69 mm Hg in 19 patients, and unobtainable in 35 patients. The mortality rates for these three groups were 6 per cent, 79 per cent, and 86 per cent, respectively. The increase in mortality rate with a sBP less than 70 mm Hg was highly significant (p less than 0.001). The duration of initial shock in the OR and emergency department (ED) exceeded 30 minutes in 56 patients, and 35 patients (62%) died. In contrast, of 45 patients who had less than 30 minutes of shock, only 13 patients (29%) died (p less than 0.001). Of the 54 patients who presented to the OR with a sBP less than 70 mm Hg, 42 patients had early cross-clamping of the thoracic aorta. This was performed as a prelaparatomy thoracotomy in 25 patients with abdominal injuries and as part of the thoracotomy in 17 patients with chest trauma. Nineteen (45%) of these 42 patients responded favorably to aortic cross-clamping with a sustained increase in sBP to greater than 90 mm Hg within 5 minutes. Of these 19 patients, 42 per cent survived. The 23 patients who did not respond to aortic cross-clamping died in the OR.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1989U969400004
View details for PubMedID 2729768
ENDOSCOPIC RETROGRADE SPHINCTEROTOMY IN THE TREATMENT OF BILIARY-TRACT DISEASE
1988; 54 (7): 412-418
During a 7-year period (1980-1987), 161 patients underwent emergency thoracotomy for penetrating lung injuries. Of these, 25 (15%) had injuries involving central pulmonary (hilar) vascular structures. Anterolateral thoracotomies were performed in 14 patients because of unstable vital signs (ten) or cardiac arrest (four), and only two (14%) of these patients survived. In seven of these patients the incision was extended into a bilateral thoracotomy to provide better exposure for continued severe bleeding, and all seven died. Of 11 relatively stable patients having a posterolateral incision (ten) or a median sternotomy (one), only two (18%) died. Of 18 patients in whom the initial procedure was hilar clamping, ten (63%) survived. In seven patients an attempt was made to control the bleeding before hilar clamping and only one (14%) survived. In six patients, resection of a lobe (five) or a segment (one) was used to achieve hemostasis with five (83%) survivors. Eight of the 14 deaths were clearly due to blood loss, which was treated with an average of 19.5 units of blood. However, in six of the earlier deaths with much less blood loss, air emboli may have been a factor, but was unproven. Early vascular control at the hilum for central lung injuries seems to be needed not only to stop the bleeding but also to prevent systemic air emboli.
View details for Web of Science ID A1988Q605900002
View details for PubMedID 3172299
INFERIOR VENA-CAVA INJURIES - THE CHALLENGE CONTINUES
1988; 54 (7): 423-428
Endoscopic retrograde sphincterotomy (E.R.S.) is rapidly becoming popular. In the past 5 years, E.R.S. was technically successful in 124 of 130 patients (95%) in whom it was attempted. One hundred twenty four had choledocholithiasis, and six had papillary stenosis after cholecystectomy. Urgent E.R.S. was performed for septic cholangitis in 12 patients and biliary pancreatitis in four. There were six patients with choledocholithiasis in whom sphincterotomy was not possible. Of the 118 patients with successful papillotomy for choledocholithiasis, spontaneous passage of calculi after E.R.S. occurred in 28 cases (24%), and instrumental extraction of stones was possible in 81 (69%). Duct clearance failed in nine patients (8%), mostly due to the large size of the retained stones. The largest stone extracted was 26 mm in diameter. The overall success rate of removing common bile duct stones was 109 in 118 cases (88%). In patients with papillary stenosis, E.R.S. was successful in relieving symptoms and biochemical cholestasis in six of six cases (100%). Complications occurred in only two patients. The complications were pancreatitis in one and hemorrhage in one. None of these patients required surgical treatment of the complication. Endoscopic retrograde sphincterotomy is effective for the removal of stones of the common bile duct, and at relieving the symptoms of papillary stenosis. It is safe in experienced hands and has led to only rare complications.
View details for Web of Science ID A1988P098400004
View details for PubMedID 3389588
GASTROJEJUNOSTOMY - IS IT HELPFUL FOR PATIENTS WITH PANCREATIC-CANCER
1987; 102 (4): 608-613
The records of 67 patients with inferior vena cava (IVC) injuries seen from 1980-1986 were reviewed. The mortality rate (MR) overall was 57 per cent, and for specific portions of the IVC it was: retrohepatic - 60 per cent (9/15); suprarenal 59 per cent (16/27); pararenal - 45 per cent (5/11); and infrarenal - 57 per cent (8/14). Several prognostic factors were identified. Of 44 patients who presented to the emergency department (ED) with a BP less than 70 mm Hg, 33 (75%) died. Of 28 patients who experienced greater than 30 minutes of shock, 15 (83%) died. Of 26 patients presenting to the OR with a systolic blood pressure less than 70 mm Hg, 22 (85%) died. Of 40 patients who received greater than 10 units of blood in the ED and OR, 31 (78%) died. Of 19 patients who had a prelaparotomy thoracotomy with cross-clamping of the thoracic aorta for persistent severe shock (BP less than 70), nine responded rapidly with a sustained increase in systolic BP to greater than 90 mm Hg with four (44%) survivors. All ten patients who did not respond to prelaparotomy aortic cross-clamping died in the OR. Of seven patients with persistent shock (BP less than 70) without a prelaparotomy thoracotomy, there were no survivors. Six patients with retrohepatic IVC injuries underwent atrio-caval shunting with no survivors; of nine others with similar injuries treated without a shunt, six (67%) survived. Of 18 patients who received more than ten units of blood and survived the surgery, ten (56%) developed septic complications, and four of these patients died. Of 17 patients who received less than ten units of blood and survived the surgery, none became septic. Thus, early control of shock and bleeding is essential, not only to reduce mortality rate, but also later septic complications.
View details for Web of Science ID A1988P098400006
View details for PubMedID 3389590
HEMOPTYSIS IN TRAUMA
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1987; 27 (10): 1123-1126
A retrospective review of palliative outcome of gastrojejunostomy in patients with pancreatic cancer was conducted. Eighty-one patients were analyzed in two groups depending on duodenal patency. Forty-five patients (group I) had no evidence of duodenal obstruction. Thirty-six patients (group II) had evidence of impingement on the duodenum by the pancreatic cancer. A third subset of patients was also studied for outcome. These 21 patients (five group I and 16 group II) had nausea and vomiting as major symptoms and were judged to have the most to gain from gastrojejunostomy. Patients were categorized by outcome. Poor outcome was defined as either death during the hospitalization for gastrojejunostomy or death within 30 days of operation even if the patient left the hospital. Risk for poor outcome depended on group. In group I, 18 of 45 patients (40%) had a poor outcome compared with 25 of 36 (70%) patients in group II (p less than 0.001). Nineteen of the 21 (90%) patients with nausea and vomiting had a poor outcome. It is an unfortunate paradox that the more patients need gastrojejunostomy for pancreatic cancer, the less likely they are to have a favorable outcome. Gastric outlet obstruction in pancreatic cancer appears to be a terminal event. A prospective study is needed to see if any true palliation of vomiting can be affected in these patients.
View details for Web of Science ID A1987K318800009
View details for PubMedID 2443991
INJURIES TO THE ABDOMINAL VASCULAR SYSTEM - HOW MUCH DOES AGGRESSIVE RESUSCITATION AND PRELAPAROTOMY THORACOTOMY REALLY HELP
1987; 102 (4): 731-736
In an attempt to more clearly delineate the importance and pathophysiology of moderate-severe hemoptysis, a clinical and experimental study was performed. The clinical portion consisted of a retrospective review of 344 patients undergoing thoracotomy for penetrating trauma. There were 138 patients with injuries to the trachea, mainstem bronchi or lungs. Six with GSW to the chest had severe hemoptysis in the Emergency Department (ED) and had a cardiac arrest just after endotracheal intubation. At thoracotomy, all six had air in their coronary arteries and could not be resuscitated, Of 14 patients with posterolateral OR thoracotomies, three had significant (20-30 mm Hg) drops in systolic pressure plus increased aspiration of blood into the dependent lung when turned onto their sides. Of 12 patients surviving surgery, six with continued aspiration of blood required prolonged ventilatory support. In an experimental study, minimally heparinized (0.07 units/ml) blood was infused into the lower trachea of 17 anesthetized normovolemic supine dogs at 0.15 ml/kg/min. The PaO2 fell from 100 +/- 11 to 65 +/- 16 mm Hg after infusion of 4.5 ml/kg of blood. At the same time peak ventilator pressure rose only minimally (8.5 +/- 1.7 to 11.2 +/- 3.1 mm Hg). The PCO2, mean PA pressure, PAWP, CVP, and cardiac output were essentially unchanged. In a second study of 18 dogs, reducing the systolic BP by one third reduced cardiac output by almost 48% and oxygen transport by 58%. After 4.5 ml/kg blood were infused into the trachea, the PaO2 fell from 84 +/- 19 to 52 +/- 9 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1987K655500005
View details for PubMedID 3669107
USEFULNESS OF SELECTIVE PREOPERATIVE CHEST-X-RAY FILMS - A PROSPECTIVE-STUDY
1987; 53 (7): 396-398
The records of 154 patients with 254 abdominal vascular injuries seen over 5 years (1980 to 1985) were reviewed. The overall mortality rate (MR) was 46%. This included 100% (5/5) for blunt injuries, 49% (59/119) for gunshot wounds, and 23% (7/30) for stab wounds. The most common venous injuries and the MRs were: inferior vena cava, 59% (33/56) and iliac veins, 65% (10/16). The most common arterial injuries and the MRs were: aorta, 68% (15/22), iliac artery, 57% (12/21), and superior mesenteric artery, 67% (8/12). Of 84 patients who presented to the emergency department (ED) with a blood pressure (BP) less than 70 mm Hg, 60 (71%) died, and of 64 patients with four or more associated injuries, 41 (64%) died. Failure to reduce the duration of shock, amount of bleeding, or severity of hypotension before surgery is highly lethal. Of the 42 patients who had shock for more than 30 minutes, 38 (90%) died. Of the 93 patients who received more than 10 U of blood in the ED and operating room (OR) 60 (64%) died. Of the 60 patients presenting to the OR with a systolic BP less than 70 mm Hg, 52 (87%) died. Prelaparotomy cross-clamping of the thoracic aorta for persistent shock is controversial. However, of the 26 patients with this procedure, 12 responded with a sustained increase in systolic BP greater than 90 with five (42%) survivors. Of the 14 no responders, none survived. Of 17 patients with persistent shock without a prelaparotomy thoracotomy, only one (6%) survived. In the high-risk group (admission systolic BP less than 70 mm Hg and four or more associated injuries), if shock was kept to less than 30 minutes and bleeding to 10 U of blood or less, the MR was reduced from 92% (24/26) to 0% (0/12). In patients presenting to the OR with a BP less than 70, a prelaparotomy cross-clamping of the aorta should be considered. In those patients not responding, prolonged surgical efforts are futile.
View details for Web of Science ID A1987K318800026
View details for PubMedID 3660244
ACUTE INJURIES OF THE DIAPHRAGM - AN ANALYSIS OF 165 CASES
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
1986; 92 (6): 989-993
Preoperative screening chest x-ray studies continue to be used widely despite the high cost and reported low-yield. Most physicians now use "clinical judgment" to mitigate the frequency of chest x-ray. To determine the usefulness of "selective" preoperative chest x-ray studies, 403 consecutive patients undergoing operation were prospectively studied. Chest x-ray films were analyzed both for abnormality and the frequency with which the changes seen on x-ray films led to cancellation of surgery or resulted in a further evaluation of the pathology discovered. There were 228 male and 175 female patients, (average age: 54 years). A total of 166 (41%) patients had operations performed without a preoperative chest x-ray study. The x-ray studies on 136 of the 237 patients who had preoperative chest x-ray were considered normal. A variety of abnormalities such as effusion, cardiomegaly, atelectasis, or granuloma were found in the remaining 101 patients. Sixty-four of these patients were known from previous studies to have the abnormality that was recorded. Eight of 37 (21%), who had surgery as scheduled, subsequently underwent evaluation for the new pulmonary problem detected on x-ray films. Only two operations were cancelled as a result of the screening x-ray. The majority of abnormalities detected were already known or were considered insufficient for further evaluation. In a metropolitan area of Michigan the cost for a chest x-ray is $70. Projected nationwide, more than $1 billion could be saved on needless "selective" preoperative chest x-ray studies each year. These data suggest that preoperative chest x-ray is still widely overused.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1987J369500010
View details for PubMedID 3605857
ABDOMINAL VENOUS INJURIES
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1986; 26 (9): 771-778
The records of 165 patients with diaphragmatic injuries seen at Detroit Receiving Hospital from July 1980 through June 1985 were reviewed. Causes included gunshot wounds in 89 patients, stab wounds in 65, and blunt trauma in 11. Mortality rates were 18%, 5%, and 27%, respectively, deaths being caused primarily by bleeding from associated injuries. Operations on these patients included laparotomy in 123 (75%), thoracotomy in four (2%), and both in 38 (23%). The mortality rates for these operations were 0%, 50%, and 53%, respectively. A presumptive preoperative diagnosis of diaphragmatic injury from chest x-ray findings was possible in only 24 (15%) patients. Of 42 thoracotomies, five were performed in the emergency department for cardiac arrest, with three (60%) deaths. Of 37 thoracotomies performed in the operating room, 17 were for thoracic injuries with six (35%) deaths and 20 were for resuscitation for abdominal injuries with 13 (65%) deaths. In most patients, the diaphragmatic injury was critical only in warning the surgeon that severe injuries might be present in both the chest and abdomen. Of 43 patients admitted with a blood pressure of less than 70 mm Hg or four or more associated injuries, 22 died. However, even in these high-risk patients, if resuscitation raised the initial operating room blood pressure to more than 70 mm Hg, reduced the shock time to less than 30 minutes, and kept blood loss below 10 units, the mortality was only 8% (1/12). In contrast, if none of these conditions could be met, the mortality in this high-risk group was 100% (16/16). Thus more aggressive resuscitative efforts and earlier control of bleeding seem to provide the best chance for improved survival.
View details for Web of Science ID A1986F128600004
View details for PubMedID 3784594
To improve our understanding of this frequently lethal, but potentially salvageable problem, the case records of 105 patients with 138 major intra-abdominal venous injuries seen over a 4 year period (1980-1984) were reviewed. The overall mortality rate was 54%. The most frequent abdominal venous injuries and their mortality rates were inferior vena cava, 54% (28/52); portal venous system, 51% (16/31); iliac veins, 71% (20/28); renal veins, 58% (11/19); and hepatic veins, 88% (7/8). Several important prognostic factors were identified. Of 48 patients who presented to the emergency department with no obtainable blood pressure, 41 (85%) died. Forty patients presented to the operating room with a systolic pressure less than 70 mm Hg and 36 (90%) died. Of 39 patients in hypovolemic shock for more than 15 minutes initially in the ED and operating room, 31 (79%) died. Of 71 patients who received 10 or more units of blood pre- and perioperatively, 48 (68%) died. Of 41 patients with five or more associated injuries, 30 (73%) died. Seventeen had a thoracotomy before laparotomy to cross-clamp the aorta for persistent severe shock; six responded with a substantial increase in blood pressure and three survived. Of 14 others with severe persistent shock who did not have a prior thoracotomy, only one survived. Atrial-caval shunts were attempted for severe retrohepatic bleeding in six patients with no survivors. Review of these cases suggests that improved survival might be obtained with: more vigorous administration of fluids in the emergency department and operating room; quicker movement to the operating room to control bleeding; and earlier definitive management for controlling bleeding--especially with iliac and/or retrohepatic injuries. A thoracotomy to cross-clamp the aorta prior to laparotomy with severe persisting shock should be considered.
View details for Web of Science ID A1986E062800001
View details for PubMedID 3746951