Gery Vermaut

Chronic leg pain in athletes due to a recurrent compartment syndrome

A series of 29 patients, all engaged in sports activity on a regular basis, suffering from recurrent compart mental syndrome, is reported. The syndrome is not restricted only to long distance runners but to athletes involved in a variety of sports activities (soccer, volley ball, cycle racing, gymnastics, judo, physical education, and long distance running). Although most patients presented activity-related leg pain, some patients mainly complained of ankle weakness and recurrent ankle distortions at fatigue. The wick catheter technique proved to be most useful to determine which compartments were involved. The severity of clinical symptoms correlated highly with the anomalies of the tissue pressure measurements. The predominance of deep posterior compartment and mul tiple compartment involvement are in contrast with most previous reports. Conservative treatment was unsuccessful in every patient, whereas surgical de compression of the involved compartments yielded fa vorable results in those cases where all the involved compartments were released.

Effects of 6% hydroxyethyl starch and 3% modified fluid gelatin on intravascular volume and coagulation during intraoperative hemodilution.

In the perioperative period, artificial colloids are most often infused in doses of 500-1000 mL intravenously. This randomized study compared the effects on intravascular volume and coagulation of approximate 2000 mL of two isooncotic artificial colloids: 6% hydroxyethyl starch (HES; MW 200,000; substitution ratio 0.40-0.55) and 3% modified fluid gelatin (GEL). We hypothesized more pronounced hypocoagulation with HES and a weaker intravascular volume effect of GEL. Forty-two patients, scheduled for primary total hip replacement, were allocated randomly to receive HES or GEL during acute normovolemic hemodilution and subsequent further intraoperative hemodilution. Blood samples were taken before and after 500 mL and 1000 mL of acute normovolemic hemodilution; intraoperatively after 20 mL/kg of artificial colloid and at the end of colloid infusion; on arrival in the recovery room; and 3 h later. We quantified: 1) coagulation variables; 2) blood loss; 3) hemodynamic stability; 4) necessary infusion volume; 5) interstitial extravasation, calculated from plasma volumes measured using albumin marked with technetium-99m and iodine-125, respectively; 6) percentage volume effect at the end of the study as well as hematocrit, total serum protein, and colloid osmotic pressure. Intraoperative volume therapy was guided by radial systolic pressure and systolic pressure variation, mixed venous hemoglobin saturation in the pulmonary artery, and pulmonary capillary occlusion pressure. The following differences (HES vs GEL, P < 0.05) were found: 382 vs 725 mL extravasation; 76% vs 56% intravascular volume expansion 7 h after the median point of artificial colloid infusion; 27% vs 29% hematocrit and 35 vs 45 g/L total serum protein on arrival in recovery; 4 vs 0 abnormal bleeding times (>900 s); 3437 vs 2778 mL blood loss. This study quantifies a poorer volume effect of GEL and a higher blood loss with HES. The higher blood loss was significant with one-tailed testing only. These observations warrant extra GEL infusion to avoid hemoreconcentration and caution with large dose HES. (Anesth Analg 1995;81:1235-42)

Surgical treatment of bronchogenic carcinoma: A retrospective study of 720 thoracotomies

Seven hundred and twenty patients with primary bronchogenic carcinoma were operated on at the Pellenberg Clinic, K.U. Leuven, Belgium, between January 1, 1970, and January 1, 1985. Almost 45% of the resections were pneumonectomies and 47% were lobectomies. Mortality was 6.9% and 2.9%, respectively. Patients with squamous cell carcinoma (Stages I and II) who underwent lobectomy or pneumonectomy had an absolute 5-year survival rate of 52.8% (93/176); it was 21% (4/19) in the T3 N0/N1 subgroup. Patients with adenocarcinoma who underwent a lobectomy had a 5-year survival rate of 49% (26/53) in the T1/T2 N0 group and of 27% (3/11) in the T1/T2 N1 group. Only 13.6% (3/22) of patients survived 5 years if a pneumonectomy had to be performed. Only 1 in 22 N2 patients survived 5 years after resection.

Propofol does not inhibit hypoxic pulmonary vasoconstriction in humans

The influence of increasing doses of propofol (from 6 to 12 mg/kg/h by continuous infusion) on hypoxic pulmonary vasoconstriction was studied in 10 patients prior to thoracic surgery. All patients were intubated with a left-sided double-lumen endobronchial tube. Initial anesthesia and muscle relaxation were accomplished by administering fentanyl, droperidol, and pancuronium. After 100% oxygen ventilation of both lungs for 20 min in a lateral decubitus position, the nondependent lung was deflated and one-lung ventilation was started. The dependent lung was continuously ventilated with 100% oxygen. Twenty minutes after the start of one-lung ventilation, propofol at an IV infusion rate of 6 mg/kg/h was added to the anesthetic technique. Thirty minutes later it was increased to 10 mg/kg/h and another 15 min later to 12 mg/kg/h. Then the propofol infusion was stopped. Thirty minutes later, two-lung ventilation was restarted to compare initial values. No changes in venous admixture or PaO2 were observed during propofol infusion. There was no change in any respiratory or circulatory variables except systemic vascular resistance, which decreased significantly immediately after the propofol infusion commenced but returned to control values 15 min later for the rest of the observation period. After reestablishing two-lung ventilation, all variables did not differ from control values. In all patients, the hypoxic pulmonary vasoconstriction reflex was present after institution of one-lung ventilation and was not abolished after administration of propofol in doses from 6 to 12 mg/kg/h.

Quality of washed salvaged red blood cells during total hip replacement: a comparison between the use of heparin and citrate as anticoagulants

A randomized, prospective study comparing heparin with citrate (ACD) as anticoagulant during red blood cell saving was performed in 10 ASA grade 1-II patients undergoing primary total hip replacement. Blood samples were taken before and after surgery and at several steps during cell saving. In the heparin group, salvaged red cells showed normal values, with the exception of decreased filtrability and moderate hemolysis. More differences in red cell quality were found in the ACD group. Mean corpuscular volume was higher (110 vs 95 x 10−12 mL), red cell distribution was increased (17% vs 13%), osmotic resistance was lower (0.54 vs 0.43 g NaCl/L at 50% hemolysis), antioxidative reserve capacity was lower (1.9 vs 4.6 U glutathione reductase per gram of hemoglobin) and there was more hemolysis (15% vs 11%). Despite the small volume of autologous blood retransfused (388 ± 92 mL), the differences in vitro produced significantly higher free hemoglobin levels in the patients plasma at the end of the operation (58 vs 23 mg/dL). We conclude that heparin is preferable to citrate as an anticoagulant during autotransfusion with cell washing and immediate retransfusion.

A simple method for calculating component dilution during fluid resuscitation: The Leuven approach

STUDY OBJECTIVES To test the reliability of the Leuven approach, a balance between oversimplified empiric rules and more complex calculations requiring the use of nomograms or computers, to determine blood component dilution during large transfusions. To present schemes for blood component dilution and stabilization, as well as four examples showing the practicability of the method. DESIGN Prospective study. SETTING Orthopedic operating rooms at a university hospital. PATIENTS 108 patients undergoing total hip replacement with expected large blood loss. INTERVENTIONS Component concentrations were measured after patient arrival in the recovery room. Blood loss was followed clinically. MEASUREMENTS AND MAIN RESULTS Preset target component concentrations [hematocrit (Hct) 31%; total serum protein (TSP) 5.0 g/dl; prothrombin time (PT) 50%; blood platelets (BLPL) 50,000/microliters)] were compared with concentrations measured on arrival in recovery after dilution and stabilization, according to the transfusion scheme. Average blood loss was 3,226 +/- 1,600 ml (mean +/- SD). End component concentrations were Hct, 33.4% +/- 3.3%; TSP, 5.2 +/- 0.5 g/dl; PT, 52% +/- 12%; BLPL, 97,000/microliters. Hct and TSP showed significant (p < 0.05) but clinically unimportant differences from target concentrations. Possible reasons for variability in end concentrations are discussed. CONCLUSION The Leuven approach produces reliable blood component concentrations after extensive transfusions. It allows the clinician to decide for himself or herself, in accordance with general consensus and the patients individual needs, when to stabilize blood components.