Ivan A. May

A Comparative Study of IPPB, the Incentive Spirometer, and Blow Bottles: The Prevention of Atelectasis Following Cardiac Surgery

Following cardiac operations, 145 patients were treated with either intermittent positive-pressure breathing (IPPB), blod bottles, or an incentive spirometer in an attempt to alter the incidence of atelectasis. Pulmonary complications occurred in 30% of the patients receiving IPPB, 15% of those using an incentive spirometer, and 8% of those using blow bottles. Gastrointestinal side-effects occurred in 20% of the IPPB group and were rare in other groups. The cost of IPPB is also considerably greater than either incentive spirometry or blow bottles. IPPB is not essential to prevention of atelectasis in postoperative cardiac surgical patients and may be inferior to other methods.

Vascular complications of intraaortic balloon counterpulsation

Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

Closure of bronchopleural fistulas by an omental pedicle flap

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

Pulmonary complications in benign esophageal disease

Patients with esophageal disease often aspirate with resultant pulmonary disease. Therefore, esophageal studies should be included in the evaluation of patients with pulmonary disease. The pulmonary sequelae alone may be enough to warrant surgical correction of the esophageal disease.

Autologous blood retrieval in thoracic, cardiovascular, and orthopedic surgery

A significant amount of red blood cells were conserved with use of the Cell Saver in cardiac surgery patients and in some orthopedic and vascular surgery patients. No major complications have been associated with its use in our cases. Our results are similar to those of others who have reported on the use of this device. In the cardiac surgery patients we observed significant serum protein losses which had to be replaced. We recommend the use of intraoperative albumin to help maintain adequate urinary output and hemodynamic stability.

Early detection and management of left ventricular free wall rupture during acute myocardial infarction

Abstract Left ventricular free wall rupture is generally perceived to be universally fatal. 1–3 Although most patients who have rupture with acute pericardial tamponade die rapidly, the process may be slow enough to permit diagnosis and successful management. 4–6 We present our experience with 2 patients in whom surgical management of ventricular free wall rupture was accomplished successfully.

Emergency bypass for the community

Abstract Patients with massive pulmonary emboli, aortic rupture, and aortopulmonary fistula require emergency bypass surgery. If unavailable where the patient is hospitalized, we believe these patients should be moved because in our experience moving has not caused a deterioration in their condition. The significant factor seems to be the rate of progression of their lesion. Early diagnosis in a community hospital, intensive medical treatment, rapid mobilization of the teams of physicians involved, and early transfer of the patient make it possible for our open heart team to provide care for one to two million persons within a radius of about 50 miles. The use of a large central emergency service and helicopter transport of patients [ 8 ] can be expected to extend the radius and efficacy of this coverage.

Traumatic aneurysm of the aortic arch. Report of an unusual location.

Abstract A case is presented of chronic traumatic aneurysm of the aortic arch between the innominate and left common carotid artery. The aneurysm was resected successfully with the patient on cardiopulmonary bypass.

A Technique for Avoidance of Hypothermia During Prolonged Mechanical Circulatory Support with Centrifugal Pumps

Systemic hypothermia became a major problem in one of our patients undergoing postcardiotomy mechanical circulatory support with a centrifugal pump. We have developed a technique to prevent systemic hypothermia in this setting by applying an adapted topical cardiac cooling device to the centrifugal pump heads.