James B.D. Mark

Tracheal Diameter Predicts Double-lumen Tube Size: A Method for Selecting Left Double-Lumen Tubes

Linear regression analysis (method of least squares) was used to evaluate tracheal width as related to patient height, weight, and age. The relationship between gender and tracheal width was assessed with analysis of variance. P < 0.05 was considered statistically significant.

Open lung biopsy in patients with acute leukemia

The results of open lung biopsy in 15 patients with acute leukemia, pulmonary infiltrates, neutropenia, and fever were reviewed. The patients averaged 26 hospital days of neutropenia and 20 hospital days of fever before open lung biopsy, and all patients received broad-spectrum antibacterial agents (mean 17 days) before open lung biopsy. Nine (67 percent) received amphotericin B prior to open lung biopsy (mean 22 days). Open lung biopsy yielded a specific clinically helpful diagnosis in six patients, but only two of these patients survived the hospitalization during which open lung biopsy was performed. Open lung biopsy detected fungus in four patients and leukemic infiltrates in two patients. Management was appropriately modified in these patients. In nine patients, a specific diagnosis of the pulmonary infiltrate was not obtained by open lung biopsy. Antimicrobial regimens were not changed substantially for these patients. In six patients, the results of open lung biopsy may have been misleading. Two patients had pulmonary fungal diseases at autopsy, undetected by open lung biopsy eight days and five weeks prior to death. Another patient had invasive aspergillosis and one had cytomegalovirus pneumonitis not detected by open lung biopsy. Two patients had false-positive preliminary histologic reports of pulmonary infection. On the basis of this experience, in this specific population of patients, open lung biopsy was often of little help in directing medical therapy or influencing clinical outcome.

Diagnosis of cytomegalovirus pneumonia in compromised hosts.

Sixteen patients with cytomegalovirus pulmonary infection are described. In 11 the diagnosis was made antemortem by lung aspirate or biopsy, and in five the diagnosis was made at postmortem by typical lung histology and positive viral lung cultures. All patients were immunosuppressed by both their underlying diseases and treatment with corticosteroids and other chemotherapy. Although other pathogens were identified at lung biopsy in most patients (73 per cent), primarily Pneumocystis carinii, evidence is offered to demonstrate that cytomegalovirus can cause significant pulmonary disease alone, leading to respiratory failure and death.

CSF and blood pharmacokinetics of hydromorphone and morphine following lumbar epidural administration

&NA; Sixteen consenting patients scheduled for elective thoracotomy were enrolled into a randomized trial of epidural morphine and hydromorphone. Each patient had a lumbar epidural catheter placed preoperatively for the purpose of post‐thoracotomy analgesia. Shortly before the end of the operative procedure each patient received 5 mg of morphine and 0.75 mg of hydromorphone via the epidural catheter. Blood was sampled at regular intervals following the opiate administration and patients were randomized to 1 of 7 cervical CSF sampling times. Blood and CSF samples were assayed for morphine and hydromorphone concentration to determine blood and CSF pharmaco‐kinetic profiles. A maximum blood morphine concentration of 60 ± 25 ng/ml (mean ± S.D.) was obtained at 11 ± 6 min (mean ± S.D.). The blood hydromorphone peak of 14 ± 13 ng/ml (mean ± S.D.) occurred 8 ± 6 min The mean peak CSF opioid concentrations of 1581 ng/ml for morphine and 309 ng/ml for hydromorphone occurred 60 min after epidural administration. The blood and CSF pharmacokinetic profiles for morphine and hydromorphone are presented. These profiles are similar for the two drugs after lumbar epidural administration.

Advantages of a New Polyvinyl Chloride Double-Lumen Tube in Thoracic Surgery

Double-lumen endobronchial tubes offer many advantages during thoracic operations. However, technical problems with tube placement and potentially life-threatening complications have discouraged widespread use of standard double-lumen tubes. Some of these problems may be reduced with a new polyvinyl chloride (PVC) double-lumen tube. A total of 214 intubations were undertaken in 204 patients using one of three endobronchial tubes. The cases of these patients were reviewed to determine differences in the complications associated with the Carlens, Robertshaw, and PVC tubes. Complications included unsuccessful or difficult intubation, tube dislodgment, unsatisfactory lung deflation, tube malposition, and hypoxemia. In 8 of 16 intubations with the Carlens tube and in 14 of 62 intubations with the Robertshaw tube, there were complications. In all, 22 of 78 intubations (28%) using conventional double-lumen tubes were complicated compared with 5 of 136 (4%) using the PVC tube. The technical problems and risks of endobronchial intubation were reduced significantly with the PVC double-lumen tube.

Combined laser therapy and endobronchial radiotherapy for unresectable lung carcinoma with bronchial obstruction

Over a 4 year period, we refined a protocol for treatment of airway obstruction due to recurrent lung carcinoma. Patients undergo bronchoscopy with the Nd:YAG laser available on standby. If bronchial obstruction is found to be due to extrinsic compression, an endobronchial catheter is inserted for iridium 192 brachytherapy, treating a cylindrical volume 7.5 to 15 mm in radius. If an endobronchial lesion is found, the presence of complete versus partial bronchial obstruction determines the course of treatment. Total airway obstruction is treated with the laser until a channel is created and then an endobronchial catheter is placed for adjuvant endobronchial radiotherapy to treat a cylindrical volume 5 mm in radius. Partial airway obstruction is treated with an endobronchial catheter and radiotherapy alone. Segmental obstruction is also treated with a distally placed endobronchial catheter instead of the laser. Using this protocol, we hope to minimize risk to the patient by restricting the use of the laser with its inherent higher potential rate of complications to cases of total obstruction. In addition, we expect to prolong the duration of palliation with endobronchial radiotherapy. The laser is an excellent tool to reopen occluded bronchi, but it is relatively ineffective in producing long-term tumor control. Instead, we have found that placement of a temporary transtracheal endobronchial catheter for radiotherapy is a simple, low-risk procedure that can be safely performed even in critically ill patients. The endobronchial catheter can provide good to excellent long-term palliation for patients with both partially and totally obstructed endobronchial lesions or malignant extrinsic compression of major airways.

Pneumothorax: A therapeutic update*

The traditional treatment of pneumothorax has been with a chest tube and hospitalization. A series of 35 patients with 41 pneumothoraces treated on an outpatient basis is presented here. A no. 12 chest tube connected to a Heimlich valve led to successful treatment in 88 percent of the cases. Failure of treatment requiring hospitalization occurred in 12 percent of cases and was due only to persistent air leaks. No complications occurred.

Continuous epidural hydromorphone for postthoracotomy pain relief

Abstract Forty-four patients were treated with a continuous infusion of lumbar epidural hydromorphone (0.05%) after thoracic operations. Postoperatively, visual analog pain scores were obtained. On postoperative day 1 and 2, more than 90% of the patients experienced either no pain (visual analog pain scale=0) or mild pain (visual analog pain score=1 to 3) at rest. The incidence of side effects (hypoventilation, pruritis, and nausea) was less than reported with other epidurally administered opioids. Continuous infusion of lumbar epidural hydromorphone produced safe, predictable analgesia after thoracotomy.

Surgical management of hepatic abscess

Abstract Fifty-five cases of hepatic abscess occurring over a twenty-eight year period are reported. The use of hepatic photoscans, early diagnosis and drainage, and the appropriate use of antibiotics have resulted in a marked improvement in mortality. The clinician must remain aware of this diagnosis if optimal results in treatment are to be obtained.

Caudal epidural morphine for post-thoracotomy pain.

A 58-year-old man with chronic low back pain underwent lumbar laminectomy at the L M level. On the morning of surgery, a chest x-ray revealed a suspicious lesion in his left upper lobe. Seven days after the laminectomy, he returned to the operating room for a thoracotomy. Past medical history was significant for acromegaly treated by transsphenoidal hypophysectomy 6 years before the current admission. Physical examination revealed a 91-kg, 180-cm male with acromegalic facial features. Blood pressure was 110166 mm Hg, heart rate 54 beatdmin, and respiratory rate 14 breaths/ min. The chest was clear to auscultation. The patient was unpremedicated. In the operating room intravenous and radial artery catheters were inserted. While in the prone position, an epidural catheter was advanced 3 cm past the end of a needle inserted into the caudal canal. After the catheter was taped to the skin, the patient returned to the supine position. A test dose of 4 ml of 1.5% lidocaine with 1/200,000 epinephrine was administered through the caudal catheter. The patient remained hemodynamically stable. Five minutes later an additional 1.5% lidocaine with 1/200,000 epinephrine to a total volume of 35 ml was injected through the catheter. After