Jerrold K. Longerbeam

The modern treatment of shock based on physiologic principles

The hemodynamic disturbances resulting from shock due to hemorrhage or endotoxins and the results of several methods of treatment are presented. The experimental data indicate that vasopressors intensify the visceral vasoconstriction, ischemia, and loss of capillary integrity characteristic of severe shock. The benefical effects of corticosteroids or phenoxybenzamine combined with volume replacement are indicated.

PHYSIOLOGY AND THERAPY OF BACTEREMIC SHOCK. EXPERIMENTAL AND CLINICAL OBSERVATIONS.

OR THE past few years we have studied irreversible shock in the dog caused by prolonged hemorrhage, endotoxins or vasopressor agents. The dog has been used exclusively in these studies in an attempt to make a continuing study in one species; although there are many individual differences between the various species of mammals, the general physiologic principles are surprisingly constant among the mammals. Gram-negative bacterial shock or bacteremic shock was first described over 50 years ago in the German literature.’ Much has since been learned about this type of shock; but most important is the fact that the lipopolysaccharide or endotoxin within the cell wall is responsible for the hypotensive effects of these gram-negativ,e bacteria; hence the term endotoxin shock.2 Endotoxin causes shock by its sympathomimetic-like effect resulting in intense vasospasm in small arteries and veins in selected areas of the body, more particularlyin the I-isceral organs of a variety of species of

Central venous pressure monitoring: A useful guide to fluid therapy during shock and other forms of cardiovascular stress☆

Abstract Important relationships between venous pressure, blood volume, and cardiac output were described over fifty years ago, but the clinical application of peripheral venous pressure measurements was limited by errors in methodology and by incomplete physiologic data on the function of the venous system. There has been a recent renewal of interest in the venous system due to the advent of open heart surgery and additional physiologic data indicating that central venous pressure could be measured more accurately and would have more clinical usefulness than peripheral venous pressures. The description of new technics for cannulation of the central venous system by Richards and associates, [19] Hughes and Magovern, [20] Aubainac, [22] Keeri-Szanto, [24] and Wilson, Grow, and Demong [25] made monitoring of CVP a simple bedside procedure. A further modification of Wilsons technic involves the use of a 15 gauge, 6 inch, Rochester needle, which is introduced percutaneously into either subclavian vein. The needle is removed, leaving the outer catheter in place. A Seldinger guide wire is used to thread the catheter into the superior vena cava without fluroscopic guidance. A total of 132 catheterizations of the superior vena cava have been carried out by this technic, with a 8.3 per cent complication rate, none of which were serious. None resulted in death of the patient. CVP is not a linear function of blood volume, except under special controlled conditions that rarely exist in clinical practice. Therefore, CVP cannot be used to estimate blood volume. CVP, on the other hand, is an expression of the rate of venous return compared with the myocardial competency (the ability of the heart to handle the venous return). Since the terms “rate of venous return” and “effective circulating blood volume” are functionally similar, CVP can be used as a measure of the effective circulating blood volume related to the competence of the heart. Isolated absolute CVP measurements are of little value unless they are unusally high or low. Continuous monitoring of CVP and correlation of changes in pressure with volume expansion or contraction are useful guides to fluid therapy. CVP monitoring is an adjunctive procedure that facilitates the diagnosis and treatment of abnormal circulatory states and is most useful when related to other data, such as history, physical findings, urinary output, systemic blood pressure, pulse pressure, blood volumes, and cardiac output.

Differential diagnosis of hypercalcemia by the chloride/phosphate ratio

The serum chloride and phosphate levels were measured and the chloride/phosphate ratios calculated in a group of eighty-four hypercalcemic patients. Although patients with hyperparathyroidism frequently had phosphate levels in the low normal range (less than 3 mg/100 ml) and chloride levels in the nigh normal range (greater than 102 mEq/L), they were nevertheless significantly different from the groups of patients with nonparathyroid hypercalcemia in whom phosphate levels were usually higher (greater than 3 mg/100 ml) and chloride levels usually lower (less than 102 mEq/L). The chloride/phosphate ratio was higher than 33 in 94 per cent of hyperparathyroid patients and lower than 33 in 96 per cent of other hypercalcemic patients. Thus, the measurements of serum phosphate and chloride levels and the calculation of the chloride/phosphate ratios were useful diagnostic screening tests that discriminated between patients with hypercalcemia of parathyroid and nonparathyroid origin with an accuracy of 95 per cent.

The present status of intestinal transplantation

Abstract A procedure has been developed to remove almost the entire small bowel of the dog, preserve it in vitro at 5 °c, for five hours, and replace it as a functioning autotransplant. Dogs with such autotransplants have been followed up to three years and apparently are normal after recovery from the initial effects of the procedure. This normal function of the small bowel autotransplant occurs in the absence of any connections between the autotransplant and the central nervous system of the animal. Lymphatics regenerate within one month allowing normal fat absorption. When almost the entire small bowel of the dog is homotransplanted, evidence indicates that the bowel homograft may reject and kill the new host. This happens because the bowel homograft shows no changes characteristic of rejection at autopsy. Moreover, when short 10 to 15 cm. segments of bowel homografts are made, the new host is able to reject these grafts in the characteristic fashion. There is possibly value in attempting to find a point at which host-homograft reactions might neutralize each other.

Treatment of liver abscesses. A conservative surgical approach.

Seventeen cases of liver abscess, twelve of which were amebic in origin, are reviewed. Accurate localization of the abscess cavity by liver scan was obtained by topographic mapping in two planes Radioactive skin markers are placed around the periphery of the defect as seen on the scanner oscilloscope. A simple technic of continuous percutaneous catheter drainage of amebic abscesses is described and the results obtained are discussed.

The Physiological Basis for the Use of Pharmacological Doses of Corticosteroids in Bacterial Shock.

Excerpt Controversy continues over the use of corticosteroids in treating bacterial shock. This is largely due to the failure to appreciate the hemodynamic, chemical, and visceral tissue disturbanc...

Transplantation of the Stomach.

Excerpt Prevously we described techniques for making transplants of the entire small bowel. The success of this procedure depended upon the ability of the bowel to withstand up to 6 hours of total ...