John J. Skillman

Antacid titration in the prevention of acute gastrointestinal bleeding: a controlled, randomized trial in 100 critically ill patients.

We randomized 100 critically ill patients at risk of developing acute gastrointestinal ulceration and bleeding into two groups. One (51 patients) received antacid prophylaxis, and the other (49 patients) received no specific form of prophylaxis. Hourly antacid titration kept the pH of the gastric contents above 3.5. Two of the 51 patients who received antacid prophylaxis and gastrointestinal bleeding. Twelve of the 49 control patients bled (P less than 0.005). Of the 12 patients in the control group who bled, seven were placed on antacid medication, and all seven apparently stopped bleeding. Analysis of all the patients showed that an increasing prevalence of respiratory, failure, sepsis, peritonitis, jaundice, renal failure and hypotension was correlated with a greater frequency of bleeding. No patients required operative treatment to control bleeding. These data indicate that the occurrence of acute gastrointestinal bleeding in critically ill patients can be reduced by antacid titration.

Current complications of diagnostic and therapeutic cardiac catheterization

Data from 2,883 cardiac catheterizations performed during an 18 month period (from July 1986 through December 1987) were analyzed to assess the current complication profile of diagnostic and therapeutic procedures. Procedures performed during the study period included 1,609 diagnostic catheterizations, 933 percutaneous transluminal coronary angioplasties and 199 percutaneous balloon valvuloplasties. Overall, the mortality rate was 0.28% but ranged from 0.12% for diagnostic catheterizations to 0.3% for coronary angioplasty and 1.5% for balloon valvuloplasty. Emergency cardiac surgery was required in 12 angioplasty patients (1.2%). Cardiac perforation occurred in seven patients (0.2%), of whom six were undergoing valvuloplasty, and five (2.5% of valvuloplasty attempts) required emergency surgery for correction. Local vascular complications requiring operative repair occurred in 1.9% of patients overall, ranging from 1.6% for diagnostic catheterization to 1.5% for angioplasty and 7.5% for valvuloplasty. Although the complication rates for diagnostic catheterization compare favorably with those of previous multicenter registries, current overall complication rates are significantly higher because of the performance of therapeutic procedures with greater intrinsic risk and the inclusion of increasingly aged and acutely ill or unstable patients.

Antacid versus cimetidine in preventing acute gastrointestinal bleeding. A randomized trial in 75 critically ill patients.

Over a 15-month period, 75 critically ill patients at risk of acute gastrointestinal bleeding were randomized into two groups: one group (38 patients) received the H2-blocker cimetidine intravenously at an initial dosage of 300 mg every six hours, and the other group (37 patients) received antacid (Mylanta II) through a nasogastric tube at an intial dosage of 30 ml every hour. Gastric pH was measured hourly and titrated above 3.5. Upper-gastrointestinal-tract bleeding occurred in seven of 38 cimetidine-treated patients but in none of 37 antacid-treated patients (P less than 0.01). When antacid titration was added to the cimetidine regimen in four of seven patients with bleeding, all four stopped bleeding. Renal failure, sepsis, peritonitis, hypotension, respiratory failure, jaundice, multiple trauma, and major operative procedures were associated with an increased incidence of bleeding. Cimetidine does not adequately protect seriously ill patients from acute upper-gastrointestinal-tract bleeding. Antacid is better for this purpose.

Respiratory Failure, Hypotension, Sepsis, and Jaundice A Clinical Syndrome Associated with Lethal Hemorrhage from Acute Stress Ulceration of the Stomach

Abstract A clinical syndrome of massive bleeding from acute multiple gastric ulcers associated with respiratory failure, hypotension, sepsis, and jaundice developed in eight of 150 consecutive patients admitted to the respiratory-surgical intensive care unit of the Beth Israel Hospital. These ulcers were almost exclusively located in the fundus of the stomach. Only one of these eight patients survived. Twenty-one gastric secretory studies performed in eighteen critically ill patients indicate that increased secretion of acid may be an important cause of this disease. One patient in whom acute gastric ulceration later developed had a maximally stimulated parietal cell mass in the basal state. Patients in whom this lethal complication develops and who do not respond to nonoperative therapy are probably best treated by gastric resection and vagotomy.

Preoperative Assessment of the Carotid Bifurcation Can Magnetic Resonance Angiography and Duplex Ultrasonography Replace Contrast Arteriography

BACKGROUND AND PURPOSE Noninvasive studies are used with increasing frequency to assess the carotid bifurcation before endarterectomy. Therefore, assessment of their diagnostic accuracies is essential for appropriate patient management. We prospectively evaluate two noninvasive tests, magnetic resonance angiography (MRA) and duplex ultrasonography (DU), as potential replacements for contrast arteriography (CA). METHODS A blinded comparison of three-dimensional time-of-flight (TOF) MRA, two-dimensional TOF MRA, and DU in 176 arteries was performed. CA was used as the standard of comparison. RESULTS Three-dimensional TOF MRA had a sensitivity of 94%, a specificity of 85%, and an accuracy of 88% for the identification of 70% to 99% stenosis; two-dimensional TOF MRA had a sensitivity and specificity that were approximately 10% lower than those of three-dimensional TOF MRA. DU resulted in a sensitivity of 94%, a specificity of 83%, and an accuracy of 86%. Combining data from three-dimensional TOF MRA and DU, allowing for CA only for disparate results, yielded a sensitivity of 100%, a specificity of 91%, and an accuracy of 94% among concordant noninvasive tests, with CA required in 16% of arteries. MRA accurately differentiated 17 carotid occlusions from 16 high-grade (90% to 99%) stenoses, whereas with DU two patent arteries were identified as occluded and one occluded artery was identified as patent. CONCLUSIONS Three-dimensional TOF MRA is the most accurate noninvasive test. Combined use of MRA and DU results in a marked increase in accuracy to a level that obviates the need for CA in a majority of patients.

A prospective study of the clinical outcome of femoral pseudoaneurysma and arteriovenous fistuals induced by arterial puncture

PURPOSE Although spontaneous thrombosis of femoral false aneurysms (FAs) and arteriovenous fistulas (AVFs) has been reported, the frequency of this occurrence is unknown. This prospective study was designed to establish the natural history of FA and AVF and to evaluate factors that might predict eventual thrombosis of these lesions. METHODS Twenty-two patients with either femoral FAs (n = 16) or AVFs (n = 6) induced by percutaneous arterial punctures were evaluated prospectively. After an initial duplex scan, all patients were monitored with serial scans, either in hospital or weekly as outpatients, depending on the stability of the process. Operative repair was performed for the following indications: (1) a greater than 100% increase in size of a FA by duplex scan, (2) the development of symptoms, or (3) continued patency of the lesion after 2 months of observation. RESULTS Nine of 16 FAs and four of six AVFs closed spontaneously; FAs greater than 6 cm3 (1.8 cm in diameter) required repair more often (p = 0.065). However, size was not an absolute predictor of the need for repair because two small aneurysms (1.6 and 0.7 cm3) remained patent, although both patients were discharged safely from the hospital, and two large aneurysms (13.2 and 10.7 cm3) thrombosed spontaneously. Three of seven patients whose aneurysms required repair received anticoagulation continuously from the time of catheterization until repair became necessary. None of the patients whose FAs closed spontaneously were receiving anticoagulants at the time of thrombosis (p = 0.02). Neither length of the FA neck, velocity in the FA cavity, size of original arterial puncture, nor velocity in the AVF correlated with thrombosis. CONCLUSIONS We conclude that (1) all FAs do not thrombose spontaneously and at least one third require surgical repair, (2) patients receiving continuous anticoagulation should undergo aneurysm repair, (3) discharge of patients with FAs less than 6 cm3 is safe (the majority of these FAs will eventually thrombose spontaneously), and (4) many AVFs close spontaneously and repair is not required unless symptoms or signs of progressive enlargement develop.

Intracerebral hemorrhage following carotid endarterectomy: a hypertensive complication?

Two patients with transient ischemic attacks and subsequent minor cerebral infarction had repair of very tight carotid stenosis, 4 and 5 weeks respectively after their stroke. Each developed intracerebral hemorrhage when hypertension was uncontrolled during the post-operative period. Hypertension is a significant complication of carotid endarterectomy, and may be a prominent factor in the development of intracerebral hemorrhage post-carotid endarterectomy.

Surgical significance of popliteal arterial variants. A unified angiographic classification.

Distal popliteal arterial variations may influence the success of femorodistal popliteal and tibial arterial reconstructions. Two patients whose bypass procedures were initially unsatisfactory because of a poor choice for anastomosis stimulated a review of variations in the distal popliteal artery in 1000 femoral arteriograms. The popliteal arterial anatomy could be assessed in 605 extremities and the tibial arterial anatomy in 495 extremities. Seventy-five variant cases were identified. Normal branching of the popliteal artery was present in 92.2%. Among the 7.8% incidence of variants, the majority (72%) were either high origin of the anterior tibial artery or a trifurcation pattern. Of variant patterns to the foot (5.6%), the most common was that in which the supply to the distal posterior tibial artery arose from the peroneal artery. We propose a unified classification of the popliteal and tibial arterial variations that encompasses both anatomic areas. Variant arterial supply to the foot can be suspected when the infrapopliteal vessels show a hypoplastic or aplastic anterior or posterior tibial artery and compensatory hypertrophy of the peroneal artery. Knowledge of these variants is important to angiographers and vascular surgeons.

Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: Incidence, risk factors, and cost

BACKGROUND Wound complications after lower extremity arterial reconstruction can range from a minor lymphatic leak that causes minimal disability to a severe infection that jeopardizes the limb and life of the affected patient. This study was designed to define more clearly the incidence, severity, and the cost of these complications. METHODS During a 1-year period the infrainguinal incisions of all patients undergoing lower limb arterial reconstruction were evaluated prospectively. One hundred fifty-six infrainguinal incisions were monitored serially for the presence of infection, hematoma, seroma, serous leak, necrosis, or wound dehiscence. The need for additional treatment or services related to these complications and the cost of these services were determined. RESULTS Complications occurred in 10% of 77 infrainguinal incisions that were isolated to the groin (groin incisions) e.g., after aortobifemoral bypass, femoral endarterectomy). In only one of these patients was significant cost related to treatment of a complication. Complications occurred in 44% of 79 incisions used for femoral popliteal/tibial and pedal bypasses (distal incisions). In this latter group independent predictors of any complication were age (p=0.02) and obesity (p=0.05); predictors of in-hospital infection were preoperative evidence of venous stasis (p=0.01) and preoperative infection in the same extremity (p=0.08). Fifteen distal wound complications provided additional expense related to reoperation, extended hospitalization or rehospitalization, and rehabilitation or visiting nurse services, with a mean cost per patient undergoing reconstruction of

Retroperitoneal hematoma after cardiac catheterization: Prevalence, risk factors, and optimal management

688. CONCLUSIONS After lower limb arterial reconstruction, infrainguinal wound complications in isolated groin incisions produce minimal morbidity and cost, whereas complications in incisions after distal bypass are both frequent and associated with significant additional expense.