Joseph D. Cohn

COMPARISON OF BLOOD FLOW DURING EXTERNAL AND INTERNAL CARDIAC MASSAGE IN MAN.

Cardiorespiratory variables measured during attempts at cardiac resuscitation in 11 patients are presented. These were obtained ten times during closed-chest massage and 15 times during open-chest massage. Three patients were studied during both techniques of resuscitation. Cardiac index and stroke index were significantly better with the internal method, and the mean circulation time was significantly shorter.

The automated physiologic profile.

&NA; The automated physiologic profile provides the critical care physician with hemodynamic, oxygen consumption and tissue utilization data at reasonable cost. A paramedical assistant performs all data acquisition, recordings and blood sampling procedures. Data reduction is performed through use of off‐the‐shelf desk‐top calculator equipment and accessories and a standardized graphic display is provided for the physician in charge. The physiologic profile has been utilized in highrisk patients requiring medical and surgical interventions. It is routinely employed in postoperative monitoring of cardiac patients and patients undergoing major surgical procedures with associated cardiovascular decompensation. Diagnosis of cardiac and pulmonary deterioration and promptness of advanced support interventions represent additional areas of effective clinical application.

A shunt equation for estimating the splenic component of portal hypertension

A modification of the Berggren pulmonary shunt equation was derived for use in estimating the splenic component of portal hypertension. It was used in nine patients, six of whom had sufficient decreases in portal flow and pressure after splenic artery and coronary vein ligation. The average decrease in portal flow was 52%.

Shunt effect of carboxyhemoglobin.

Estimation of intrapulmonary blood shunt fraction requires accurate evaluation of pulmonary capillary, arterial, and mixed venous oxygen contents. The presence of carboxyhemoglobin, as well as methemoglobin and sulfhemoglobin, may lead to large errors in the calculated intrapulmonary blood shunt fraction. The errors are most pronounced at low values of carboxyhemoglobin and low values of true intrapulmonary shunt fraction.

Delayed Pacemaker Erosion due to Electrode Seal Defects

Over a 7-year period, follow-up data were available on 163 patients who underwent 209 pacemaker-related operations for initial insertion or revision of previously implanted units. During the follow-up period, 16 pacemaker generator units were remoaved from 16 pacemaker generator units were removed from 12 patients solely because of the development of local skin erosion. This represents a 7.7% incidence of pacemaker generator erosion. Tree units were removed within a 3-month interval following pacemaker implantation and were associated with positive bacterial cultures, theraby indicating an infectious cause. Findings at removal of the remaining 13 pacemaker generators included extensive fibrosis with chronic inflammation, fibroblastic proliferation, and granulation tissue, which was most prominent at the site of insertion of the pacemaker lead into the pacemaker generator unit. Granulation tissue frequently led from this area to the area of skin attenuation and erythema. Inspection of the pacemaker generator units and electrodes demonstrated fluid ingress and tissue ingrowth toward the electrode due to inadequate seal mechanisms. Inadequate seal design of the pacemaker generator and electrode junction leads to tissue ingrowth with fibroblastic proliferatiog chronic inflammation, and eventual pacemaker erosion.

Persistent left superior vena cava complicating hemodynamic monitoring catheterization.

Two cases of flow-directed, balloon-tipped catheterizations of the right heart via a persistent left superior vena cava are presented. In both cases, the monitoring catheters assumed similar, atypical configurations on plain chest roentgenograms. Recognition of the characteristic configuration of the course of transvenous catheters through the persistent left superior vena cava allows for plain film diagnosis of this anomaly.

Monitoring: Methods and Significance

Surgical monitoring, to justify its cost and risk, must provide useful information to those caring for high risk patients. A monitoring system which has worked well for the authors is based upon oxygen transport and utilization with a graphic display derived from hemodynamic and blood gas data obtained at the bedside.

Papillary adenocarcinoma in a thyroglossal cyst. Case report and review of the literature

Papillary adenocarcinoma arising in a thyroglossal cyst was described in a 46‐year‐old man. The diagnosis was based on the demonstration within the cyst wall of ectopic follicles displaying progressive alterations and atypical morphology ranging from frank epithelial unrest to early papillary formation. The sex and age distribution of the recorded cases in the literature is similar to those of the carcinoma of thyroid gland. Follow‐up of 17 pathologically documented cases point to the absence of correlation between the relatively innocent histologic picture of the neoplasm and its unpredictable biologic behavior. This strongly underlines the importance of the complete resection of the intact cyst without delay.

Spontaneous Major Intra-Abdominal Arteriovenous Fistulas: A Report of Several Cases

Most major intra-abdominal fistulas result from trauma or surgery. Sponta neous fistulas are rare with less than 100 reported cases since 1831. From a review of hospital records, five such spontaneous fistulas were identified among 215 cases of abdominal aortic aneurysm between 1975 and 1983. These cases are presented and supplemented by 73 similar cases collected from a literature re view for discussion of the salient features of clinical presentation and manage ment of spontaneous major fistulas. Major intra-abdominal arteriovenous fistulas usually present with a machin ery bruit over a pulsatile mass, but may present more subtly with pain and otherwise unexplained hematuria. Because these fistulas lead to refractory heart failure, surgery should be expeditious. Closure should be performed from within the aneurysm with arterial and pulmonary artery pressure monitoring. Care must be taken to prevent pulmonary embolization.

Physiologic profiles in circulatory support and management of the critically III

An automated system has been developed for measuring hemodynamic, oxygen transport and tissue utilization functions. Rapid measurement and data analysis of physiologic profiles by paramedical personnel allow prompt evaluation of altered cardiovascular function. Evaluation of physiologic function allows therapeutic interventions to be instituted on a timely basis, appropriately directed toward improvement of the measured cardiovascular abnormalities. Physiologic profile studies were performed on 1016 occasions in 580 patients during a three-year period and form the basis of this report. Although utilized on hospitalized patients, there are implications for use in evaluating and treating all critically ill patients.