Louis R. M. Del Guercio

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 use of mixed venous blood gas determinations in traumatic shock.

A series of 10 seriously injured patients requiring resuscitation and definitive operative control of hemorrhage was studied. Simultaneous arterial and mixed venous blood gases were measured sequentially throughout the resuscitative and operative periods. Improvement of the mixed venous oxygen saturation was associated with survival. In this study, mixed venous oxygen saturations were valuable predictors of survival and were a helpful parameter to monitor during the resuscitative, operative, and immediate postoperative periods.

Preoperative Assessment of High-Risk Surgical Patients

From the foregoing accounts of preoperative assessment of myocardial performance, as well as preload and afterload status it is clear that the proper anesthesia techniques and agents can be selected. Physiologically optimal adjustments of preload, afterload, and myocardial function can be attained by the appropriate, harmonious selection of anesthesia technique and vasoactive drugs made on the basis of close hemodynamic monitoring preoperatively, intraoperatively, and in the immediate postoperative period.

An Integrated Procedure for the Rapid Diagnosis of Biliary Obstruction, Portal Hypertension and Liver Disease of Uncertain Etiology

Abstract An integrated procedure consisting of transhepatic cholangiography, liver biopsy and omentoportography, performed under local anesthesia through a 5-cm subxiphoid incision, was used in 100 patients with hepatobiliary disorders that presented major diagnostic or therapeutic problems. Cholangiography was successful in 80 of 91 patients, liver biopsy in all of 54 patients, and omentoportography in 13 of 15 patients. Diagnosis was achieved in all cases. The frequency of two of the three major complications that occurred should be reducible by sulture ligation of puncture sites. There were no deaths attributable to the procedure. Coagulation abnormalities were present in 29 patients. The only recognized contraindication is sensitivity to contrast medium. The integrated procedure is an effective method of resolving puzzling cases of hepatobiliary disease and should save much time and expense. It has also been helpful in the planning and execution of surgery for biliary obstruction and portal hypertension.

A Metropolitan Airport Disaster Plan—Coordination of a Multihospital Response to Provide On-site Resuscitation and Stabilization before Evacuation

At the John F. Kennedy International Airport in New York City, disaster planning has been an integral part of the airport operations for the past 20 years. The medical component of this disaster planning has focused around the Medical Office at JFK. Through this office, on-site emergency medical teams have been established and trained from all ranks of airport personnel. Following the crash of a Boeing 727 aircraft in 1975, a new concept was added to disaster planning for JFK, which involves bringing the hospital, its facilities, and its personnel to the scene. A new piece of equipment, known as Emergency Mobile Hospital, was developed with the cooperation of the airlines, the operating authority of the airport, and other interested parties. Two such vehicles are now in constant readiness at the airport, and together provide two operating rooms, 12 monitored ICU beds, a 16-bed burn unit, and 72 other beds to be used for on-site stabilization of critically ill patients, before transfer to a definitive care facility. Under the auspices of a single area medical school (New York Medical College) and its affiliated departments of surgery, trauma teams are made available to be airlifted to the scene within 30 minutes of notification. Additional medical teams from other medical school hospitals serve as backup support. The principle of bringing the hospital to the emergency, and of assembling trauma teams for the initial phase, remains the same for Kennedy Airport as for that of any other metropolitan airport.

DOES PULMONARY ARTERY CATHETER USE CHANGE OUTCOME? YES

This article discusses the advantages of pulmonary artery catheters, with emphasis on the Swan-Ganz catheter. Various studies and published reports confirming the efficacy of pulmonary artery catheter use are reviewed. In the authors opinion, it is evident that the Swan-Ganz catheter has withstood the test of time and scrutiny.

Open chest cardiac massage: an overview

Open-chest cardiopulmonary resuscitation has been shown to produce better blood flow in man than closed-chest massage. It therefore should be taught as part of the protocol for all hospital CPR teams.

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.

Cardiorespiratory determinants of survival in cirrhotic patients requiring surgery for portal hypertension

Abstract Detailed hemodynamic and respiratory data are presented on forty-seven patients who required surgery for portal hypertension. Morbidity seems related to systemic and pulmonary shunting. Ventricular reserve is important in determining survival because the patients ability to withstand the hyperdynamic cardiovascular state that develops in the postoperative period depends on this. Metabolic alkalosis developing in the postoperative period is of critical prognostic import and in our experience heralds death. Patients receiving elective surgery who died and patients who required emergency surgery demonstrated postoperative metabolic alkalosis. In our hospital, emergency surgery for variceal hemorrhage carries an exceptionally high mortality. Hypoxia, ventricular function defects, and hemorrhage combined to produce an acute clinical situation. Finally, comparison by retrospective analysis of portacaval shunt with splenorenal shunt shows no postoperative hemodynamic difference in a small series of patients.

DYNAMIC ADAPTATION OF THE OXYHEMOGLOBIN DISSOCIATION CURVE TO ABNORMAL, CIRCULATORY PATTERNS IN CIRRHOSIS*

Serial hemodynamic assessment of patients undergoing portal systemic shunting procedures has been in progress for the past eight years1 At the General Clinical Research Center-Acute, approximately 75 such patients have been studied by flow-guided cardiac catheterization and indicator dilution techniques performed at the bedside and in the operating room at suitable intervals. The Clinical Research Center services a large city hospital (Bronx Municipal Hospital Center); about one-third of the patients studied were actively bleeding from gastroesophageal varices. Survivors, who were not lost to follow-up, generally agreed to subsequent hemodynamic evaluation. The sum total of our experience in these desperately ill patients has raised more questions than it has answered regarding the mechanism of death following surgery in patients with portal hypertension. It is the purpose of this paper to summarize what has been learned about the systemic circulation in advanced cirrhosis of the liver and to show that inefficient oxygen delivery and unloading appear to be key problems. Kowalski and Abelmann were the first to demonstrate that these patients frequently had elevated cardiac outputs contrary to what one would expect of chronically ill, debilitated patients subject to varying degrees of alcoholic cardiomyopathies. As other physiologic aberrations associated with the high levels of blood fiow were recognized, the term hyperdynamic syndrome was applied to include the decrease in net vascular tone and diminished coefficient of oxygen utilization. Considerable evidence has been presented to suggest that the decreased rate of oxygen transport to the peripheral tissues is secondary to arteriovenous shunt^.^ The blood circulates but gives up relatively little oxygen. Sometimes this excessive flow work wears out the heart and high cardiac output failure result^.^^^ Britton and coworkers reported a 38% increase in cardiac output after portacaval shunt, and they correlated the magnitude of the increase to the volume of shunt flow estimated by flowmeter or cineangiography. They blamed the shunt flow for the congestive failure that developed in 10% of their postshunt patients without apparent heart disease or systemic