Paul M. James

The relationship between transfusion and hypoxemia in combat casualties.

The relationship between transfusion and subsequent hypoxemia was examined retrospectively in the records of combat casualties studied by the first three U.S. Army Surgical Research Teams in Vietnam. There was no evident relationship in 425 casualties studied before anesthesia and operation. In 199 casualties studied preoperatively and on at least two of the first three postoperative days, there was no evident relationship in those with injuries not involving the chest or abdomen. Eighteen such casualties received over ten units of blood each (average 24.5) and exhibited subsequent changes in arterial oxygen tension (PaO2) which were indistinguishable from those transfused lesser amounts or not all. Similar observations were made in casualties with injuries to the abdomen, although there was a tendency to lower PaO2 two days after injury in those heavily transfused. In those with thoracic injury, there was statistically significantly lower PaO2 on the first two postoperative days in those heavily transfused. Two possible interpretations are considered, one that blood transfusion contributed to hypoxemia, and alternatively, that a greater magnitude of the injuries accounted for both the worsened hypoxemia and the need for more transfusions. The latter was thought more likely. The differences in PaO2 related to the type of injury exceeded the differences associated with transfusion.

Phenoxybenzamine in Septic Shock

Abstract : A series of young patients with well defined diagnoses and refractory clinical shock were studied hemodynamically. When conventional methods of therapy failed to correct hemodynamic deficits phenoxybenzamine was administered and physiologic parameters were carefully monitored. The pattern of response suggests that phenoxybenzamine improved cardiac function directly and thereby improved tissue capillary perfusion.

Evaluation of catheter placement in the treatment of venous air embolism.

: Venous air embolism is a potential complication of many surgical, therapeutic, and diagnostic procedures. Aspiration of air via a catheter placed in the superior vena cava or right atrium or placed in the pulmonary outflow tract and pulled through the right heart chambers had been advocated for the treatment of venous air embolism. In this study, three catheter positions were analyzed to determine which was best for removal of gas after induction of massive venous air embolism in dogs. In 18 dogs, 9 of which were suspended by their forelegs to simulate the sitting position used in posterior fossa exploration and 9 of which were supine, a Swan-Ganz catheter was placed in the right atrium, right ventricle, or pulmonary artery. A measured amount of air was injected into the left jugular vein and syringe aspiration of the air was attempted through the catheter. In the group with the catheter in the pulmonary artery, aspiration was continuous while the catheter was withdrawn through the right heart chambers. The amount of air aspirated varied widely among the three catheter positions, and no one catheter position proved superior to the other two.

Adenocarcinoma of the vermiform appendix

Abstract Tumors of the appendix occur in 1 to 2 per cent of all removed appendixes. Adenocarcinoma accounts for 3 per cent of these appendiceal tumors. It occurs most frequently in patients over fifty years of age and is more common in men. Acute appendicitis is the clinical picture most often seen, but sometimes the tumor presents as an appendiceal abscess. This lesion has never been diagnosed preoperatively. It behaves and spreads like other colonic adenocarcinomas. Appendectomy is the treatment for lesions confined to the mucosa. If there is further invasion to the muscularis or invasion outside the appendix to the cecum, right hemicolectomy should be performed at the time of original surgery or two weeks after the initial appendectomy. The prognosis has been improved with this treatment. Two cases of adenocarcinoma of the appendix are reported, bringing the total of reported cases to ninety-four. All surgeons and pathologists should be alert in the recognition of this lesion so that proper treatment can be instituted. It is emphatic that all appendixes should be subject to microscopic examination, and when there is clinical suspicion at operation, frozen section is mandatory for diagnosis and decisive therapy.

Inflammatory disease of the lower gastrointestinal tract in children

Abstract Ulcerative colitis and transmural colitis present with many of the same symptoms, but there is a differing frequency in the symptom complex. Early operation is preferable in transmural colitis and limited resection is usually helpful at first. Total colectomy is usually performed in patients with chronic ulcerative colitis, but only after a prolonged trial of nonoperative therapy. The histopathologic appearance of the two entities is different in most patients, and a clear delineation can be made by the pathologist. The evaluation of the patient preoperatively, technical aspects of the procedure, and the care in the postoperative period are described. Long-term prognosis for granulomatous colitis is not as good as that for ulcerative colitis [15]. However, both diseases are amenable to surgical therapy. Limited aggressive therapy is necessary in both entities. Earlier procedures are warranted for transmural colitis, and ultimately total colectomy is needed in patients with ulcerative colitis.

Surgical Research Coordinated with the Treatment of Battle Casualties

A surgical research team attached to a surgical hospital actively engaged in the treatment of war casualties in the Republic of Vietnam provided a unique opportunity to study the physiological effects of severe trauma. The immediate application of information obtained from a sophisticated laboratory in a hospital deployed in the field has obvious benefit to the patients treated. The purpose of this paper is to illustrate the clinical problems encountered, some attempts to solve them, and the results obtained.

EVALUATION OF CATHETER PLACEMENT IN THE TREATMENT OF VENOUS AIR EMBOLISM

Venous air embolism is a potential complication of many surgical, therapeutic, and diagnostic procedures. Aspiration of air via a catheter placed in the superior vena cava or right atrium or placed in the pulmonary outflow tract and pulled through the right heart chambers has been advocated for the treatment of venous air embolism. In this study, three catheter positions were analyzed to determine which was best for removal of gas after induction of massive venous air embolism in dogs. In 18 dogs, 9 of which were suspended by their forelegs to simulate the sitting position used in posterior fossa exploration and 9 of which were supine, a Swan-Ganz catheter was placed in the right atrium, right ventricle, or pulmonary artery. A measured amount of air was injected into the left jugular vein and syringe aspiration of the air was attempted through the catheter. In the group with the catheter in the pulmonary artery, aspiration was continuous while the catheter was withdrawn through the right heart chambers. The amount of air aspirated varied widely among the three catheter positions, and no one catheter position proved superior to the other two.

RESPIRATORY FAILURE IN SHOCK

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