Robert D. Brandstetter

Laparoscopic surgery and its potential for medical complications.

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.

Swan-ganz catheter: misconceptions, pitfalls, and incomplete user knowledge—an identified trilogy in need of correction

Over the past 24 months, a significant number ~of provocative editorials and articles have appeared either supporting the continued use of the Swan-Ganz catheter (Baxter Healthcare, Corp.) or declaring that a moratorium should be placed on its use.I-9 After reading these reports, we believe that too much has been asked of the pulmonary artery (PA) catheter. The historical development of the catheter demonstrates that it reached the bedside too quickly, without adequate laboratory or clinical research studies.lO-I 7 Furthermore, during those years, no practice guidelines for PA catheter use were agreed on; therefore, misconceptions associated with its use perpetuated. Compounding this was the growing body of evidence suggesting that catheter users lacked fundamental knowledge concerning PA catheter management and troubleshooting. 58 We believe, over the period of the PA catheters lifetime, assessment of the catheters capabilities were not fairly performed. Misconceptions were not considered as variables during the studies, nor was the impact of incomplete user knowledge regarding PA catheter insertion, management, and interpretation of data. The catheters design and function--as well as its normal limitations, which may vary from patient to patient (ie, position of patient, position of catheter in thorax, ventilation

Clinical Pharmacy Case Reports: Recurrence of Intravenous-Diazepam-Induced Phlebitis from Oral Diazepam

A patient who developed phlebitis from the intravenous administration of diazepam is described. This episode resolved in two days after treatment with moist heat packs. Three days after complete resolution, the phlebitis recurred approximately eight hours after a single oral dose of diazepam. This recurrence of phlebitis resolved slowly over seven days, with warm soaks and aspirin therapy. Oral diazepam may have exacerbated the initial phlebitis by interfering with a subclinical healing process.

Increased muscle enzyme activity after yoga breathing during an exacerbation of asthma.

The case is reported of a yoga practitioner who, during an exacerbation of asthma, developed a substantial increase in serum muscle enzymes. This was related to his yoga breathing exercises, which he used to enhance the delivery of aerosolised bronchodilators. As his condition improved and the use of these yoga manoeuvres diminished, the muscle enzyme levels fell to normal.

Flexible Fiberoptic Bronchoscopy in the Intensive Care Unit

For the past 20 years, flexible fiberoptic bronchoscopy (FOB) has been shown to be an important procedure in the diagnosis and management of patients in intensive care units (ICU). In adults, FOB is used therapeutically to remove retained secretions and to correct atelectasis not improved by conservative means. In the pediatric population, however, FOB is mainly used to diagnose tracheal disease in critically ill children. The principal risks of FOB are hypoxemia and dysrhythmias; hemor rhage and pneumothorax may occur as a result of biopsy procedures. In competent hands, these adverse compli cations of FOB are minimal. Although rigid bronchos copy remains pivotal in most pediatric bronchoscopic procedures, massive hemoptysis, foreign body removal, and laser therapy for occluding tumors of the upper airway, flexible FOB has an increasingly important role in the diagnosis and management of these disorders.

Problems in Respiratory Care— The Respiratory Muscles: Guest Edited by Martin Tobin, MD New York, Lippincott, 1990 288 pp, Illustrated

A-obbm irr Respiratory Cnre-The Respiratory hllcsc(e is one of a series of monographs with a unique approach to answering problems frequently encountered by pulmonary physicians, respiratory therapists, and specialty nurses. This particular monograph is a state-of-the-art review of the topic, and explores new clinically relevant information that has resulted from basic and clinical studies of the respiratory muscles. The book has 16 chapters and is rich in tables, graphs, and descriptive figures. The bibliography is extensive, with many references from 1990. The contributing authors are some of the leaders in the field of muscle physi-

Book Reviews : Textbook of Pulmonary Diseases, ed 4 By Gerald L. Baum, MD, and Emanuel Wolinsky, MD Boston, Little, Brown, 1989 1,660 pp, illustrated,

typographical error on the subject of supplemental oxygen treatment. Arterial carbon dioxide tension on two occasions was used instead of arterial oxygen tension. The other chapters in the book were well done, and included renal disorders (more on rhabdomyolysisinduced renal failure would be appreciated in the future), acid-base disorders, derangements of fluids, electrolytes (once again, a future edition should omit electrocardiograms of hypo/hyperkalemia) endocrinological disorders, nutrition, infectious disease (strong AIDS section), and gastrointestinal and hematological abnormalities. Excellent chapters are found on neurological disorders, drug overdose-poisoning, trauma, burns, and obstetrical critical care.

175.00

pass over 1,500 pages. The 13 sections are carefully divided into not only individual major organ dysfunction, but also special areas such as therapeutic regimens, transplantation, nursing, and organization of critical care units. All of the sections are further divided into pertinent chapters that provide quick access to the in-depth material presented. Thirdly, the illustrations are superb. The quality of the tables is quite good and all of the figures are clear. The roentgenographs are reproduced very well, and the photographs of actual techniques and procedures are competently and graphically well done. The book has a strong resuscitation section that includes excellent chapters on critical care units and prehospital and interhospital transport of adults as well as infants. Shoemaker’s chapter on resuscitation in acute

Book Reviews : Textbook of Critical Care, ed 2 Edited by Shoemaker, Ayres, Grenvik, et al Philadelphia, Saunders, 1989 Illustrated,

as complications secondary to treatment. The book includes detailed medical management of the principal complications of cancer therapy as well as an overview of the role of surgery in the critically ill cancer patient. The book is supported by 15 contributors and is edited and written, in part, by Groeger and Carlon of the Memorial Sloan-Kettering Cancer Center. There are 948 references, 15 figures, and 15 tables. The chapters progress from complications of chemotherapeutic agents to separate chapters devoted to individual organ systems, treatment, and the complications that occur in each organ system. There are also chapters

95.00

The second edition of Neurological and Neurosurgical Intensive Care is a well-expanded version of the previous volume. Divided into an initial section on general principles of neurological intensive care and a second section covering specific disease entities, it is quite a hefty compendium of the management of serious neurological disorders. As such, it suffers in the area of digestibility, and probably serves best as a reference text because each