William S. Howland

The seventies evolution in liver surgery for cancer.

During the past decade, one of the major changes in the field of oncology has been in the surgical approach to primary and secondary cancer of the liver. As a result of data and experience gained in liver transplantation programs and with the application of vascular surgical principles, resectability rates have been increased. The present rate of 32% has been achieved with an overall 30‐day operative mortality rate of 9%. More sophisticated intraoperative and postoperative supports have been essential in achieving these results. The median operating time is now 4′3/4 hours in length. Complications are minimal. The median postoperative hospital stay is now 13 days.

High-Frequency Jet Ventilation in Major Airway or Pulmonary Disruption

High-frequency jet ventilation is an experimental method of mechanical support, which achieves satisfactory alveolar ventilation and oxygenation at low peak-inspiratory pressures of 5 to 8 cm H2O and low end-expiratory pressures of 3 to 5 cm H2O. This characteristic was used to advantage in 23 patients with cancer, 12 of whom had tracheal or bronchial disruption complicated by pneumonia. Eight patients who could not be supported by conventional means were salvaged. Barotrauma complicated the very high peak airway pressures required to ventilate 8 of 11 patients with respiratory failure associated with diffuse interstitial pneumonia or pulmonary fibrosis. There were only 2 survivors despite temporary normalization of arterial blood gas values in 7 patients. Earlier use of high-frequency jet ventilation in patients with poor compliance may prevent pulmonary disruption in addition to deleterious hemodynamic and systemic effects of conventional high-pressure ventilation. Other applications under study include the role of jet ventilation in resection of the trachea or carina, and in major airway trauma.

Hemodynamic oxygen transport and 2,3-diphosphoglycerate changes after transfusion of patients in acute respiratory failure

The goals of management of patients with respiratory failure include improving arterial oxygenation with PEEP and red cell transfusion to maintain oxygen carrying capacity, both of which contribute to improving tissue oxygen delivery. However, standard CPD-stored blood is rapidly depleted of 2,3 diphosphoglycerate (2,3 DPG) and ATP, with resultant inadequacy of the red cell oxygen transport function. In 15 patients requiring mechanical ventilation with PEEP whose initial Hct≤35%, we studied the effect of transfusion of 7 ml/kg of CPD-stored packed red blood cells on hemodynamic and oxygen delivery variables, pulmonary venous admixture (QA/QT), and erythrocytic P50, 2,3 DPG and ATP concentrations. Hemodynamics were not significantly altered by transfusion. 2,3 DPG decreased significantly from 14.5±1.1 to 13.1±1.5 mcmol/g Hb (mean±SD, p<0.05). There was no significant change in P50 or ATP. QA/QT rose significantly, from 20.1±7.8 to 28.9±12.3% (mean±SD, p<0.02). In our patients, an increase in arterial oxygen content obtained by transfusion was not followed by any associated decrease in cardiac work, as implied by solution of equations for oxygen delivery and oxygen consumption. The rise in QA/QT is undesirable in patients requiring PEEP, since it complicates management of their mechanical ventilatory support.

The role of an intensive care unit in a cancer center. An analysis of 1035 critically ill patients treated for life-threatening complications editorial

Life‐threatening complications of cancer therapy often involve multiple organ systems and offer a therapeutic challenge which can be met with efficiency and success by concentrating personnel and equipment in a facility devoted to these problems. Three years ago, an Intensive Care Unit was created at Memorial Cancer Center to offer such patients the benefit of highly skilled nursing, advanced monitoring and supportive techniques, and full‐time attendance by physicians and surgeons with a particular interest in Critical Care Medicine. Since then, 1035 patients have been admitted to the eight‐bed unit with a mortality rate of 22.3%, which compares favorably with those reported from other institutions. Analysis of this experience has revealed that an average of 16% of those who survived their acute problems after considerable effort and expense, subsequently died of their underlying disease within 2 months. This experience has suggested the need for prognostic criteria to facilitate recognition of those patients for whom intensive supportive measures offer a reasonable chance of worthwhile palliation.

The therapeutic intervention scoring system: An application to acutely ill cancer patients

The Therapeutic Intervention Scoring System (TISS) has been introduced (Cullen DJ, Civetta JM, Briggs BA, et al: Therapeutic intervention scoring system: A method of quantitative comparison of patient care. Crit Care Med 2:57–60, 1974) at the Massachusetts General Hospital as a means of quantifying the medical and nursing care required by critically ill patients. The method has been instituted in the Intensive Care Unit of Memorial Cancer Center to evaluate its applicability to patients who develop life-threatening complications of their disease or its treatment. This is a preliminary report of the systems use in 55 consecutive patients who averaged 33.4 intervention points per day. This average compares closely with that of postcardiac surgery patients (31.8 points), the group that required the most care of all patients in the initial study.The results indicate the usefulness of this system in evaluating severity of illness, predicting survival, and assessing cost benefits. It has proven to be a simple and accurate method of assessment when applied to this patient population, but certain modifications seem warranted and have been suggested herein.

Unexpected Giant "V" Waves During Pulmonary Artery Catheterization

Two cases of catheterization of the pulmonary artery, in which the hemodynamic findings were very different from the initial clinical diagnosis, are presented. The importance of verifying the adequate position and motion of the pulmonary artery catheters with two consecutive chest x-rays is discussed. In particular, attention is brought to the possible misinterpretation that occurs in patients with very elevated pulmonary artery mean pressure.