1/11. safety and efficacy of three arthroscopic procedures using holmium: Yag laser in two high-responder haemophiliacs.We report here on the efficacy and safety of three arthroscopic procedures using a holmium: Yag laser in two high-responder haemophiliacs. The two patients were treated with an activated prothrombin complex concentrate (FEIBA; Immuno, Vienna, austria). Treatment was started just before surgery and continued for 4-8 days. On one occasion antifibrinolytics were concomitantly used without thromboembolic complication. Post-operative blood loss was slight, joint mobility was rapidly acceptable and full weight bearing without pain was possible on day 4. Such a procedure would appear to be superior to conventional arthroscopic synovectomy utilizing mechanical devices in haemophiliacs, because it might improve the quality of local haemostasis and the rapidity of post-operative recovery. In addition, it is also the technical procedure of choice in haemophilic patients with inhibitors who need synovectomy.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
2/11. Rationale for the use of high dose rFVIIa in a high-titre inhibitor patient with haemophilia B during major orthopaedic procedures.Inhibitor development is a serious complication in patients with haemophilia A and B. Historically, a lack of optimal therapies and factor products for treating inhibitor patients resulted in many patients developing chronic haemophilic arthropathies and flexion contractures of the involved joints. The introduction of immune-tolerance protocols to eradicate high-titre inhibitors has greatly diminished the incidence of these types of complications but as in the case reported here, immune tolerance is not always successful. Various elective surgical procedures were often delayed or not even considered in patients with inhibitor because of the variability in achieving adequate haemostasis and the thrombotic risks involved with the use of activated prothrombin-complex concentrates (APCCs) over extended periods of time. The development of recombinant factor viia (rFVIIa; NovoSeven) and its demonstrated safety and efficacy in treating inhibitor patients has opened new possibilities for addressing severe arthropathy with flexion contracture. This case report demonstrates that the use of rFVIIa in such a situation must include dosing flexibility that is both patient-specific and related to the potential for bleeding; the ability to maintain clinical haemostasis with a prophylactic dose of rFVIIa given as little as once daily; and the capacity for higher doses of rFVIIa, particularly in children because their kinetic profiles differ from adults.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
3/11. Multidisciplinary management of a Jehovah's Witness patient for the removal of a renal cell carcinoma extending into the right atrium.PURPOSE: To highlight the management of a Jehovah's witness surgical patient presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. CLINICAL FEATURES: A 47-yr-old male, Jehovah's Witness, with renal cell carcinoma was admitted for left radical nephrectomy and excision of tumour thrombus extending into the junction of the inferior vena cava (IVC) and right atrium (RA). The preoperative goals were to maximize red blood cell mass, delineate the extent of tumour extension and develop a surgical plan incorporating blood conservation strategies to minimize blood loss. A midline abdominal incision was made to optimize removal of the non-caval portion of the tumour from the intra-abdominal region. CPB and deep hypothermic circulatory arrest were instituted to aid in removing the tumour from the IVC and RA. Intraoperative blood conservation strategies included the use of acute normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care monitoring of heparin and protamine blood concentrations, leukocyte-depleting filter, and meticulous surgical techniques. The patient was successfully weaned from CPB and was transported to the cardiothoracic intensive care unit without complication. The patient was discharged home one week after the operation with a hemoglobin of 10.2 g x dL(-1) and a hematocrit of 31.2%. CONCLUSION: Multiple blood conservation techniques were employed to manage this Jehovah's Witness patient through complex cardiac surgery, which was previously denied to him at other institutions. The successful outcome of this patient, while respecting the right to refuse allogeneic blood products, is a result of a multidisciplinary collaboration as well as the application of established blood conservation techniques.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
4/11. Perioperative management of face-to-face craniopagus twins separation.Craniopagus conjoining represents a complex and challenging issue for neurosurgeons as well as for anesthesiologists. A rare face-to-face case of conjoined twins underwent surgical separation and presented peculiar differences compared with those already reported in the literature. Even in cases lacking large cerebrovascular sinus connections, the impending risk of large blood loss and hemorrhagic shock in the infant requires a high level of surveillance and the institution of invasive monitoring.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
5/11. Prophylaxis and therapy with factor VII concentrate (human) immuno, vapor heated in patients with congenital factor vii deficiency: a summary of case reports.Hereditary factor vii deficiency is a rare autosomal recessive condition, usually associated with normal or reduced levels of a functionally defective molecule. The available means of treating this condition in north america presents serious health risks to the patient. Transfusion with fresh frozen plasma carries a risk of volume overload and a significant risk for viral transmission. Sustained prothrombin complex therapy is associated with a high risk for thrombogenic complications. This communication describes the use of Factor VII Concentrate (Human) Immuno, Vapor Heated--an intermediate purity factor VII concentrate from Immuno A.G.--for the treatment of 13 patients with factor vii deficiency. Treatment regimens described include those for long-term prophylaxis (three children), acute hemorrhages (two children, one adult), peripartum prophylaxis (one patient), and surgical coverage (two children, four adults). Prophylaxis and therapy were successful in all cases, the medication was well-tolerated, and there were no complications. In the three cases of long-term prophylaxis in children, doses of 10-50 IU/kg were given one to three times a week; one patient has undergone long-term prophylaxis for approximately 8 years, one patient for 1 year, and one patient for 1 1/2 years. Three cases in which Factor VII Concentrate was principally used for treatment of acute episodes of bleeding are described. One infant received Factor VII Concentrate on about 50 occasions for treatment of mucosal bleeding; a correction to 40-100% resulted in cessation of bleeding within 15 min in all cases. For treatment of an episode of intracranial bleeding, an 8-year-old boy received a dose of 37 IU/kg Factor VII Concentrate every 6 hr for peak factor VII levels of approximately 100% and troughs as low as 4% over the 11-day treatment period. A 37-year-old adult male with intracranial bleeding received alternating doses of 16 IU/kg and 8 IU/kg every 6 hr for 10 days with peak factor VII levels in the upper thirties (%). The peak favor VII level during surgical coverage with Factor VII Concentrate (neurosurgery, open reduction of ankle bones, dental surgery, pituitary adenoma surgery, closed liver biopsy) was approximately 100% in all cases, with trough levels ranging from 8 to 65% over treatment periods of 24 hr to 16 days using treatment intervals of 6-12 hr.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
6/11. Administration of high-dose aprotinin during nonprimary cardiovascular surgery: case reports and review of the literature.The perioperative management of two patients undergoing complex "redo" cardiac surgical procedures are presented. The management of both patients included the prophylactic administration of aprotinin via a "compassionate use" protocol. aprotinin, a serine protease inhibitor, has been shown to limit the exposure to blood and blood products in patients undergoing high-risk cardiac surgical procedures. In late December 1993, the food and Drug Administration approved aprotinin for administration to cardiac surgical patients considered at high risk for post-cardiopulmonary bypass coagulopathies. Indications for the administration of aprotinin, as well as a brief review of the literature relating to the perioperative administration of aprotinin, are included.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
7/11. extracorporeal membrane oxygenation after lung or heart-lung transplantation.extracorporeal membrane oxygenation (ECMO) has proven to be life-saving in cases of reversible lung injury. One potential application of ECMO in the field of lung transplantation is the support of the patient with acute pulmonary failure immediately after transplantation until the transplanted lung has resumed satisfactory gas transfer function. The authors have had experience with ECMO in three patients who have had acute pulmonary failure and inadequate oxygenation after bilateral single lung (BSLT) or heart-lung transplantation (HLT). Patient 1 is a 47-year-old woman with alpha-1 antitrypsin deficiency who underwent a HLT and experienced fulminant pulmonary edema secondary to an intraoperative coagulopathy that required massive transfusion. Patient 2 was a 45-year-old man with a patent ductus arteriosus (PDA) that resulted in Eisenmenger's complex. Patient 2 underwent an HLT and experienced acute pulmonary failure. Patient 3 is a 58-year-old woman with an atrial septal defect (ASD) and pulmonary hypertension who underwent repair of the ASD and BSLT. Patient 3 experienced complete atelectatic collapse of the right lung and pulmonary edema of the left lung. These three patients had PO2 measurements of 23, 39, and 23 mmHg, respectively, despite receiving 100% FiO2 and maximal ventilatory support. All three patients were subsequently placed on ECMO and had improvement of their oxygenation. patients 1 and 3 were successfully weaned from ECMO and extubated on post-operative day (POD) 21 and 16, respectively. Patient 2 had significant improvement in oxygenation but died on POD 4 of persistent mediastinal hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
8/11. High jugular bulb: implications for posterior fossa neurotologic and cranial base surgery.The suboccipital-retrosigmoid approach to the internal auditory canal and cerebellopontine angle is being used with increasing frequency for neurotologic surgery, including vestibular nerve section and resection of acoustic neuroma. It offers wide exposure of the cerebellopontine angle and the cranial nerve VII-VIII complex as it courses from the brain stem to the temporal bone. Exposure of the internal auditory canal can be achieved by removing its posterior bony wall. Safe utilization of this approach requires familiarity with the variable position of structures within the petrous bone, including the lateral venous sinus and jugular bulb. We report here a case in which bleeding resulted from injury to a high jugular bulb during surgical exposure of the internal auditory canal via the suboccipital route and discuss the regional anatomy of the jugular bulb based on study of 378 consecutive temporal bone specimens from the collection of the massachusetts eye and Ear Infirmary. High jugular bulb was defined as encroachment of the dome of the bulb within 2 mm of the floor of the internal auditory canal. Forty-six percent of scoreable specimens met this criterion. However, when donors less than 6 years of age were excluded, a high jugular bulb was identified in 63% of specimens. Relevance to neurotologic surgery of the posterior fossa is presented.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
9/11. Are you ready for bloodless surgery?'Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
10/11. Repair of fungal aortic prosthetic valve endocarditis associated with periannular abscess.The incidence of prosthetic valve endocarditis is 2-4%; in most cases the involved organisms are staphylococcus epidermidis and Staph. aureus. Fungal endocarditis is much less common (incidence < 0.1%), but it is often fatal, with a long-term mortality rate of 90-100%. Most fungal endocarditis cases occur after aortic valvular surgery, due to candida sp. Late-onset symptoms, long-term development and aggressive nature of the fungus makes its eradication complicated and treatment difficult. Fungal valvular mycoses produce systemic embolization and cause serious perioperative bleeding on resection of infected tissue. Usually surgery includes aortic root replacement with an aortic homograft conduit after radical debridement, to attain local sterilization. This report describes a patient with complex infection, requiring replacement of an infected prosthetic valve with an aortic homograft conduit, aggressive and radical debridement of infected tissue, and reconstruction using biologic tissues. The case demonstrates the importance of perioperative and long-term antifungal treatment and presents a modified 'Cabrol procedure' to prevent critical intraoperative hemorrhage.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
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