Training and accrediting international surgeons

Background

Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification.

Methods

MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: ‘credentialing’, ‘education’, ‘global surgery’, ‘international medicine’, ‘international surgery’ and ‘training’. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons.

Results and conclusion

The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.

Non-Linear Optical Characteristics of Novel Porphyrin Dye Media

Measurements of sensitive RSA phenonema in new porphyrin dyes are presented. Both the linear and non-linear optical properties are shown to depend strongly on the molecular structure. A detailed analysis of two of the porphyrins reveals that inter-systems crossing rate and the excited state absorption profile are strongly influenced by substitution of a heavy atom into the central atom position. It is shown that by appropriate choice of wavelength values in excess of 30 can be achieved for the material parameter σex / σgr. This value compares well with previously reported results and is achieved in conjunction with excited state lifetimes on the order of 300 ns.

Porphyrin Dye Media for Optical Limiting

In this report we study nine structurally similar porphyrins and show how the material parameters that control the optical limiting depend on the molecular structure. Optical limiting measurements at 532 nm on the metal-free, zinc and lead analogues of tetraphenyl porphyrin (TPP), tetra(trimethylsilyethynyl) porphyrin (TTMSAP) and tetra(4-n-butylphenylethynyl) porphyrin (TNBBAP) reveal a strong dependence on the molecular structure. A double pump/cw probe technique is used to measure the material parameters that control the optical limiting and the results give a strong insight into how the molecular structure influences the individual parameters. These measurements revealed that one of the materials TTMSAP(Pb) has a σex/σgr ratio of ∼45 at 532 rim, which is one of the largest values ever reported. Finally, broadband measurements with a picosecond white-light source show that the excited state absorption profile for the porphyrins examined is much broader than the ground state features and is centred to the long wavelength side of the ground state Soret band.

Entangling remote nuclear spins linked by a chromophore

Molecular nanostructures may constitute the fabric of future quantum technologies, if their degrees of freedom can be fully harnessed. Ideally one might use nuclear spins as low-decoherence qubits and optical excitations for fast controllable interactions. Here, we present a method for entangling two nuclear spins through their mutual coupling to a transient optically excited electron spin, and investigate its feasibility through density-functional theory and experiments on a test molecule. From our calculations we identify the specific molecular properties that permit high entangling power gates under simple optical and microwave pulses; synthesis of such molecules is possible with established techniques.

Intermolecular interaction effects on the ultrafast depolarization of the optical emission from conjugated polymers

We have investigated the effect of interchain interactions on the ultrafast depolarization of the photoluminescence from solid films of a conjugated polymer. Accurate control was exercised over the interchain separation by threading of the conjugated chains with insulating macrocycles or complexation with an inert host polymer. Our measurements indicate that excitation into the higher electronic states of a chain aggregate is followed by a fast (<100 fs) relaxation into lower excited states with an associated rotation of the transition dipole moment. These findings emphasize the need for consideration of initial excitonic delocalization across more than one polymeric chain.

Reactive barriers for 137Cs retention

137Cs was dispersed globally by cold war activities and, more recently, by the Chernobyl accident. Engineered extraction of 137Cs from soils and groundwaters is exceedingly difficult. Because the half-life of 137Cs is only 30.2 years, remediation might be more effective (and less costly) if 137Cs bioavailability could be demonstrably limited for even a few decades by use of a reactive barrier. Essentially permanent isolation must be demonstrated in those few settings where high nuclear level wastes contaminated the environment with 135Cs (half-life 2.3 x 10(6) years) in addition to 137Cs. Clays are potentially a low-cost barrier to Cs movement, though their long-term effectiveness remains untested. To identify optimal clays for Cs retention, Cs desorption was measured for five common clays: Wyoming Montmorillonite (SWy-1), Georgia Kaolinites (KGa-1 and KGa-2), Fithian Illite (F-Ill), and K-Metabentonite (K-Mbt). Exchange sites were pre-saturated with 0.16 M CsCl for 14 days and readily exchangeable Cs was removed by a series of LiNO3 and LiCl washes. Washed clays were then placed into dialysis bags and the Cs release to the deionized water outside the bags measured. Release rates from 75 to 139 days for SWy-1, K-Mbt and F-Ill were similar; 0.017% to 0.021% sorbed Cs released per day. Both kaolinites released Cs more rapidly (0.12% to 0.05% of the sorbed Cs per day). In a second set of experiments, clays were Cs-doped for 110 days and subjected to an extreme and prolonged rinsing process. All the clays exhibited some capacity for irreversible Cs uptake. However, the residual loading was greatest on K-Mbt (approximately 0.33 wt.% Cs). Thus, this clay would be the optimal material for constructing artifical reactive barriers.

Respiratory failure. Conventional and high-tech support

Although significant progress has been made in the treatment of patients with acute lung failure in the critical care setting, the mortality rate from acute lung injury and ARDS is unacceptably high, given the numbers of patients treated for these syndromes each year. The improved understanding of the pathophysiology of respiratory failure from basic science and clinical research is reflected in improved survival rates over the years. Advances in the mechanical ventilator (through microprocessor technology); biosurface technology; liquid ventilation; and, in some cases, returning to so-called "antiquated" practices of patient care (e.g., prone positioning) seem to have had an impact nonetheless. As refinement continues to occur in these areas, morbidity and mortality from lung failure will have a lesser impact on patients as physicians treat the consequences of organ failure in the ICU.

Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation

OBJECTIVE

Unplanned endotracheal extubation (UEE) is a common complication in medical intensive care units but very little data about UEE in surgical populations are available. Our hypothesis is that the surgical intensive care unit (SICU) population requires reintubation less frequently compared with the medical intensive care unit population. We prospectively gathered data on patients in a SICU in an attempt to identify the incidence of UEE and to study the need for reintubation after UEE.

METHODS

During an 18-month period, we prospectively identified SICU patients from a quality improvement database who required ventilatory support. All patients who self-extubated were included in the study.

RESULTS

Fifty-eight of 1,178 intubated patients experienced unplanned extubation 61 times during the 18-month period. A total of 22 patients (36%) required reintubation, whereas 39 patients (64%) did not. Thirty-three patients self-extubated while being actively weaned from ventilatory support. Of these, only 5 patients (15%) required reintubation and 28 patients (85%) did not (p < 0.01).

CONCLUSION

A total of 85% of patients who self-extubate during the weaning process did not require reintubation in our study. Those who have an FiO2 >50%, a lower PaO2/FiO2 ratio, had UEE occur by accident, or were not being weaned when UEE occurred required reintubation more frequently. These data suggest that some of our SICU patients are intubated longer than necessary, which may translate into more ventilator related complications, longer ICU stays and increased cost.

Hepatitis C virus-associated glomerular disease in patients with human immunodeficiency virus coinfection

Chronic infection with hepatitis C virus (HCV) has been linked to the development of glomerular disease. HCV infection is highly prevalent among intravenous drug users, a population that is also at risk for HIV coinfection. This study reports the clinical-pathologic features and outcome of HCV-associated glomerular disease (HCV-GD) in 14 patients with HIV coinfection. All were intravenous drug users and all but one were African-Americans. Renal presentations included renal insufficiency, microscopic hematuria with active urine sediment, hypertension, and nephrotic syndrome or nephrotic-range proteinuria without hypercholesterolemia. Hypocomplementemia and cryoglobulinemia were present in 46 and 33% of patients, respectively. The predominant renal biopsy findings were membranoproliferative glomerulonephritis type 1 or type 3 (Burkholder subtype) in 79% of patients and membranous glomerulopathy with atypical features in 21% (including overlap with collapsing glomerulopathy in one patient). The clinical course was characterized by rapid progression to renal failure requiring dialysis. The overall morbidity and mortality were high with median time of 5.8 mo to dialysis or death. Although most patients died in renal failure, cause of death was primarily attributable to long-term immunosuppression and advanced AIDS. Patients with AIDS had shorter survival than those without (median survival time of 6.1 mo versus 45.9 mo, log-rank test P = 0.02). Only two patients were alive with stable renal function at follow-up of 28.5 mo. In patients with HCV-GD, coinfection with HIV leads to an aggressive form of renal disease that can be easily confused with HIV-associated nephropathy. Although hypocomplementemia, cryoglobulinemia, and more prominent hypertension and microscopic hematuria may provide clues to the presence of HCV-GD, renal biopsy is essential to differentiate HCV-GD from HIV-associated nephropathy.

Effects of an organized critical care service on outcomes and resource utilization: a cohort study

OBJECTIVE

To determine whether the presence of an on-site, organized, supervised critical service improves care and decreases resource utilization.

DESIGN

The study compared two patient cohorts admitted to a surgical intensive care unit during the same period of time. The study cohort was cared for by an on-site critical care team supervised by an intensivist. The control cohort was cared for by a team with patient care responsibilities in multiple sites supervised by a general surgeon. The main outcome measures were duration of stay, resource utilization, and complication rate.

SETTING

Study patients were general surgical patients in an academic medical center.

RESULTS

Despite having higher Acute Physiology and Chronic Health Evaluation II scores, patients cared for by the critical care service spent less time in the surgical intensive care unit, used fewer resources, had fewer complications and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst APACHE II score.

CONCLUSIONS

Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource. In this study, the critical care service model performed favorably both in terms of quality and cost.

Enoxaparin suppresses thrombin formation and activity during cardiopulmonary bypass in baboons

OBJECTIVE

This study tests the hypotheses that enoxaparin, a low molecular weight heparin and potent inhibitor of factor Xa, alone or in combination with standard heparin, inhibits thrombin formation and activity and modulates complement activation and neutrophil elastase release during cardiopulmonary bypass in baboons.

METHODS

After preliminary studies to determine doses and possible species differences to anticoagulants and protamine, 27 anesthesized baboons had normothermic cardiopulmonary bypass with standard, unfractionated, porcine intestinal heparin, enoxaparin, or a combination of heparin and enoxaparin. Protamine in appropriate doses was used to reverse anticoagulation. Blood samples were obtained at 6 time points. Activated clotting times were monitored; template bleeding times were measured before and up to 24 hours after cardiopulmonary bypass.

RESULTS

Hemodynamic measurements were not affected by the anticoagulant. Activated clotting times remained above 400 seconds throughout bypass, and no clots were observed. The anticoagulant did not alter platelet count, aggregation to adenosine diphosphate, release of beta-thromboglobulin, release of neutrophil elastase, or complement C3b/c and C4b/c. Enoxaparin alone, but not in combination, significantly reduced plasma levels of prothrombin fragment F1.2, fibrinopeptide A, and thrombin-antithrombin complexes but prolonged template bleeding times for more than 24 hours.

CONCLUSION

Enoxaparin significantly reduces thrombin formation and activity during cardiopulmonary bypass but does not suppress complement activation and neutrophil elastase release and is not adequately reversed by protamine after bypass.

Successful utilization of ECMO to treat an adult burn patient with ARDS

We present an interesting case of the first adult reported in the United States to suffer from thermal burns, adult respiratory distress syndrome (ARDS) and to be treated with extracorporeal membrane oxygenation (ECMO) who survived. Our patient is a 26 year old male who sustained thermal burns (12% TBSA) to his face and anterior trunk and broncoscopically demonstrable inhalation injury. He was transported to our regional burn center for burn wound care and ventilatory support. The patient was treated with silver sulfadiazine 1% to his wounds which healed per primam. Because of low oxygen saturation he required increasing FIO2. The following parameters: FIO2= 1, PEEP = 17, minute ventilation of 15.1 1, peak airway pressure of 45 and mean of 27, along with chest X-rays corroborated the severity of ARDS. The patient failed volume control ventilation. A trial of pressure ventilation was attempted but the patient only reached O2 saturation in the low 80s. At this point, the decision was made to transfer the patient to a hospital capable of ECMO treatment. The patient was subsequently treated with veno venous ECMO. Six weeks later the patient was discharged from the hospital off all ventilatory support.

Mechanical ventilation and pharmacologic strategies for acute respiratory distress syndrome

Acute or adult respiratory distress syndrome (ARDS) contributes to mortality and morbidity in the intensive care environment. Appropriate application of microprocessor-controlled mechanical ventilatory support, pathophysiology of the disease, and new pharmacologic modalities are currently being investigated. Mechanical ventilation is usually begun when respiratory failure is caused by alveolar hypoventilation or hypoxia. Primary choices for this therapy are control-mode ventilation, assist-control ventilation, pressure-control ventilation, intermittent mandatory ventilation, and synchronized intermittent mandatory ventilation with the addition of positive end-expiratory pressure. Patients who deteriorate despite these interventions may require alternative modes of ventilation. Pharmacologic agents in ARDS is important due to the multifactorial pathophysiologic and pharmacodynamic processes that are part of the disease. Clinical studies will continue to determine advantageous agents. Unfortunately, no convincing data exist that any pharmacologic or nonpharmacologic strategy is superior for the support of these patients or results in a better outcome than others.

A baboon model for hematologic studies of cardiopulmonary bypass

Objective investigation of new inhibitors of blood protein or cellular systems that are activated during cardiopulmonary bypass (CPB) is impeded by the absence of a satisfactory animal model. Because most baboon hematologic proteins immunologically cross-react with those used for human assays, we developed a robust, reusable baboon model of CPB. Blood samples were obtained from adult baboons at six time intervals before, during, and after 60 minutes of partial CPB at 37 degrees C with peripheral cannulas. Both membrane (n = 7) and bubble oxygenators (n = 7) were investigated. We measured platelet and white blood cell counts; platelet response to adenosine diphosphate and release of beta-thromboglobulin; fibrinopeptide A, prothrombin fragment F1.2, thrombin-antithrombin complex, D-dimer, and plasmin-antiplasmin complex; activated complement (C3b/c and C4b/c); elastase-alpha1 proteinase inhibitor complex; and bleeding times. Adherent glycoprotein IIIa antigen in Triton X-100 washes of the perfusion circuit was also measured. Markers of baboon platelet, complement, and neutrophil activation and thrombosis significantly increased during CPB with bubble oxygenator systems but did not change appreciably in membrane oxygenator circuits. Markers of fibrinolysis, D-dimer, and plasmin-antiplasmin complex did not change with either oxygenator. The baboon model of CPB, when a bubble oxygenator is used, is a robust, reusable animal model for evaluating inhibitors of platelet, complement, and neutrophil activation and thrombosis during and after CPB.

Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy

OBJECTIVE

Tracheostomy is one of the most commonly performed surgical procedures in the critical care setting. The early use of tracheostomy as a method of primary airway management has been proposed as a means to decrease pulmonary morbidity and to shorten the number of ventilator, intensive care unit, and hospital days. We set out to (1) determine whether hypercarbia occurs during tracheostomy of the critically ill patient and (2) determine the extent to which the partial pressure of carbon dioxide in arterial blood (PaCO2) rises during percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy.

DESIGN

Prospective, open clinical trial.

SETTING

Surgical intensive care unit and operating room in teaching hospitals.

PATIENTS

During mechanical ventilation, patients underwent either percutaneous endoscopic (PET), percutaneous Doppler (PDT), or standard surgical tracheostomy (ST), based on surgeon preference. Arterial blood gas readings were obtained approximately every 4 min throughout each procedure.

MEASUREMENTS AND RESULTS

All tracheostomies were successfully performed. No serious complications (including hypoxia) occurred during the study. Significant (p < 0.05 vs PDT and ST) hypercarbia (maximum delta PaCO2 24 +/- 3 mmHg) and acidosis (maximum delta pH -0.16 +/- 0.02) developed during PET. The changes in PaCO2 and pH during PDT (maximum delta PaCO2 8 +/- 2 mmHg; maximum delta pH -0.07 +/- 0.02) and ST (maximum delta PaCO2 3 +/- 1 mmHg; maximum delta pH -0.04 +/- 0.01) were markedly less pronounced.

CONCLUSIONS

Continuous bronchoscopy during percutaneous tracheostomy contributes significantly to early hypoventilation, hypercarbia, and respiratory acidosis during the procedure. Percutaneous tracheostomy, when performed using the Doppler ultrasound method to position the endotracheal tube, significantly reduces CO2 retention when compared to PET. Because of a possible rise in intracranial pressure, the potential for hypercarbia should be considered when choosing the method of tracheostomy in the critically ill and/or head-injured patient, where hypercarbia may be detrimental. If PET is to be performed, steps to minimize occult hypercarbia, such as using the smallest bronchoscope available, minimizing suctioning during bronchoscopy, and minimizing the length of time the bronchoscope is in the endotracheal tube, should be undertaken.

Mortality is directly related to the duration of mechanical ventilation before the initiation of extracorporeal life support for severe respiratory failure

OBJECTIVE

To investigate the relationship between the period of mechanical ventilation before extracorporeal life support and survival in patients with respiratory failure.

DESIGN

Retrospective review.

SETTING

Surgical intensive care unit at a university medical center.

PATIENTS

Thirty-six consecutive adult patients with severe respiratory failure managed with extracorporeal life support.

INTERVENTIONS

Extracorporeal life support was utilized in 36 acute respiratory failure adult patients with a variety of diagnoses and an estimated mortality rate of > 90%. Management protocols were followed before and during extracorporeal life support. The 36 patients were physiologically similar before extracorporeal life support was initiated: shunt of 48 +/- 17%; F10(2) of 1.0 +/- 0.1; peak inspiratory pressure of 56 +/- 16 cm H2O; positive end-expiratory pressure of 14 +/- 6 cm H2O; and respiratory rate of 23 +/- 10 breaths/ min. Ventilation was utilized for 1 to 17 days before extracorporeal life support. Typical lung rest settings during extracorporeal life support were F10(2) of 0.40, peak inspiratory pressure of 30 cm H2O, positive end-expiratory pressure of 10 cm H2O, and respiratory rate of 6 breaths/min. Death was almost always secondary to end-stage pulmonary failure.

MEASUREMENTS AND MAIN RESULTS

Survival (hospital discharge) in these 36 patients was inversely associated with the number of days of preextracorporeal life support ventilation, with a 50% mortality rate predicted by logistic regression after 5 days of mechanical ventilation. The overall survival rate was 18 (50.0%) of 36 patients.

CONCLUSIONS

In severe acute respiratory failure treated with lung rest and extracorporeal life support, a predicted 50% mortality rate was associated with 5 days of preextracorporeal life support mechanical ventilation.

Tirofiban provides "platelet anesthesia" during cardiopulmonary bypass in baboons

OBJECTIVE

Tirofiban (Aggrastat) is a reversible, nonpeptide inhibitor of platelet glycoprotein II/IIIa receptors. We tested the hypothesis that tirofiban preserves platelet number and function and shortens postoperative bleeding times in baboons after cardiopulmonary bypass.

METHODS

Four groups were studied: control, n = 12; low-dose tirofiban (0.1 microg/kg per minute), n = 7; high-dose tirofiban (0.3 microg/kg per minute), n = 7; and bolus tirofiban (15 microg/kg) followed by 0.1 microg/kg per minute during cardiopulmonary bypass, n = 7. After heparin, animals were perfused for 60 minutes at 50 ml/kg per minute and 37 degrees C with a bubble oxygenator, roller pump, and peripheral cannulation. Hemodynamics, platelet count, platelet aggregation to adenosine diphosphate, and release of beta-thromboglobulin were measured before tirofiban infusion, before heparin, after heparin before bypass, after 5 and 55 minutes of bypass, after protamine, and 60 minutes after protamine. Template bleeding times were measured at the same times except during cardiopulmonary bypass and 120 and 180 minutes after protamine administration. Platelet glycoprotein IIIa antigen was measured in Triton X-100 washes (Sigma Chemical Company) of the perfusion circuit after bypass.

RESULTS

High-dose tirofiban completely prevents platelet loss during cardiopulmonary bypass. beta-Thromboglobulin release and sensitivity to adenosine diphosphate are significantly less than control at the end of bypass in all tirofiban groups. Template bleeding times return to preoperative values in both the low- and high-dose tirofiban groups 180 minutes after protamine administration and are significantly less than control bleeding times at both 120 and 180 minutes after protamine. Surface glycoprotein IIIa antigen does not significantly differ between groups.

CONCLUSION

High-dose tirofiban completely preserves platelet number and improves platelet function during cardiopulmonary bypass in baboons and significantly accelerates restoration of normal template bleeding times after bypass.

Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review

Blood-borne pathogens threaten all individuals involved in emergency health care. Despite recommendations by the Centers for Disease Control and the American College of Emergency Physicians, documented compliance with universal precautions in trauma resuscitation has been poor. The purpose of this study was to determine the factors that predispose to noncompliance with barrier precautions at a level I trauma center. Videotapes of trauma resuscitations performed during 1 month (n = 66) were reviewed. Full compliance with barrier precautions was documented in 89.1% of health care workers. Of the noncompliant health care workers, 50.7% were emergency department personnel and 47.8% were first responders to the trauma resuscitation area. Barrier precaution compliance improved from 62.5% to 91.8% with prenotification of patient arrival. Immediate access to barrier equipment is essential for all potential in-hospital first responders. Prehospital communication systems should be optimized to ensure prenotification.

Occult hypercarbia. An unrecognized phenomenon during percutaneous endoscopic tracheostomy

Bronchoscopy has been incorporated as a useful adjunct to increase the safety and effectiveness of percutaneous endoscopic tracheostomy (PET). Insertion of the bronchoscope, along with the intraluminal dilators of the PET set, into the airway potentially leads to hypoventilation and hypercarbia during the procedure. Using continuous in-line arterial blood gas monitoring, we documented profound hypercarbia in two patients undergoing PET in the surgical ICU. In a third patient, the rise in PaCO2 was accompanied by a marked rise in intracranial pressure (ICP), and a corresponding fall in cerebral perfusion pressure. While transient hypercarbia seems well tolerated by most patients, this phenomenon and its effect on cerebral blood flow should be strongly considered before performing PET on the critically ill patient with evidence of elevated ICP.

Extracorporeal life support after heart or lung transplantation

Extracorporeal life support (ECLS) has been used in 10 patients after heart (5 patients), lung (3 patients), and heart-lung (2 patients) transplantation. The age range was 7 months to 55 years. Cardiopulmonary failure leading to institution of ECLS was due to acute postoperative organ malfunction in 4 patients (2 survived), subacute organ malfunction in 3 patients (none survived), and late rejection or infection in 3 patients (2 survived). Neurologic complications occurred in 3 patients (1 survived) and bleeding, in 5 patients (2 survived). Six patients (60%) were successfully weaned from ECLS, and 4 (40%) survived to leave the hospital. Survival was associated with younger age, shorter duration of ECLS, and longer interval from operation to initiation of ECLS but not to reason for initiating ECLS. Extracorporeal life support is feasible for sustaining both adults and children after heart, lung, or heart-lung transplantation. Best results were obtained in patients with conditions that, in retrospect, were treatable and reversible within days. More experience is needed to predict preoperatively which patients will benefit most from ECLS.

Extracorporeal life support for respiratory failure after multiple trauma

Respiratory failure may complicate multiple trauma and can add significant morbidity, mortality, and cost to the care of such patients. We used extracorporeal life support (ECLS) to treat 24 patients with multiple trauma who, after their injury, developed respiratory failure refractory to conventional ventilatory management. Injuries in these patients were the result of motor vehicle crashes (16 patients), pedestrian versus car collisions (3 patients), gunshots (2 patients), stabs (1 patient), and a recreational vehicle crash (1 patient). Patients were placed on venovenous or venoarterial ECLS, using continuous systemic anticoagulation with heparin, and percutaneous cannulation where possible. Average time on ECLS was 287 +/- 43 hours (12 +/- 1.8 days). The major complication was bleeding, which occurred in 75% of patients. Fifteen patients survived to be discharged from the hospital (63% survival). Early intervention (mechanical ventilation < or = 5 days prior to ECLS) was associated with good outcome. Despite risks of anticoagulation in patients with multiple injuries, ECLS can be life-saving in cases of respiratory failure refractory to conventional mechanical ventilation.

Efficacy of extracorporeal life support in the setting of adult cardiorespiratory failure

The efficacy of extracorporeal life support (ECLS, ECMO) in the management of severe adult cardiorespiratory failure remains controversial. The purpose of this review is to evaluate the authors' institutional experience with ECLS in adult patients. Between 1988 and 1993, 65 moribund patients with respiratory (n = 51) and cardiac (n = 14) failure were supported with ECLS. Criteria for initiation of ECLS were: 90% chance of mortality despite maximal conventional respiratory management, good potential for recovery, and age younger than 60 years. Venovenous bypass was used in 40 and venoarterial in 25 patients. Respiratory management included low rate, low pressure ventilation with an inspired oxygen fraction < or = 0.5 and tracheostomy tube placement. Continuous systemic heparinization was used, maintaining whole blood activated clotting time (ACT) between 180 and 200 sec. Survival data are summarized as follows: pneumonia (n = 25) 56%, adult respiratory distress syndrome (n = 24) 58%, airway support (n = 2) 100%, and cardiac support (n = 14) 29%. The most common complication was bleeding (68%), which was managed in most patients by reduction of anticoagulation or local measures such as packing. Data from survivors and nonsurvivors of ECLS in patients with respiratory failure were compared in an attempt to define prognostic indicators of improved survival. The only prognostic indicator of survival that could be identified was the period of time on the ventilator before the initiation of ECLS (survivors = 3.0 +/- 2.4 days, nonsurvivors = 6.1 +/9- 4.0 days, P < 0.005). It is concluded that ECLS can be a life saving modality for the management of severe adult cardiorespiratory failure. Earlier institution of ECLS in the course of cardiopulmonary failure may improve outcome.

Multicenter comparison of conventional venoarterial access versus venovenous double-lumen catheter access in newborn infants undergoing extracorporeal membrane oxygenation

A multicenter trial was designed to compare standard venoarterial (VA) access versus single-catheter, venovenous access using the double-lumen catheter (VV-DLC) for newborns with respiratory failure undergoing extracorporeal membrane oxygenation (ECMO). Twenty-seven ECMO centers participated, each submitting data from the center's most recent VA cases, and data from VV-DLC cases completed upon entering the study. Data from 135 VA ECMO cases and 108 VV-DLC cases were submitted. All diagnoses resulting in neonatal respiratory failure were submitted, including patients with congenital diaphragmatic hernia (24 patients VA bypass, 11 patients VV-DLC bypass). Overall survival in patients undergoing VA bypass was 87%, while survival in patients undergoing VV-DLC bypass was 95%. Eleven patients required conversion from VV-DLC bypass to VA bypass because of insufficient support--10 of these patients survived (91% survival). Average bypass time for newborns undergoing VA bypass was 132 +/- 7.4 hours versus 100 +/- 5.1 hours for those undergoing VV-DLC bypass. Neurologic complications were more common in the VA bypass patients, although the VV patients were more stable. Hemorrhagic, cardiopulmonary, and mechanical complications, other than kinking of the DLC, occurred with approximately equal frequency in each group. In conclusion, in newborns with adequate cardiac function, venovenous ECMO using the DLC can provide the same level of support as conventional VA ECMO, without ligation of the carotid artery.

Extracellular fluid and total body water changes in neonates undergoing extracorporeal membrane oxygenation

After being placed on extracorporeal life support (ECLS), newborn patients typically weight 5% to 30% more than their birthweight. Recovery and eventual decannulation from ECLS is associated with a return to baseline weight or birthweight values after a pronounced diuresis. It has been assumed that the increases in weight in these patients are due to increases in extracellular fluid (ECF) and total body water (TBW). This study was undertaken to prove or disprove this hypothesis. ECF space was measured using the compound sodium bromide and TBW was determined with the use of deuterium oxide (nonradioactive heavy water). Fluid compartment measurements were made prior to the institution of ECLS, immediately after placement on bypass, approximately every other day while on bypass, and a final measurement was made once the patient was off bypass. Sodium bromide concentration was analyzed by high-pressure liquid chromatography, and deuterium oxide concentration was measured by the falling drop method. Eight newborns with respiratory failure were placed on either venoarterial (4 patients) or venovenous (4 patients) ECLS for an average of 106 hours (range, 71 to 219 hours). Pre-ECLS TBW was high in the neonates (87% of total body weight v the normal of 75% to 80%). Mean values for each fluid compartment were corrected for the additional volume of the bypass circuit when the patient was on bypass. ECF increased immediately after the institution of ECLS; however, both ECF and TBW decreased during the bypass run, and post-ECLS levels of ECF and TBW were similar to those found prior to ECLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Early experience with adult extracorporeal membrane oxygenation in the modern era

In 1980 we stopped using extracorporeal membrane oxygenation for adults because only 1 of 20 patients treated between 1973 and 1979 survived. In October 1988 we returned to adult extracorporeal life support (ECLS) with a modified protocol including venovenous access when possible, large oxygenators for CO2 clearance, activated clotting time of 180 to 200 seconds, and case selection based on 90% mortality (30% transpulmonary shunt). Of 19 patients referred, 14 met criteria for ECLS. Three of these 14 patients with isolated respiratory failure died before ECLS could be started, and 1 patient refused ECLS and died. Ten were placed on ECLS for 2 to 24 days. Indications were pneumonia (3), post-cardiac operation (2), and adult respiratory distress syndrome (5). Five recovered and 5 died. The cause of early death was progressive pulmonary injury (3), hemorrhage (1), and ventricular arrhythmia (1). One late death occurred at 3 months secondary to intraabdominal complications related to liver transplantation. In conclusion, 10 adult patients with severe respiratory failure were treated with extracorporeal life support; 5 patients recovered lung function and 4 of these patients survived and were discharged to home. Surviving patients were typically younger and were placed on ECLS early in their disease process, emphasizing that early intervention is one key factor to a successful outcome.

Elective tracheotomy for mechanical ventilation by the percutaneous technique

Percutaneous dilatational tracheotomy is a safe, efficient procedure for elective tracheostomy placement. It is not a technique for emergency tracheotomy. It should be performed only by surgeons experienced in conventional tracheotomy. The advantages of placement at the bedside, speed, and relative inexpense make it attractive in the care of critically ill patients.

Extracorporeal membrane oxygenation for pediatric cardiopulmonary failure

Extracorporeal membrane oxygenation is now standard treatment of severe respiratory failure in newborn infants in our center (200 cases) and worldwide (over 2500 cases), but there are few reports of such trials in older children. We reviewed our experience with extracorporeal membrane oxygenation in 33 children aged 1 week to 18 years between 1971 and 1989. The modality was used when all other treatment failed. Extracorporeal membrane oxygenation provided excellent cardiopulmonary support for 1 to 25 days (average 7 1/2 days). The survival rate was 25% for cardiac support patients and 47% for respiratory failure patients (36% overall survival). Mechanical complications included membrane lung failure, tubing rupture, and pump failure, all managed without mortality. Physiologic complications included bleeding, pneumothorax, cardiac arrest, renal failure, hepatic failure, and brain injury. The major cause of death was irreversible injury to lung, heart, or brain. Extracorporeal life support is a reasonable approach for children with serious but reversible cardiopulmonary failure.

Laboratory evaluation of a double lumen catheter for venovenous neonatal ECMO

The authors designed and tested a 14F outside diameter thin-walled double lumen catheter (DLC) for neonatal venovenous (VV) extracorporeal membrane oxygenation (ECMO). In vitro tests with water and dye solution showed capacity of the drainage lumen was 1,096 ml/min at 100 cm siphon, and pressure drop across the perfusion lumen was 300 mmHg at 500 ml/min flow. Recirculation at 500 ml/min flow ranged from 5 to 29%, depending upon simulated cardiac output. The highest serum hemoglobin during 12 hour 400 ml/min flow VV bypass in five dogs was 49 mg/dl. Typical oxygen transport in four dogs was 25 cc/min at 400 ml/min flow. This catheter is well suited for clinical VV ECMO in neonates.

Venovenous extracorporeal life support in neonates using a double lumen catheter

After satisfactory development and testing of a polyurethane 14 Fr double lumen catheter, we used this device for venovenous extracorporeal life support in neonates who had respiratory failure. This catheter was designed for single site cannulation of the internal jugular vein, thereby sparing the carotid artery from ligation. Cannulation was successful in 17 of 21 neonates, with 15 successful venovenous runs, whereas 2 of the 17 patients were converted to venoarterial bypass because of inadequate support. Oxygenation and CO2 removal were adequate in the remaining patients. Average time on bypass was 111 hours. All 15 patients survived, and exploration of the cannulation site for bleeding was required in three patients. Preoxygenator pressure, recirculation of oxygenated blood, and hemolysis were all within acceptable levels during each run. Venovenous extracorporeal life support with the double lumen catheter can replace venoarterial access in most cases of neonatal respiratory failure.

Copper absorption and retention in young men at three levels of dietary copper by use of the stable isotope 65Cu

Eleven young men were confined to a metabolic research unit for 90 d to determine the effect of the level of dietary copper on absorption and retention. Cu absorption was determined by feeding the stable isotope 65Cu. Absorption and retention averaged 36.3 +/- 1.3% and 0.17 mg/d, respectively, with an adequate-Cu diet (1.68 mg/d). Absorption averaged 55.6 +/- 0.9% and retention averaged -0.316 mg/d for 6 d and 0.093 mg/d for the next 36 d of a low-Cu diet (0.785 mg/d). Absorption averaged 12.4 +/- 0.9% with a high-Cu diet (7.53 mg/d) and retention was strongly positive at first, decreasing linearly with time. The study demonstrated that Cu absorption is strongly dependent on dietary Cu level and that Cu balance can be achieved by most young men from a diet of 0.8 mg Cu/d. These results suggest that current dietary Cu recommendations may be higher than necessary. The apparent regulation of Cu absorption and endogenous losses would tend to protect humans from Cu deficiency and toxicity.

Apparatus for direct counting of beta-rays from two-dimensional protein gels: measurement of changes in protein synthesis due to changes in density of Chinese hamster ovary cells

A method is described for scanning two-dimensional protein gels that utilizes direct counting of beta-rays instead of autoradiography. The methodology is compared with autoradiographic results and data are presented demonstrating changed patterns of protein synthesis accompanying changes in cell density. The method is rapid and permits identification of differences in protein abundance of approximately 10% for a substantial fraction of the more prominent proteins. A modulation effect of greater than 5 standard deviations is shown to occur for an appreciable number of the proteins that accompany the inhibition of cell growth due to contact inhibition. The method promises application to a variety of biochemical and genetic problems designed to delineate changes in protein synthesis accompanying changes in genome, molecular environment, history, and state of differentiation of the cell populations studied.

The lysine requirement of young growing male guinea pigs

The lysine requirement of young, growing male guinea pigs was investigated by using crystalline amino acid diets containing 3.58% nitrogen. One hundred eighty-seven 3-wk-old guinea pigs were fed one of 10 crystalline amino acid diets ranging from 0.4 to 2.0% lysine or the control diet consisting of 30% casein in four 21-d performance trials. Diets were evaluated on the basis of changes in body weight, nitrogen retention, carcass weight, gastrointestinal tract weight, liver weight, hematocrit and hemoglobin plus carcass weight, gastrointestinal tract weight and liver weight as percentages of live body weight. A 0.7% dietary lysine level (0.875% lysine X HCl) was the lowest that gave results similar to those attained when casein or higher levels of lysine were fed.