Alterations in regional tissue perfusion may precede global indications of shock. This study compared regional tissue oxygenation saturation (StO2) using near-infrared spectroscopy with standard hemodynamic and biochemical variables in 40 patients undergoing cardiopulmonary bypass (CPB). Mean arterial pressure, cardiac output, oxygen delivery, arterial blood gases, and lactate were recorded at specific intervals during surgery. Data were organized by stage of procedure, and the relationship of StO2 to established parameters was investigated. With initiation of CPB, StO2 declined by 12.9 per cent (standard deviation ± 14.75%) with a delayed increase in lactate from 0.9 (interquartile range [IQR], 0.6–1.5) mmol/L to 2.3 (IQR, 1.8–2.5) mmol/L. The minimum StO2 value preceded the maximum lactate level by an average time of 93.9 (standard deviation ± 86.3) minutes. Additionally, a decrease in StO2 corresponded with an increase in base deficit of 4.84 (standard deviation ± 2.37) mEq/L over the same period. Calculated oxygen delivery decreased from a baseline value of 754 (IQR, 560–950) mL/min to 472 (IQR, 396–600) mL/min with initiation and maintenance of CPB. For patients undergoing CPB, StO2 is a reliable, noninvasive monitor of perfusion, which correlates well with oxygen delivery and identifies perfusion deficits earlier than lactate or base deficit.
Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.
The prevalence of primary hyperparathyroidism (PHPT) will increase with the growth of the elderly population. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in elderly patients with PHPT, the majority of them reporting increased fracture-free survival and symptomatic relief postoperatively and thus experiencing improved quality of life.
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