Patients undergoing upper abdominal surgery characteristically develop changes in lung function and are liable to develop atelectasis in the lower lobes. We studied 15 patients to assess lung function and, in particular, diaphragm function in patients undergoing cholecystectomy. Postoperatively, forced expiratory volume in one second and vital capacity decreased in all patients. The alveolar-arterial oxygen difference widened in the 10 patients in whom it was measured. Chest roentgenograms demonstrated patchy atelectasis in 9 of the 10 patients in whom films were obtained. There was a significant reduction in tidal volume with no change in minute ventilation immediately postoperatively. Diaphragm function was assessed by: changes in transdiaphragmatic pressure swings during quiet tidal breathing, the ratio of changes in gastric to esophogeal pressure swings, and the ratio of changes in abdominal to rib cage diameters. The results showed a significant decrease in changes in transdiaphragmatic pressure and the ratio of changes in gastric to esophogeal pressure swings in the postoperative period. In the 4 patients studied with magnetometers, there was a reduction in the ratio of changes in abdominal to rib cage diameters in all patients. These data indicate reduced diaphragm activity in the postoperative period, with a shift from predominantly abdominal to rib cage breathing. There was a reversal toward normal function by 24 h. This reduction in diaphragm function may be responsible for the atelectasis, reduced vital capacity, and hypoxemia in postoperative patients.
Admission of a patient with group A streptococcal cellulitis and bacteremia to the intensive care unit of a tertiary care teaching hospital was followed by two subsequent cases of group A streptococcal bacteremia with pneumonia in the unit. All streptococcal isolates were the same M- and T-type. Endotracheal intubation with respiratory ventilation was a risk factor for disease acquisition. The characteristics of onset of the two nosocomially acquired cases suggested that a staff member may have been, at least transiently, a streptococcal carrier, but no such carrier was identified. No further cases occurred subsequent to a period when all patients in the unit received antibiotics effective for group A streptococcal therapy.
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