Infections of Scribner and Brescia Arteriovenous Shunts

Abstract

blood pressure was 220/170 mm Hg, he had grade IV hypertensive retinopathy, and the serum creatinine level was 5 0 mg/100 ml. He still felt well. Diazoxide 300 mg intravenously lowered the blood pressure, but methyldopa, debrisoquin, reserpine, and clonidine failed to maintain control. There was pronounced orthostatic hypotension, but the blood pressure in the lying posture was high. Renal biopsy showed severe hypertensive nephropathy with many hyalinized glomeruli, the serum creatinine rose to 11-3 mg/100 ml, and there were bouts of left ventricular failure. It was decided to perform bilateral nephrectomy, and an infusion of sodium nitroprusside readily controlled the blood pressure (Table II). At the time of writing he was awaiting a renal transplant and his blood pressure was under control without drugs.Case 4.-A 48-year-old man had a 10-month history of hypertension and renal failure. Control of hypertension had become increasingly difficult, and on admission the blood pressure was 230/ 150 mm Hg, the serum creatinine 13-0 mg/100 ml, and there was a grade IV hypertensive retinopathy. Pentolinium, 25 mg subcutaneously in 12 hours, had no effect on the blood pressure, but it fell briefly to 90/70 mm Hg after 300 mg of diazoxide intravenously. Sodium nitroprusside was then used with good effect. It was continued during peritoneal dialysis preparatory to bilateral nephrectomy, but there were pronounced swings in blood pressuresystolic 80-260, mean 156 (S.D.43); diastolic 50-160, mean 112 (S.D.28)-with severe anginal pain. There was no evidence of myocardial infarction. Sodium nitroprusside was continued after dialysis ended and blood pressure control again became satisfactory and the anginal pain ceased. After bilateral nephrectomy his blood pressure returned to normal without further therapy, but unfortunately he died six days after the operation from bronchopneumonia and septicaemia.Discussion Sodium nitroprusside has a direct depressant effect on vascular musculature, independent of the nervous system (Page et al., 1955). The effect is immediate and ends when the infusion is stopped. The latter property is of special value in patients in whom the cause of hypertension is to be abruptly removed. I have not used the drug during surgery for a phaeochromocytoma, but it would seem to be the drug of choice for this purpose and for when controlled lowering of blood pressure is needed during surgery. Though it is less effective in normotensive subjects than in hypertensives it produces a fall of blood pressure, and Kaneko et al. (1967) used it rapidly to lower the blood pressure in normotensive subjects to study renin release.The drug is virtually non-toxic during short-term use. Long-term toxic effects are due to accumulation of thiocyanate, to which sodium nitroprusside is converted. One case reported by Nourok et al. (1964) developed high serum levels of thiocyanate and features of hypothyroidism after 21 days, which improved when the nitroprusside infusion was stopped. The longest period of infusion in my cases ...

Blood Access for Haemodialysis

“…The incidence of clotting and infection is considerably reduced [5,16] though when local infection has occurred a higher incidence of associated septicaemia has been reported [20]. Septic pulmonary emboli [15] with abscess formation has occurred mainly due to Staphylococci but Pseudomonas was also reported as have a few cases of bacterial endocarditis.…”

Brachial Arteriovenous Shunts for Hemodialysis and Extracorporeal Procedures

“…The second complication was dislodgement of the arterial cannula due to a technical error in positioning the shunt, which is preventable. Other complications like thrombosis, infection, and revisions which have been reported to occur in 25-30°/» of patients with peripheral shunts [8,12], were not encountered in these patients. Also, no untoward cardiac manifestations were noted as a result of these shunts even in small children, and this is in keeping with the findings of J ohnson and Blythe [7]Follow-up studies of these patients, demonstrated the reestablishment of normal circulation through the distal brachial artery and its ulna and radial branches, within a very short time after the construction of the shunt.…”

Surveillance and Prophylactic Intervention of Staphylococcus aureus Nasal Colonization in a Hemodialysis Unit

“…data]. Patients with chronic renal failure not yet on dialysis have been documented to have a higher incidence of S. aureus nasal colonization (21%) than nor mal controls (11 %), but an incidence lower than patients on chronic hemodialysis (62%) [7], In the hemodialysis population, the incidence has been documented to be as high as 80% [2], Regular skin puncture every 48-72 h for access to vascular grafts or native fistulas and continuous integral disruption by central venous catheters or shunts place the hemodialysis patient at unique life-long risk.…”

“…This pathogen accounts for 70-96% of all vascular access infections [1][2][3]. Ensuing bacteremia, septic emboli, and vascular access loss cause significant morbidity and mor tality in these patients [4], Thus, effective prophylaxis of vascular access infection and bacteremia is a worthwhile goal in the management of the hemodialysis population.…”