- Email: [email protected]
Practical fiberoptic bronchoscopy
Complications of Parenteral Nutrition
convenience is not enough to justify their use. In addition, there should be development of a softer triple lumen line. Steatohepatitis is an insidious metabolic complication in our patients receiving long-term TPN and is associated with increases in serum glutamic pyruvate transaminase and alkaline phosphatase levels as well as jaundice in a few. Dr. Wolfe, have you encountered this complication, and do you have a protocol for its management? Bruce M. Wolfe (closing): The use of the triple lumen catheter is not entirely resolved, because many patients require additional central venous access for the purpose of hemodynamic monitoring and administration of cardioactive or vasoactive drugs. A separate protocol is necessary to determine whether total patient morbidity is decreased by putting an additional central venous catheter in place for the purpose of having a dedicated line for the TPN. With regard to the Swan-Ganz catheter, it is crucial that the TPN be administered through the central venous port and that the position of the catheter be constantly confirmed, because catheters are often repositioned to determine the wedge pressure. When this is done, the various ports on the Swan-Ganz catheter move, and when hypertonic solutions are infused into a smaller vein, it promptly results in injury to the vein wall and thrombosis. Dr. Fonkalsrud, only 7 percent of our patients were children. This presumably accounts for many of the differences that we have seen as opposed to the UCLA experience, such as thrombosis of the superior vena cava, more
Book Reviews (cont’d) expected, the sections on abdominal healing and control of adhesions are splendid. The pioneer work of the senior author in the understanding of development and clinical control of fibrous adhesions is summarized in elegant fashion, Selection of sutures and dressings is also covered well and without redundancy. A highlight of the text is a complete bibliography at the end of every chapter. I am not aware of a single significant reference that was omitted. The weaknesses of the book are not significant. The chapter on management of burns concisely presents the general consensus most surgeons already hold for proper management of thermal injuries. I do not agree with all of these concepts and will, therefore, list as a minor deficit failure to present competing views. Overemphasis on the use of mesh grafts is an example of such a topic. There are more photographs in several chapters than are needed to enhance the text, some of which will not add anything to a surgeon’s knowledge of wound healing. The publishers have done a nice job producing a clean, easy to read volume, but it is overpriced, as most medical texts are today. Overall, this book is one of the most clearly presented
Continued
Vdume152,July1996
often in our permanent, long-term patients. Our study was limited to inpatient complications of total parenteral nutrition. We have generally treated acute TPN-related thrombosis by removal of the catheter and have proceeded with anticoagulation only if the patient’s clinical condition would permit it and if the patient had apparent morbidity in terms of swelling or associated sepsis. We have used streptokinase in one of our patients receiving long-term TPN at home whose survival depends on our capacity to maintain permanent central venous access. Otherwise, we have not used this more hazardous and costly treatment for venous thrombosis. Dr. Pitt, the issue of metabolic complications, particularly with regard to the biliary tract and gallbladder, is difficult to resolve. We have limited ourselves to those complications that could clearly be attributed to the TPN itself in this study. Complications such as acalculous cholecystitis are prone to occur in the critically ill population whether they are given parenteral nutrition or not. We have seen bone disease, but this is a long-term complication rather than one that is seen in the hospital. Dr. McConnell, the stiffness of the triple lumen catheter is part of the reason why it induces more sepsis, although we have not confirmed a higher thrombosis rate with this catheter. Pericardial tamponade is a fatal complication when it occurs, and it is important that these catheters not be placed low in the right atrium unless they are soft Silastic catheters. Our studies indicate that hepatic steatosis is a function of the severity of illness rather than the provision of TPN as long as caloric excess is avoided.
and engaging texts available today. It is literally crammed with useful information presented in a refreshingly direct and simple style. I recommend it to students and accomplished surgeons without reservation. It is a very useful addition to the connective tissue biology and clinical surgery literature alike. Erie E. Peacock, Jr., MD Chapel Hill, North Carolina Practical Fiberoptic Bronchoscopy. 2nd Edition. By Kenkichi Oho and Ryuta Amemiya (translated by J.P. Barron). Tokyo: Kgaku-Shoin, 1984.218 pages. The excellence of the first edition of this book is admirably present in this second edition. Although only 4 years have passed since publication of the first edition, Oho and Amemiya have successfully updated the important technical developments in fiberoptic bronchoscopy instrumentation. More importantly, an entire section is devoted to their evaluation of technique, and indications and limitations of laser methods now recognized as a major development in the field. Their description of bronchscopic instrumentation and of the normal anatomy of the bronchus remains unsurpassed. The photographic presenta-
on page 109.
99
The Cell-Saver and Autologous Transfusion
of hypothermia and the interplay of multiple transfusions is very important. The heparin is removed by the cellsaver. We also carefully monitor the activated clotting time and know what the state of anticoagulation is and when it is appropriately reversed to control levels. Coagulopathy occurs infrequently if the temperature is well controlled and less than 10 units of autotransfused blood are used. One purpose of autologaus blood transfusion is defeated by administering blood components. We use them sparingly and only when it appears we have serious bleed-
ing, a coagulation problem, or hemodynamic instability. The operative field must be observed for signs of coagulopathy and therapy adjusted accordingly. In the last couple of years, we have sent people with 8 or 9 g of hemoglobin home on iron therapy rather than given them any blood postoperatively. Our blood bank incidence of hepatitis, fortunately, has been quite low, around 2 percent. We rarely use more than 1 or 3 unite of autologous blood donated preoperatively. On Dr. Ullyot’s cardiac service, the use of homologous banked blood has decreased from 8 units per case on reoperations to about 0.8 units.
Book Reviews (cont’d)
newer culture techniques are presented. The final chapter on immunotherapy includes a good discussion of the chemistry and biologic properties of endotoxin as well as a review of antibody and vaccine therapy for Escherichia coli sepsis. Future implications of immunotherapy are also covered, including the role of nonspecific immunotherapy in gram-negative sepsis. Overall, this book is an excellent overview of the pathogenesis of septic shock. It will be particularly valuable to the beginning investigator and the clinician who wishes to update his knowledge of septic shock. The majority of chapters are extremely well referenced thereby allowing additional in-depth reading of a particular topic by the interested reader.
tions of both normal anatomic and pathologic findings visualized with the fiberoptic bronchoscope are outatanding. The publisher, Igaku-Shoin of Tokyo, is to be congratulated for the excellence of the photographic reproductions. Anyone engaged in fiberoptic bronchoscopy should have this text as a reference source. I also recommend it to those who do not perform these procedure but are students of thoracic disease. Thomas W. Shields, MD Chicago, Illinois Septic Shock. Volume 4. Contemporary Issues in Infectious Disease. Edited by Richard K. Root and Merle A. Sande. New York: Churchill Livingstone, 1985.276 pages. $42.00. Septic shock is a topic pertinent to all fields of medicine. Although the majority of the 25 contributing authors represent the discipline of internal medicine, the disciplines of surgery, pharmacology, and obstetrics and gynecology are also included. As stated in the foreword, the volume was designed for both the investigator and the clinician in the area of septic shock. It succeeds in presenting a good overview of this important subject, with an excellent review of the pathogenesis of septic shock in the first chapters. Particularly outstanding is the discussion of the role of lipopolysaccharides, complement, and phospholipase products in the pathogenesis of sepsis. The bibliography is very useful for further investigation. The remaining chapters tend to be somewhat clinically oriented but as a group, are less impressive than the earlier portion of the book. The chapter on principles of antimicrobial therapy is concise and clearly elucidates the philosophy of empiric therapy of sepsis with combinations of antibiotics. Similarly, the chapter on new antibiotics for the treatment of sepsis presents a comprehensive review of the third generation cephalosporins. However, the chapters on pulmonary injury, sepsis in the surgical patient, and sepsis in obstetrics and gynecology seem somewhat superficial and repetitive in some instances. The discussion of opioid antagonists is a good review of an important and difficult topic, whereas the chapter on newer microbial techniques seems strangely inappropriate to this volume, even though detailed review of the
William Browder, MD New Drleans, Louisiana Manual of Surgical Therapeutics. 6th Edition. Edited by Robert E. Condon and Lloyd M. Nyhus. Little, Brown and Company, 1985.482 pages. $17.95. The editors’ purpose in organizing this book was to bring together in a single, convenient volume, information pertinent to the operative management of surgical patients. In this effort, the editors and contributing authors have done a thoroughly commendable job. The editors note in the preface that the methods of treatment outlined are limited to only single, but successful, plans of management. This is certainly true but unavoidable as the volume had to be kept small enough to preserve its stated purpose. The sections on cardiac dysrhythmias and acute abdominal pain are especially well written. The selected readings at the end of each chapter are thoughtfully chosen and offer the house officer and student good direction for further study. The format, style, and topic selection are essentially unchanged from the 5th edition, but all topic discussions have been updated and, in some cases, expanded. It is impossible to cover the totality of surgical therapeutics in 482 pages, but the authors and editors have succeeded better than most. Furthermore, the spiral notebook design allows the book to fit comfortably in a coat pocket, ready for instant perusal. This little volume is a valuable resource reference. Royce Laycock, MD Dallas, Texas
Continued on page 151 Volume 152,July 1956
109
convenience is not enough to justify their use. In addition, there should be development of a softer triple lumen line. Steatohepatitis is an insidious metabolic complication in our patients receiving long-term TPN and is associated with increases in serum glutamic pyruvate transaminase and alkaline phosphatase levels as well as jaundice in a few. Dr. Wolfe, have you encountered this complication, and do you have a protocol for its management? Bruce M. Wolfe (closing): The use of the triple lumen catheter is not entirely resolved, because many patients require additional central venous access for the purpose of hemodynamic monitoring and administration of cardioactive or vasoactive drugs. A separate protocol is necessary to determine whether total patient morbidity is decreased by putting an additional central venous catheter in place for the purpose of having a dedicated line for the TPN. With regard to the Swan-Ganz catheter, it is crucial that the TPN be administered through the central venous port and that the position of the catheter be constantly confirmed, because catheters are often repositioned to determine the wedge pressure. When this is done, the various ports on the Swan-Ganz catheter move, and when hypertonic solutions are infused into a smaller vein, it promptly results in injury to the vein wall and thrombosis. Dr. Fonkalsrud, only 7 percent of our patients were children. This presumably accounts for many of the differences that we have seen as opposed to the UCLA experience, such as thrombosis of the superior vena cava, more
Book Reviews (cont’d) expected, the sections on abdominal healing and control of adhesions are splendid. The pioneer work of the senior author in the understanding of development and clinical control of fibrous adhesions is summarized in elegant fashion, Selection of sutures and dressings is also covered well and without redundancy. A highlight of the text is a complete bibliography at the end of every chapter. I am not aware of a single significant reference that was omitted. The weaknesses of the book are not significant. The chapter on management of burns concisely presents the general consensus most surgeons already hold for proper management of thermal injuries. I do not agree with all of these concepts and will, therefore, list as a minor deficit failure to present competing views. Overemphasis on the use of mesh grafts is an example of such a topic. There are more photographs in several chapters than are needed to enhance the text, some of which will not add anything to a surgeon’s knowledge of wound healing. The publishers have done a nice job producing a clean, easy to read volume, but it is overpriced, as most medical texts are today. Overall, this book is one of the most clearly presented
Continued
Vdume152,July1996
often in our permanent, long-term patients. Our study was limited to inpatient complications of total parenteral nutrition. We have generally treated acute TPN-related thrombosis by removal of the catheter and have proceeded with anticoagulation only if the patient’s clinical condition would permit it and if the patient had apparent morbidity in terms of swelling or associated sepsis. We have used streptokinase in one of our patients receiving long-term TPN at home whose survival depends on our capacity to maintain permanent central venous access. Otherwise, we have not used this more hazardous and costly treatment for venous thrombosis. Dr. Pitt, the issue of metabolic complications, particularly with regard to the biliary tract and gallbladder, is difficult to resolve. We have limited ourselves to those complications that could clearly be attributed to the TPN itself in this study. Complications such as acalculous cholecystitis are prone to occur in the critically ill population whether they are given parenteral nutrition or not. We have seen bone disease, but this is a long-term complication rather than one that is seen in the hospital. Dr. McConnell, the stiffness of the triple lumen catheter is part of the reason why it induces more sepsis, although we have not confirmed a higher thrombosis rate with this catheter. Pericardial tamponade is a fatal complication when it occurs, and it is important that these catheters not be placed low in the right atrium unless they are soft Silastic catheters. Our studies indicate that hepatic steatosis is a function of the severity of illness rather than the provision of TPN as long as caloric excess is avoided.
and engaging texts available today. It is literally crammed with useful information presented in a refreshingly direct and simple style. I recommend it to students and accomplished surgeons without reservation. It is a very useful addition to the connective tissue biology and clinical surgery literature alike. Erie E. Peacock, Jr., MD Chapel Hill, North Carolina Practical Fiberoptic Bronchoscopy. 2nd Edition. By Kenkichi Oho and Ryuta Amemiya (translated by J.P. Barron). Tokyo: Kgaku-Shoin, 1984.218 pages. The excellence of the first edition of this book is admirably present in this second edition. Although only 4 years have passed since publication of the first edition, Oho and Amemiya have successfully updated the important technical developments in fiberoptic bronchoscopy instrumentation. More importantly, an entire section is devoted to their evaluation of technique, and indications and limitations of laser methods now recognized as a major development in the field. Their description of bronchscopic instrumentation and of the normal anatomy of the bronchus remains unsurpassed. The photographic presenta-
on page 109.
99
The Cell-Saver and Autologous Transfusion
of hypothermia and the interplay of multiple transfusions is very important. The heparin is removed by the cellsaver. We also carefully monitor the activated clotting time and know what the state of anticoagulation is and when it is appropriately reversed to control levels. Coagulopathy occurs infrequently if the temperature is well controlled and less than 10 units of autotransfused blood are used. One purpose of autologaus blood transfusion is defeated by administering blood components. We use them sparingly and only when it appears we have serious bleed-
ing, a coagulation problem, or hemodynamic instability. The operative field must be observed for signs of coagulopathy and therapy adjusted accordingly. In the last couple of years, we have sent people with 8 or 9 g of hemoglobin home on iron therapy rather than given them any blood postoperatively. Our blood bank incidence of hepatitis, fortunately, has been quite low, around 2 percent. We rarely use more than 1 or 3 unite of autologous blood donated preoperatively. On Dr. Ullyot’s cardiac service, the use of homologous banked blood has decreased from 8 units per case on reoperations to about 0.8 units.
Book Reviews (cont’d)
newer culture techniques are presented. The final chapter on immunotherapy includes a good discussion of the chemistry and biologic properties of endotoxin as well as a review of antibody and vaccine therapy for Escherichia coli sepsis. Future implications of immunotherapy are also covered, including the role of nonspecific immunotherapy in gram-negative sepsis. Overall, this book is an excellent overview of the pathogenesis of septic shock. It will be particularly valuable to the beginning investigator and the clinician who wishes to update his knowledge of septic shock. The majority of chapters are extremely well referenced thereby allowing additional in-depth reading of a particular topic by the interested reader.
tions of both normal anatomic and pathologic findings visualized with the fiberoptic bronchoscope are outatanding. The publisher, Igaku-Shoin of Tokyo, is to be congratulated for the excellence of the photographic reproductions. Anyone engaged in fiberoptic bronchoscopy should have this text as a reference source. I also recommend it to those who do not perform these procedure but are students of thoracic disease. Thomas W. Shields, MD Chicago, Illinois Septic Shock. Volume 4. Contemporary Issues in Infectious Disease. Edited by Richard K. Root and Merle A. Sande. New York: Churchill Livingstone, 1985.276 pages. $42.00. Septic shock is a topic pertinent to all fields of medicine. Although the majority of the 25 contributing authors represent the discipline of internal medicine, the disciplines of surgery, pharmacology, and obstetrics and gynecology are also included. As stated in the foreword, the volume was designed for both the investigator and the clinician in the area of septic shock. It succeeds in presenting a good overview of this important subject, with an excellent review of the pathogenesis of septic shock in the first chapters. Particularly outstanding is the discussion of the role of lipopolysaccharides, complement, and phospholipase products in the pathogenesis of sepsis. The bibliography is very useful for further investigation. The remaining chapters tend to be somewhat clinically oriented but as a group, are less impressive than the earlier portion of the book. The chapter on principles of antimicrobial therapy is concise and clearly elucidates the philosophy of empiric therapy of sepsis with combinations of antibiotics. Similarly, the chapter on new antibiotics for the treatment of sepsis presents a comprehensive review of the third generation cephalosporins. However, the chapters on pulmonary injury, sepsis in the surgical patient, and sepsis in obstetrics and gynecology seem somewhat superficial and repetitive in some instances. The discussion of opioid antagonists is a good review of an important and difficult topic, whereas the chapter on newer microbial techniques seems strangely inappropriate to this volume, even though detailed review of the
William Browder, MD New Drleans, Louisiana Manual of Surgical Therapeutics. 6th Edition. Edited by Robert E. Condon and Lloyd M. Nyhus. Little, Brown and Company, 1985.482 pages. $17.95. The editors’ purpose in organizing this book was to bring together in a single, convenient volume, information pertinent to the operative management of surgical patients. In this effort, the editors and contributing authors have done a thoroughly commendable job. The editors note in the preface that the methods of treatment outlined are limited to only single, but successful, plans of management. This is certainly true but unavoidable as the volume had to be kept small enough to preserve its stated purpose. The sections on cardiac dysrhythmias and acute abdominal pain are especially well written. The selected readings at the end of each chapter are thoughtfully chosen and offer the house officer and student good direction for further study. The format, style, and topic selection are essentially unchanged from the 5th edition, but all topic discussions have been updated and, in some cases, expanded. It is impossible to cover the totality of surgical therapeutics in 482 pages, but the authors and editors have succeeded better than most. Furthermore, the spiral notebook design allows the book to fit comfortably in a coat pocket, ready for instant perusal. This little volume is a valuable resource reference. Royce Laycock, MD Dallas, Texas
Continued on page 151 Volume 152,July 1956
109