Arch Intern Med
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Review
Preoperative spirometry before abdominal operations. A critical appraisal of its predictive value.
Preoperative spirometry is commonly ordered before abdominal surgery, with the goal of predicting and preventing postoperative pulmonary complications. We assessed the evidence for this practice with a systematic literature search and critical appraisal of published studies. The search identified 135 clinical articles, of which 22 (16%) were actual investigations of the use and predictive value of preoperative spirometry. ⋯ The available evidence indicates that spirometry's predictive value is unproved. Unanswered questions involve (1) the yield of spirometry, in addition to history and physical examination, in patients with clinically apparent lung disease; (2) spirometry's yield in detecting surgically important occult disease; and (3) its utility, or beneficial effect on patient outcome. Spirometry's full potential for risk assessment in the individual patient has not yet been realized.
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Factors related to risk of perioperative pulmonary complications include site of incision, obstructive lung disease, prolonged anesthesia time, smoking history with productive cough, and obesity. Hypercapnia is a consistent indicator of high risk. There is no difference between spinal and general anesthesia with regard to risk of pulmonary complications. ⋯ Newer methods of assessing cardiopulmonary reserve may prove useful in identifying which patients with one or more of these risk factors are suitable operative candidates. Prevention of postoperative complications in chronic obstructive pulmonary disease patients should begin in the preoperative period with discontinuation of smoking at least eight weeks before surgery and vigorous pulmonary toilet in the 48 to 72 hours before surgery. Prophylactic lung expansion maneuvers can be effective in decreasing the incidence of postoperative atelectasis in high-risk patients undergoing high-risk operations.
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Review Case Reports
Candida pericarditis and tamponade in a patient with systemic lupus erythematosus.
Candida pericarditis and tamponade developed in a patient with sterile purulent pericarditis secondary to systemic lupus erythematosus. Therapy with amphotericin B and properly timed surgical intervention led to a clinical and microbiological cure. This article emphasizes the importance of differentiating an infected pericardial effusion from the sterile pericarditis of systemic lupus erythematosus and provides suggested guidelines for the management of that complication.
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During the last six years, there has been increased interest in the detection of abnormalities of left ventricular diastolic function in patients with heart disease. Before 1981, most studies on diastolic function were performed in the catheter laboratory using invasive techniques and complex methods. Recently, radionuclide angiograms and Doppler echocardiography have been employed to measure the dynamics of filling in normal individuals and in patients with heart disease. ⋯ It is also important to remember that left ventricular diastolic abnormalities have to be identified after the elimination of the confounding influence of variables such as ejection fraction, heart rate, age, and preload (end-diastolic volume). Automation of the derivation of indexes of diastolic filling should provide an objective assessment of the dynamics of left ventricular filling. Although the value of measurement of diastolic filling in the individual patient remains controversial, we believe that the practice of cardiology is incomplete without consideration of the second half of cardiac function.
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The clinical manifestations of sepsis may be flagrant or subtle. Awareness of the signs and symptoms of sepsis allows early recognition and prompt, appropriate management. ⋯ While therapy for the underlying infection (such as antibiotics and drainage of abscesses) is often sufficient, therapy for the specific manifestations of sepsis may also be necessary. Guidelines for therapy for these manifestations of sepsis are given.