Surgery
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Major medical advances occur during wartime because of the presence of a high concentration of overwhelming casualties and the resulting requirement for innovative solutions. Examples of these advances include the propagation of hospitals with sanitary conditions, the use of blood transfusions, dialysis, air transportation of casualties, and advancements in vascular reconstruction. ⋯ The approach to the injured soldier has involved every aspect of patient care to include prevention using body armor, hypotensive resuscitation, tourniquets, intravenous and topical hemostatic agents, and a proactive approach of aggressive correction of coagulopathy using blood products. These advances currently are being translated to civilian practice altering the care of the urban patient.
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The fate of the circulatory system in response to vascular injury is governed by a series of complex biochemical reactions involving cellular elements and plasma proteins. Alteration of this hemostatic balance can result in excessive bleeding or procoagulant complications. In the field of vascular surgery, modulation of this process can have severe implications with respect to the maintenance of vascular conduit patency by avoiding thromboembolic events and the prevention of excess bleeding in the operative setting. ⋯ This review addresses the management of blood loss in the setting of vascular surgery. In so doing, insight will be shed on the interdependence and manipulation of hemostatic events as they relate to surgery. Topics related to preoperative evaluation, surgical technique, monitoring, and pharmacologic manipulation will be discussed.
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Anticoagulant therapy is challenging to modern surgical practice because it complicates risks of bleeding and the need for allogeneic blood transfusions. In an aging population, there is extensive use of antiplatelet agents, and patients present for operations receiving these agents. Hemostatic inhibitors are reviewed here, including anticoagulants, platelet inhibitors (clopidogrel), low-molecular-weight heparins, pentasaccharide (fondaparinux), and other factor Xa inhibitors. Agents used to manage bleeding, including aprotinin, lysine analogs, desmopressin, and recombinant factor VIIa, are discussed.
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The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis. ⋯ Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.
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Hemorrhage-induced activation of endothelial cell Na+/H+ -exchanger results in cellular swelling, which physically impedes capillary filling and compromises gut perfusion. We hypothesized that correction of the vascular volume deficit by conventional resuscitation does not improve capillary filling unless cellular swelling is prevented. Also, we hypothesized that adjunctive direct peritoneal resuscitation (DPR) with topical peritoneal dialysis solution (Delflex; Fresenius USA, Inc., Ogden, Ut) enhances capillary filling and gut perfusion by mechanisms that are independent of the Na+/H+ function. ⋯ Paradoxical endothelial cell swelling occurs early during hemorrhagic shock because of activation of the Na+/H+ exchanger. This cellular edema, which is not resolved by correction of the vascular volume deficit, explains the persistent postresuscitation endothelial cell dysfunction and gut hypoperfusion. Simulated adjunctive DPR in this study reversed endothelial cell swelling and enhanced gut perfusion by mechanisms that are independent of the Na+/H+ exchanger activity.