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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Emergency hemipelvectomy (HP) is a rare procedure. Only three incidents have been previously reported. This paper describes six additional cases, analyzes our results, and sets forth criteria for patient selection. There were five men and one woman. The median age was 38.5 years. Primary underlying diseases were sarcoma (three cases), peripheral vascular disease (one), deep vein thrombosis (one), and drug abuse (one). Life-threatening peripelvic sepsis and hemorrhage were indications for emergency HP. All six patients had multiple procedures prior to definitive HP. Four classical and two modified HPs were performed. The mean operative time was 3.5 hours, the mean blood loss 2292 ml. There were no intraoperative complications. The median duration of hospitalization was 56 days. Five of six patients were saved. Life-threatening peripelvic sepsis or hemorrhage associated with tumor recurrence, radiation, or failed vascular reconstruction is an indication for emergency HP. Neither age nor physical condition should be a deterrent. The patient should not be allowed to advance to a premorbid state before HP is considered, although concomitant intra-abdominal disease is a contraindication. HP is recommended in lieu of hip disarticulation. We anticipate that the need for emergency HP will increase as limb salvage procedures for extremity sarcomas and dysvascular disease become more frequent.
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PMID:Emergency hemipelvectomy in the control of life-threatening complications. 685 96

A review of 99 case histories (57 males and 42 females) involving 117 amputations of the lower limb during a four-year period is presented. Fifty-eight below-the-knee amputations were performed: five were revised to the above-the-knee (AK) level. There were 54 primary AK amputations. Complications associated with peripheral vascular disease constituted the main reason for performing surgery. The overall mortality rate was 20.2%: sepsis was the main cause of death.
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PMID:Above vs. below knee amputations: a retrospective analysis. 722 48

Accurate information on short-term prognosis is needed to help patients, their doctors, and society to make appropriate decisions concerning starting dialysis. We sought to develop a clinically applicable prognostic scoring system to aid in the prediction of death within 6 months of starting maintenance dialysis. Factors potentially predictive of early death were examined retrospectively in an inception cohort of all 325 patients starting dialysis for irreversible renal failure between 1980 and 1991 at a single tertiary care center. The overall mortality rate was 22% at 6 months. Age, cardiac failure, ischemic heart disease, dysrhythmia requiring therapy, severe peripheral vascular disease, advanced neoplasia, ventilator dependency, coma, systemic sepsis, and hepatic failure were independent, significant, prognostic indicators for early death. Multivariate models were used to suggest weights for these variables in a simplified scoring system. Patients with scores < or = 4 (N = 201) had a 6-month mortality rate of 4%, whereas those with a score higher than 9 (N = 21) had a 6-month mortality rate of 100%. Thus, when age and multiple comorbid illnesses were taken into account, it was possible to identify with 100% accuracy 29% of the patients who died within 6 months of starting maintenance dialysis therapy, accounting for 6.5% of the cohort studied. A larger prospective study is warranted to validate this scoring system.
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PMID:Advance prediction of early death in patients starting maintenance dialysis. 820 66

Eicosanoids were discovered as "prostaglandins" in the mid-1930s. The discovery that eicosanoids were ubiquitous in mammalian cells and that nonsteroidal anti-inflammatory drugs worked by inhibiting enzymes that synthesized these chemicals heralded their extensive investigation in all fields of biology. Precursor fatty acids (arachidonic acids) are stored in cell phospholipids, acted on by two enzymes (cyclooxygenase and lipooxygenase) that yield prostaglandins, thromboxane, prostacyclin, and leukotrienes. Knowledge of their biochemical processes continue to unfold, but it is now believed that eicosanoids are part of a larger group of agents termed phospholipid mediators. Eicosanoids are intimately involved with cardiovascular function as well as central and peripheral vascular disease processes and ischemia. In the gastrointestinal tract, these potent lipids not only participate in many normal functions (eg, acid secretion and motility) but also in disease states (eg, inflammatory bowel disease and peptic ulcer disease). In shocklike states of sepsis and/or endotoxemia, eicosanoids have assumed a major role in many events that occur. Recently, discoveries have demonstrated that platelet-activating and tumor necrosis factors exert their effects in part through eicosanoids. The future will demonstrate these compounds to be critical not only in intracellular (molecular) events but also in the effects they produce that are far from the source of origin.
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PMID:Eicosanoids. Critical agents in the physiological process and cellular injury. 823 81

Eight adult insulin-requiring diabetics with peripheral vascular disease were admitted with foot infection and signs of systemic sepsis. Transcutaneous oxygen tension was measured at the foot and ankle prior to surgery. None of the values were sufficient to support wound healing. Four of the patients underwent open ray resection and four open midfoot amputation. After resolution of the local infections, transcutaneous oxygen tensions were repeated. Seven of the eight patients exhibited an appreciable increase in the value following decompression of the foot infection, sufficient to support wound healing.
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PMID:Transcutaneous oxygen tension in the dysvascular foot with infection. 834 9

In-hospital and late complications related to percutaneous placement of 240 intraaortic balloon pump catheters in 231 consecutive patients from March 1985 through June 1990 were reviewed. Mean age was 64 +/- 11 years and 34% were women. Average duration of counterpulsation was 44.2 hours. Indications for counterpulsation included complications of myocardial infarction (34.6%), prophylactic placement before high-risk coronary angioplasty (20.0%) or open heart surgery (12.9%), complicated coronary angioplasty (18.3%), end-stage cardiomyopathy (5.4%) and miscellaneous (8.8%). Early major complications occurred in 11 cases (4.6%) and included limb ischemia requiring surgery (n = 9), bleeding requiring arterial repair (n = 1) and septicemia (n = 1). Other complications included hematoma requiring transfusion (n = 7), limb ischemia resolving with balloon catheter removal (n = 12), and superficial wound infection (n = 1). Overall in-hospital complication rate was 13% (31 of 240). Peripheral vascular disease and diabetes were found to be significant predictors of limb ischemia (p = 0.01 and p = 0.02, respectively). Follow-up information was obtained in 97% of patients with a mean duration of 19 months: 2 patients (1.1%) required vascular surgery for femoral false aneurysms and 1 patient experienced new onset of claudication. In conclusion, compared with previous experience, contemporary intraaortic balloon counterpulsation with percutaneous placement of smaller size (8.5Fr to 10.5Fr) catheters is associated with improved complication profile. This will further enhance the current trend for an expanding role of intraaortic balloon counterpulsation in complex interventional procedures.
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PMID:Complications associated with percutaneous placement and use of intraaortic balloon counterpulsation. 842 77

Necrotizing fasciitis is an uncommon soft-tissue infection, usually caused by toxin-producing, virulent bacteria, which is characterized by widespread fascial necrosis with relative sparing of skin and underlying muscle. It is accompanied by local pain, fever, and systemic toxicity and is often fatal unless promptly recognized and aggressively treated. The disease occurs more frequently in diabetics, alcoholics, immunosuppressed patients, i.v. drug users, and patients with peripheral vascular disease, although it also occurs in young, previously healthy individuals. Although it can occur in any region of the body, the abdominal wall, perineum, and extremities are the most common sites of infection. Introduction of the pathogen into the subcutaneous space occurs via disruption of the overlying skin or by hematogenous spread from a distant site of infection. Polymicrobial necrotizing fasciitis is usually caused by enteric pathogens, whereas monomicrobial necrotizing fasciitis is usually due to skin flora. Tissue damage and systemic toxicity are believed to result from the release of endogenous cytokines and bacterial toxins. Due to the paucity of skin findings early in the disease, diagnosis is often extremely difficult and relies on a high index of suspicion. Definitive diagnosis is made at surgery by demonstration of a lack of resistance of normally adherent fascia to blunt dissection. Treatment modalities include surgery, antibiotics, supportive care, and hyperbaric oxygen. Early and adequate surgical debridement and fasciotomy have been associated with improved survival. Initial antibiotic therapy should include broad aerobic and anaerobic coverage. If available, hyperbaric oxygen therapy should be considered, although to our knowledge, there are no prospective, randomized clinical trials to support this. Mortality rates are as high as 76%. Delays in diagnosis and/or treatment correlate with poor outcome, with the cause of death being overwhelming sepsis syndrome and/or multiple organ system failure.
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PMID:Necrotizing fasciitis. 868 31

To assess the long-term outcome of kidney/pancreas transplantation, patients were identified who had good graft function at one year posttransplant and a minimum of 3 years' follow-up. Fifty recipients from 1987-92 met these criteria. Records were reviewed for graft survival, graft function, readmissions, and medical complications. Psychosocial adjustment and quality of life were assessed using the SCL-90-R and SIP surveys, respectively. Patient, kidney, and pancreas survivals were 94%, 86%, and 85% at five years (Kaplan-Meier), with a mean follow-up of 4.3 years. The 3 deaths were due to 2 sudden arrests at home (presumed to be cardiac events) and 1 episode of sepsis. Other graft losses were due to rejection, except for one case of sepsis. The remaining patients are normoglycemic (glucose 92 +/- 23 mg/dl) and have a creatinine of 1.8 +/- 0.6 mg/dl. Mortality after the first year was 0.9%/year. Estimated kidney and pancreas half-lives were 15 +/- 2 and 23 +/- 7 years, respectively. Hospitalization, acute rejection, graft pancreatitis, dehydration, and severe infections all decreased dramatically after the first year. While CMV was the most common infection in the first year, foot infections predominated thereafter. Retinal hemorrhage was infrequent. Sudden death (presumably cardiac) was the chief cause of mortality, while peripheral vascular disease resulted in several amputations. Fractures were common, suggesting the need for increased attention to bone demineralization. Psychosocial and quality of life evaluations were within normal limits. In conclusion, most complications specifically related to transplantation occur in the first year, but underlying disease renders these patients susceptible to a variety of cardiovascular, bone, and other disorders.
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PMID:Long-term outcome of kidney-pancreas transplant recipients with good graft function at one year. 878 9

Infectious complications are a source of substantial morbidity and a common cause of death among dialysis patients. This article considers the magnitude and impact of the problem of infection among patients treated with hemodialysis (HD) and peritoneal dialysis (PD) using data from national registries and large cohort studies of patients with end-stage renal disease (ESRD). United States Renal Data System (USRDS) data indicate that in the United States for years 1991 to 1992, infection accounted for 12% of all deaths among HD patients and 15% of all deaths among PD patients. Septicemia was the underlying cause in 76% of these infectious deaths among HD patients, of which the vascular access, peritonitis, peripheral vascular disease, and other causes accounted for 12%, 5%, 24%, and 59% respectively. Among PD patients, septicemia accounted for 79% of infectious deaths. Of these deaths attributable to septicemia, peritonitis, peripheral vascular disease, and other causes were reported as the cause in 35%, 23%, and 41% respectively. Infection is also a major cause of morbidity in the dialysis population. Among HD patients, an average of 7.6 bacteremic episodes per 100 patient years (0.076 per year) has been described, of which 48% were associated with access infections. Among PD patients, studies have reported peritonitis rates ranging from 1 in 7.6 to 21.5 months (0.56 to 1.58 per patient year) and exit and/or tunnel infections occurring at a rate of 0.6 episodes per year. The known predictors of infectious complications among these populations are reviewed.
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PMID:Epidemiological perspective on infections in chronic dialysis patients. 882 98

Difficulties in creating vascular access in patients on hemodialysis are encountered in most dialysis centers. This is usually due to a lack of suitable peripheral vessels due to previous access surgery in patients on long-term hemodialysis, but also may be seen in some patients de novo, particularly diabetics and patients with peripheral vascular disease. Surgical techniques used to overcome this problem vary depending on patient characteristics and, to a certain extent, on local expertise/preference. We report our experience of using silicon dual-lumen hemodialysis catheters over a 3-year period; during this time, 54 catheters were inserted into 32 hemodialysis patients. The indication for this procedure in 52 catheters (31 patients) was either exhausted vascular access or obvious difficulty identifying a suitable peripheral blood vessel. Of the catheters inserted, 20 were placed into subclavian veins by primary insertion (ie, patients did not have existing subclavian catheter); 34 were replaced over a guidewire (a procedure used to allow technique salvage). The catheter survival rate was 72.7% at 90 days and 48.7% at 1 year. Corresponding rates at 90 days and 1 year for technique survival were 93.3% and 81.8%, respectively. The mean catheter and technique survival was 387 (95% confidence intervals [CIs], 273, 502) and 844 (95% CIs, 684, 1,005) days, respectively. Poor flow accounted for 70.4% of catheter failures and, despite 18 episodes of catheter-related sepsis, no catheters were lost due to infection. Factors identified as leading to reduced catheter survival were left-sided placement and catheter tip placement in the superior vena cava (as opposed to right atrial placement). We did not observe poorer survival or increased sepsis in catheters replaced over a guidewire, and would advocate this technique as a means of salvage in this group of patients.
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PMID:Long-term vascular access for hemodialysis using silicon dual-lumen catheters with guidewire replacement of catheters for technique salvage. 910 44


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