Faculty Bibliography

Nursing documentation in the medical record is an important source of information for the medical record coder. Coded data are necessary for quality assurance, risk management, research and statistical purposes, as well as for proper DRG assignment for reimbursement. Facts gleaned from nursing documentation, supported by physician documentation and laboratory data, can often result in increased reimbursement for the hospital.

Crossover femoral-popliteal or femoral-tibial bypass has been employed as an alternative extra-anatomic bypass in 3 patients who had occlusion of an iliac artery with subsequent occlusion of the ipsilateral femoral artery with patency of either a popliteal or tibial artery and a patency of the contralateral common femoral artery. Each patient had a contraindication to a more conventional type of procedure. All procedures were performed with reinforced PTFE grafts. All grafts have remained patent for 6 months to 3 years. This operation should be considered as an alternative extra-anatomic reconstructive procedure in patients with the appropriate anatomy and who are not candidates for more standard types of vascular reconstruction.

The presence of a bruit after carotid endarterectomy may indicate a persistent or recurrent lesion. The authors noninvasively evaluated, by Duplex scanning, 18 asymptomatic postoperative patients who underwent a total of 23 carotid endarterectomies and who developed a postoperative bruit to determine the significance of the bruit. Eleven men and seven women were studied from 6 weeks to 2 years postsurgery. Ages ranged from 49 to 75 years (63.6 +/- 8.0 years). Indications for endarterectomy were: transient ischemic attacks (including amaurosis fugax), 17 vessels; completed stroke with significant functional recovery and residual carotid disease, 3 vessels; and asymptomatic bruit with hemodynamically significant carotid stenosis, 3 vessels. Each patient had a Duplex scan performed to noninvasively evaluate the carotid artery. All scans were independently reviewed by two observers. Real-time B images were interpreted as normal in 14 vessels, mild thickening in eight vessels, and moderate thickening in only one vessel. Doppler recordings demonstrated a spectral range of 15-40 cm/sec (26 +/- 8 cm/sec). Ratio of velocity in the internal carotid artery to common carotid artery (VIC/VCC) ranged from 0.389 to 1.281 (0.779 +/- 0.250). This study demonstrates that the presence of a postoperative carotid bruit does not necessarily signify the presence of residual carotid disease or a hemodynamically significant lesion.

Papaverine hydrochloride was added to a standard asanguinous cardioplegic solution to study its effect on cardioplegic distribution by evaluating coronary resistance, myocardial temperature, and postoperative enzyme changes. Seventeen patients were randomized into a control group (8 patients) and a papaverine group (9 patients). All patients received 300 cc of a standard asanguinous cardioplegic solution into the aortic root after systemic cooling to 28 degrees C and measurement of septal temperature (To). The duration of infusion (t1), root pressure (p1), and septal temperature (T1) were recorded. All patients received a subsequent infusion of 200 cc of cardioplegia to which had been added either 10 cc normal saline (control group) or 1 mg papaverine hydrochloride in 10 cc normal saline (papaverine group). Time of infusion, root pressure, and septal temperature (t2, p2, T2) were recorded. Coronary resistance was calculated. Postoperative CPK and CPK-MB were recorded and compared. Mean high CPK in the papaverine group was 163 units and 182 units in the control group. There was no statistically significant difference in any parameter between groups. This study, in contradistinction to experience with animal research models, failed to demonstrate any significant value in adding papaverine hydrochloride to standard cardioplegic solutions.

Seven patients who underwent femoral-femoral by pass between June 1980 and September 1982 underwent pre-operative angiography and pre and post-operative non-invasive evaluation to determine: (1) the hemodynamic effects created by the crossover graft, and (2) if angiographic findings would be predicative of post-operative results. The mean ankle/arm (a/a) index in the donor extremity changed from 0.82 +/- 0.20 to 0.70 +/- 0.27 (NS). The a/a index in the recipient extremity increased from 0.39 +/- 0.30 to 0.74 +/- (p less than 0.02). One patient developed a "steal" syndrome. There was no correlation between angiographic findings and post-operative changes. This study demonstrated a significant increase in recipient extremity ankle pressure and a clinically insignificant decrease in donor limb pressure.

Full thickness chest wall resection and single stage reconstruction for osteoradionecrosis of the chest wall was performed on five patients. All patients had undergone radical mastectomy and radiation therapy from 5 to 18 years prior to chest wall resection. Defects varied from 12 X 5 cm to 15 X 15 cm, and included from two to four ribs. Reconstruction was performed using Marlex mesh to reconstruct the bony thorax and a rotated latissimus dorsi myocutaneous flap. Coverage was successfully performed in all cases, and no patient experienced postoperative pulmonary dysfunction. There were no complications related to either the bony thorax reconstruction or the latissimus flap. The use of this technique has provided a safe, convenient, and reliable method of chest wall reconstruction.

The onset of symptoms from a congenital posterolateral (Bochdalek Hernia) defect is rare in the adult. We are reporting a 25-year-old female with a previously asymptomatic Bochdalek hernia who presented with acute intestinal obstruction. The abnormal embryology, pathophysiology, and clinical manifestations of this condition in the adult are discussed.

In a four-year period, 45 patients underwent counterpulsation for cardiogenic shock following myocardial infarction. Of these patients, 27 underwent angiography. Fifteen of them were not considered to be operative candidates because angiography demonstrated only single-vessel disease or diffuse distal coronary artery disease. Twelve patients were candidates for operation and were divided into three subgroups depending on the time of surgical intervention. One patient (Group 1) deteriorated while on counterpulsation, and underwent urgent angiography and operative intervention within 24 hours of balloon insertion. He is now in New York Heart Association (NYHA) Functional Class I. Group 2 consisted of 7 patients whose condition stabilized with use of the balloon but who could not be weaned. All underwent angiography from 7 to 14 days after insertion of the balloon. One patient died suddenly prior to operation. Six patients underwent coronary bypass from 8 to 21 days after balloon insertion. Five survived and are in NYHA Class II or III. Four patients were able to be weaned after angiography (Group 3). All had triple-vessel disease. Operation was undertaken six to eight weeks after infarction to treat persistent congestive heart failure or angina, or to improve chances of long-term survival. Two patients in this group survived. Our experience demonstrates that delayed intervention is an acceptable alternative to urgent operation.