Faculty Bibliography

A simple and inexpensive means of creating autologous fibrin glue is described that avoids the potential disadvantages of conventionally obtained material. This improvement may allow more widespread use of fibrin glue for operative bleeding

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results

If sepsis due to a catheter is suspected in a patient receiving parenteral nutrition, the doctor responsible for the patient usually withdraws the catheter and sends the point to the bacteriological laboratory for examination. This operation is usually accompanied by the extraction of several blood samples for haemoculture. With this attitude, it has been observed that most of the catheters withdrawn are sterile or if they are contaminated, they are not the cause of the sepsis. This leads to a series of unnecessary expenses and risks. This problem has prompted us to design a clinical study for the prospective investigation of the efficiency of quantitative haemocultures in the diagnosis of sepsis due to the catheter. During an 8-month period, all the patients who received parenteral nutrition in our centre were followed up by members of the nutritional support unit and participated in the study. In the face of the clinical suspicion of sepsis due to the catheter, blood was obtained for haemoculture, both through the catheter and from the peripheral veins. However, the catheters were not withdrawn until after the results of the cultures, between 16 and 24 hours following the extraction. A count of colonies in blood proceeding from the catheter which was five times or more greater than the count in the peripheral blood was interpreted as sepsis due to the catheter and the catheter was withdrawn. Differences between both counts (central and peripheral) which were less were interpreted as sepsis with a different origin to the catheter and in this case, the catheter was not withdrawn. A total of 26 catheters were evaluated using this method.(ABSTRACT TRUNCATED AT 250 WORDS)

Until recently, when a patient receiving total parenteral nutrition (TPN) was suspected of having catheter-related sepsis, the catheter was removed and the tip and the patient's blood was cultured. Using this method at our institution, greater than two thirds of the central venous catheters (CVC) removed were sterile, or if colonized, proved not to be the source of sepsis. This practice led to the unwarranted removal of numerous catheters and posed a clinical dilemma because it necessitated replacement of the catheter with its attendant risks, cost, and inconvenience. To address this problem, we instituted a protocol for determining in situ catheter-related sepsis based on a quantitative blood culture method using lysis centrifugation (Isolator; Dupont Co., Wilmington, Del.). When catheter-related sepsis was clinically suspected, quantitative blood cultures were obtained simultaneously via a peripheral (PER) vein and through the CVC suspected as the source of sepsis. The CVC, however, remained in situ pending culture results (approximately 16 to 24 hours). A CVC colony of greater than or equal to five times the PER colony count was considered significant and the catheter was removed. Equivocal colony counts between the CVC and PER cultures were interpreted as incriminating a source of sepsis other than the CVC. An 8-month prospective study was undertaken to evaluate the efficacy of this method for determining in situ catheter sepsis. One hundred third-eight patients received TPN by means of 160 catheters. In 113 patients no sepsis-related problems were noted. In the remaining 25 patients, 28 catheters were suspected as the source of sepsis. Twenty-six catheters were evaluated by the Isolator culture method. In eight instances significant differences in colony counts between the CVC and PER cultures were seen, implicating the CVC as the source of infection. In all these cases the CVC was removed and the patients underwent defervescence. In 18 cases, the CVC samples revealed either no growth or insignificant differences between the CVC and PER colony counts. Nine of these CVCs were removed without clinical improvement. The remaining nine catheters were left in place, and another source of sepsis was ultimately identified and treated. These results confirm the use of the quantitative blood culture method for determining in situ catheter-related sepsis. In all cases, when the catheter was incriminated by culture data, removal of the CVC led to patient improvement.(ABSTRACT TRUNCATED AT 400 WORDS)