pituitrin and Emergencies

Excessive secretion of vasopressin in the course of Syndrome of Inappropriate Antidiuretic Hormone Secretion is a common cause of hyponatremia in cancer patients. Clinical symptoms depend on the cause, rate of change of sodium level and their absolute values. Treatment options include fluid restrictions, intravenous administration of hypertonic sodium chloride solutions, loop diuretics and vaptans. The sodium level should not be adjusted too fast, because it may lead to irreversible brain damage. The article presents pathophysiology, diagnostics and recommendations of management of this oncological emergency.

Topics: Emergencies; Humans; Hyponatremia; Inappropriate ADH Syndrome; Infusions, Intravenous; Neoplasms; Saline Solution, Hypertonic; Vasopressins

Emergency sclerotherapy is still widely used as a first line therapy for variceal bleeding in patients with cirrhosis, particularly when banding ligation is not available or feasible. However, pharmacological treatment may stop bleeding in the majority of these patients.. To assess the benefits and harms of emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis.. Search of trials was based on The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded through January 2010.. Randomised clinical trials comparing sclerotherapy with vasoactive drugs (vasopressin (with or without nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.. Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding, mortality, number of blood transfusions, and adverse events. Data were analysed by a random-effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, type of publication, and risk of bias.. Seventeen trials including 1817 patients were identified. Vasoactive drugs were vasopressin (one trial), terlipressin (one trial), somatostatin (five trials), and octreotide (ten trials). No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcome. Combining all the trials irrespective of the vasoactive drug, the risk differences (95% confidence intervals) were failure to control bleeding -0.02 (-0.06 to 0.02), five-day failure rate -0.05 (-0.10 to 0.01), rebleeding 0.01 (-0.03 to 0.05), mortality (17 randomised trials, 1817 patients) -0.02 (-0.06 to 0.02), and transfused blood units (8 randomised trials, 849 patients) (weighted mean difference) -0.24 (-0.54 to 0.07). Adverse events 0.08 (0.03 to 0.14) and serious adverse events 0.05 (0.02 to 0.08) were significantly more frequent with sclerotherapy.. We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs. Vasoactive drugs may be safe and effective whenever endoscopic therapy is not promptly available and seems to be associated with less adverse events than emergency sclerotherapy. Other meta-analyses and guidelines advocate that combined vasoactive drugs and endoscopic therapy is superior to either intervention alone.

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Cirrhosis; Lypressin; Octreotide; Sclerotherapy; Somatostatin; Terlipressin; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

A POTENTIALLY SEVERE EVENT: Upper gastrointestinal haemorrhage in a cirrhotic patient is always extremely serious, particularly in the case of rupture of the oesophageal varices, which is the most frequent cause. THE TWO POLES OF TREATMENT: Early vasoactive treatment permits elastic ligature in optimal conditions using an endoscope. The prevention of other complications of cirrhosis is an essential element in the management of these patients.

Topics: Acute Disease; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Hepatic Encephalopathy; Hormones; Humans; Hypertension, Portal; Ligation; Liver Cirrhosis; Octreotide; Recurrence; Risk Factors; Rupture; Sclerotherapy; Shock, Hemorrhagic; Somatostatin; Vasopressins

Topics: Adult; Advanced Cardiac Life Support; Aged; Algorithms; Amiodarone; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiac Pacing, Artificial; Cardiopulmonary Resuscitation; Child; Child, Preschool; Defibrillators, Implantable; Electric Countershock; Emergencies; Female; First Aid; Heart Massage; Humans; Intubation, Intratracheal; Lidocaine; Male; Practice Guidelines as Topic; Prognosis; Time Factors; Vasodilator Agents; Vasopressins

The endocrine response to stress is complex. Elevations in the serum concentrations of the "classic" stress hormones, epinephrine and cortisol, occur following many kinds of physiologic challenge and are accompanied by elevations in corticotropin, GH, and glucagon levels. These changes are probably responsible for the hyperglycemia and hypercatabolism common to most critical illness. If volume depletion is present, vasopressin, renin, and aldosterone secretion are also likely to be stimulated. These hormones, if present in excess, may produce fluid retention and hyponatremia. In some critically ill patients, there is a dissociation of renin and aldosterone production called hyperreninemic hypoaldosteronism, but the clinical importance of this syndrome is poorly understood. Thyroid hormone metabolism is commonly affected by critical illness, which results in characteristic abnormalities of thyroid function testing known as the euthyroid sick syndrome. The reproductive axis is exquisitely sensitive to physiologic stress; hypogonadotropic hypogonadism is a common finding in critical illness. The ongoing challenge to the clinician is to determine whether seemingly abnormal hormone measurements in critically ill patients reflect an appropriate homeostatic response to severe illness or, instead, whether they denote an independent metabolic disorder that might actually cause or contribute to the patient's unstable condition. In view of the exceedingly complex (and poorly understood) interactions involved in the human response to a severe illness, a thoughtful approach to the whole patient is essential and far preferable to indiscriminate hormone testing. Such testing, at best, may be uninterpretable in light of the clinical circumstances or, at worst, may lead to therapeutic misadventures.

Topics: Acute Disease; Catecholamines; Emergencies; Endocrine System Diseases; Glucagon; Glucocorticoids; Gonadal Steroid Hormones; Growth Hormone; Humans; Renin-Angiotensin System; Thyroid Hormones; Vasopressins

Once the bleeding patient has been resuscitated and the diagnosis of acute variceal hemorrhage established by endoscopy, emergency injection sclerotherapy should be employed as the therapeutic option of choice. Endoscopic band ligation is a promising new technique that may prove to be as effective as sclerotherapy, with fewer complications. Pharmacologic treatment (with vasopressin and nitroglycerin) and balloon tamponade remain important alternative treatments, both as empiric temporizing therapy before sclerotherapy can be arranged and in the approximately 30% of patients who continue to bleed after a single sclerotherapy session. Continued bleeding in many of these patients can be controlled with a second session of sclerotherapy. If active acute bleeding persists after two sclerotherapy treatments, treatment should be considered a failure. Some of these patients may be suitable for surgical treatment with either staple-gun transection of the esophagus or emergency portacaval shunting.

Topics: Acute Disease; Balloon Occlusion; Catheterization; Drug Administration Schedule; Emergencies; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Ligation; Nitroglycerin; Portacaval Shunt, Surgical; Sclerotherapy; Somatostatin; Vasopressins

Plasma sodium concentration depends on water balance, and is normally maintained in a narrow range by an integrated system involving the precise regulation of water intake via thirst mechanism and control of water output via vasopressin secretion. Anything that interferes with the full expression of either osmoregulatory function exposes the patient to the hazards of abnormal decreases or increases in plasma sodium level. Hyponatraemia is almost always due to a defect in water excretion. Increased intake may contribute to the problem but is rarely, if ever, a sufficient cause. Hypernatraemia is almost always due to deficient water intake; excessive water losses may contribute to the problem, but they are never a sufficient cause. The most dangerous and usually the most blatant clinical effects of the disturbed water balance are those involving the central nervous system. Complex adaptive mechanisms have been developed to mitigate the impact of both hypo- and hypernatraemia on brain cells. However, the same protective changes render the brain more susceptible to severe neuropathology that may arise from inappropriate treatment of these disorders.

Topics: Diagnosis, Differential; Emergencies; Humans; Hypernatremia; Hyponatremia; Vasopressins; Water-Electrolyte Balance

Variceal bleeding has a high mortality, as the majority of patients have cirrhosis, with hepatic coma, renal failure, ascites and clotting deficiencies as complicating factors. Bleeding varices must therefore be treated as an emergency. Resuscitation, endoscopic diagnosis and haemostasis are the cornerstones of treatment. Once bleeding varices have been identified, attempts to stop the bleeding must be made at once as this will lessen the chances of hepatic failure developing. Endoscopic sclerotherapy at the time of diagnosis is the best available treatment at present, although profusely bleeding varices can be difficult to see and inject. In these circumstances the passage of a Sengstaken tube should stop the bleeding, allowing later sclerotherapy to be successful. If rebleeding recurs and cannot be controlled, oesophageal transection with a stapling gun may be life-saving, although the varices may later recur and long-term endoscopic follow-up will be necessary. Portacaval shunting and the distal splenorenal shunt involve arduous surgery and are followed by a significant incidence of hepatic encephalopathy; they should be reserved for those few cases when simpler measures have failed, although shunts do lead to permanent decompression of the portal system. The acute variceal bleed may also be dealt with pharmacologically. Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects, is cheaper and as effective as terlipressin or somatostatin and its synthetic analogue octreotide. Several courses of injection sclerotherapy will be required to eliminate oesophageal varices. Thereafter, long-term follow-up will be necessary to deal with any recurrence. The place of non-selective beta-blockers is still contentious, but they do reduce portal pressure and may lessen the chance of rebleeding. There is also a growing role for hepatic transplantation, which not only eliminates the varices but also restores liver function to normal and greatly reduces the risk of subsequent hepatoma development.

Topics: Catheterization; Emergencies; Esophageal and Gastric Varices; Esophagus; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans; Lypressin; Resuscitation; Sclerosing Solutions; Sclerotherapy; Somatostatin; Terlipressin; Vasopressins

Topics: Anesthesia; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Blood Transfusion, Autologous; Christianity; Deamino Arginine Vasopressin; Decision Making; Emergencies; Hematocrit; Hemodilution; Hemodynamics; Hemoglobins; Humans; Intraoperative Care; Oxygen; Surgical Procedures, Operative; Transfusion Reaction; Vasopressins

In recent years the technique of selective portasystemic shunting (Warren procedure) and sclerotherapy, and also the possibility of lowering portal pressure with beta-blockers, have changed the approach to management of patients with bleeding esophageal varices. Treatment of these patients is reviewed in the light of experience of 204 cases and the literature. The advantages and disadvantages of vasopressin, balloon tamponade, sclerotherapy, transhepatic embolization and various shunt and non-shunt operations in the acute phase are presented. For elective cases the discussion centers mainly on treatment by distal splenorenal shunt and sclerotherapy.

Topics: Acute Disease; Clinical Trials as Topic; Embolization, Therapeutic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Portasystemic Shunt, Surgical; Prospective Studies; Recurrence; Sclerosing Solutions; Terlipressin; Vasopressins

Topics: Blood Transfusion; Central Venous Pressure; Cimetidine; Emergencies; Esophageal and Gastric Varices; Esophagoscopy; Esophagus; Fluid Therapy; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Humans; Hypertension, Portal; Liver Cirrhosis, Alcoholic; Prognosis; Sclerosing Solutions; Vasopressins; Vitamin K

Topics: Embolization, Therapeutic; Emergencies; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Portasystemic Shunt, Surgical; Recurrence; Sclerosing Solutions; Stomach; Varicose Veins; Vasopressins

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intravenous; Ligation; Mesenteric Veins; Methods; Portacaval Shunt, Surgical; Radiography; Renal Veins; Splenic Vein; Suture Techniques; Vasopressins; Venae Cavae

Topics: Age Factors; Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Middle Aged; Peptic Ulcer Hemorrhage; Tampons, Surgical; Vagotomy; Vasopressins

Topics: Catheterization; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Cirrhosis; Portacaval Shunt, Surgical; Survival Rate; Vasopressins

Despite urgent sclerotherapy, active variceal hemorrhage has a 70%-90% mortality rate in patients with advanced age, sepsis, renal or pulmonary compromise, tense ascites, or deep coma. The aim of this study was to test the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) performed semiemergently and preceded by stabilization by balloon tamponade in such patients.. Patients with actively bleeding esophageal or contiguous gastric varices despite sclerotherapy were assessed for risk of dying after emergent portacaval shunt. Those considered to be at high risk were stabilized by balloon tamponade and vasopressin/nitroglycerin and TIPS placed semiurgently within 12 hours. Balloon tamponade and pharmacological therapy were discontinued within 24 hours after TIPS in all cases.. Thirty-two patients met entry criteria, and 2 were excluded due to portal vein thrombosis. TIPS was successfully placed in 29 of 30 patients and achieved hemostasis in all. Thirty-day and 6-week survival rates were 63% and 60%, respectively; in those without aspiration, the 6-week survival rate was 90%. After a median follow-up period of 920 days, 46% of the original cohort was alive. Only 2 episodes of early rebleeding and 4 late rebleeds occurred. Eight patients developed encephalopathy. Stent stenosis requiring dilation occurred in 6 of 11 patients within 6 months.. TIPS is highly effective as salvage therapy in high-risk patients with active variceal hemorrhage despite endoscopic sclerotherapy.

Topics: Adult; Aged; Balloon Occlusion; Catheterization; Combined Modality Therapy; Emergencies; Esophageal and Gastric Varices; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Hemostatics; Humans; Male; Middle Aged; Nitroglycerin; Portasystemic Shunt, Surgical; Prognosis; Prospective Studies; Salvage Therapy; Sclerotherapy; Survival Rate; Vasopressins

A prospective randomized trial was conducted in unselected, consecutive patients with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamponade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received identical supportive therapy initially. All patients were followed up for at least 10 yr. The protocol contained no escape or cross-over provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p < 0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p < 0.001). Mean requirement for blood transfusion was 7.1 +/- 2.6 units in the shunt group and 21.4 +/- 2.6 units in the medical group (p < 0.001). Eighty-one percent of the patients in the shunt group were discharged alive compared with 45% in the medical group (p = 0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p < 0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.

Topics: Adult; Aged; Balloon Occlusion; Catheterization; Emergencies; Esophageal and Gastric Varices; Esophagus; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Portacaval Shunt, Surgical; Prospective Studies; Quality of Life; Survival Rate; Vasopressins

In recent years the technique of selective portasystemic shunting (Warren procedure) and sclerotherapy, and also the possibility of lowering portal pressure with beta-blockers, have changed the approach to management of patients with bleeding esophageal varices. Treatment of these patients is reviewed in the light of experience of 204 cases and the literature. The advantages and disadvantages of vasopressin, balloon tamponade, sclerotherapy, transhepatic embolization and various shunt and non-shunt operations in the acute phase are presented. For elective cases the discussion centers mainly on treatment by distal splenorenal shunt and sclerotherapy.

Topics: Acute Disease; Clinical Trials as Topic; Embolization, Therapeutic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Portasystemic Shunt, Surgical; Prospective Studies; Recurrence; Sclerosing Solutions; Terlipressin; Vasopressins

Topics: Cimetidine; Clinical Trials as Topic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Peptic Ulcer; Peptic Ulcer Hemorrhage; Stomach Ulcer; Stress, Physiological; Vasopressins

The occurrence of electrolyte disorders as hypocalcemia and/or hyponatremia is an uncommon event in preeclampsia, which can be the sign of serious situation, with potentially unfavourable consequences for the mother and her fœtus. Hyponatremia in the setting of preeclampsia is an indicator of severity, and requires the understanding of the etiologic mechanisms to initiate an appropriate treatment. Indeed the often-considered fluid restriction is rarely a treatment option for pregnant women. Hypocalcemia is a complication that must be monitored when a treatment with high doses of intravenous magnesium sulphate is introduced. In this context, hypocalcemia must be sought, with the exclusion of other etiologies as vitamin D deficiency, hypoparathyroidism or renal and extrarenal loss of calcium. A replacement therapy, intravenous or oral according to circumstances, should be considered in case of severe or symptomatic hypocalcemia.

Topics: Adult; Aldosterone; Antihypertensive Agents; Capillary Leak Syndrome; Cesarean Section; Emergencies; Female; Fertilization in Vitro; Fetal Growth Retardation; Humans; Hypocalcemia; Hyponatremia; Infant, Newborn; Infusions, Intravenous; Labetalol; Magnesium Sulfate; Male; Pre-Eclampsia; Pregnancy; Pressoreceptors; Renin-Angiotensin System; Vasopressins

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.

Topics: Aged; Blood Transfusion; Cause of Death; Colectomy; Combined Modality Therapy; Embolization, Therapeutic; Emergencies; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Radiography; Retrospective Studies; Vasopressins

Topics: Antacids; Blood Transfusion; Diagnosis, Differential; Emergencies; Gastric Lavage; Gastrointestinal Hemorrhage; Gravity Suits; Humans; Monitoring, Physiologic; Physical Examination; Resuscitation; Shock, Hemorrhagic; Somatostatin; Vasopressins

Topics: Adrenergic beta-Antagonists; Emergencies; Esophageal and Gastric Varices; Esophagoscopes; Gastrointestinal Hemorrhage; Gastroscopes; Hemodynamics; Humans; Hypertension, Portal; Portasystemic Shunt, Surgical; Recurrence; Risk; Sclerosing Solutions; Somatostatin; Vasopressins

Fifty patients with massive lower gastrointestinal bleeding were initially managed with emergency angiography. The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units. Thirty-six patients (72%) had bleeding site located; bleeding sites were distributed throughout the colon. Etiologies of bleeding included diverticular disease (19 patients) and arteriovenous malformations (15 patients). Twenty of 22 (91%) patients receiving selective intra-arterial vasopressin stopped bleeding; however, 50% rebled on cessation of vasopressin. Thirty-five of 50 (70%) patients underwent surgery, with 57% operated on electively after vasopressin therapy. Seventeen patients had segmental colectomy, with no rebleeding. Nine of the 17 patients had diverticular disease in the remaining colon. Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency subtotal colectomy without angiography (8.6% vs. 37%) (p less than 0.02). Emergency angiography successfully locates the bleeding site, allowing for segmental colectomy. Vasopressin infusion transiently halts bleeding, permitting elective surgery in many instances.

Topics: Adult; Aged; Angiography; Arteriovenous Malformations; Barium Sulfate; Colectomy; Colon; Diverticulum; Diverticulum, Colon; Emergencies; Female; Gastrointestinal Hemorrhage; Humans; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Since 1963, a prospective evaluation of the emergency portacaval shunt procedure has been conducted in 264 unselected patients with cirrhosis and bleeding varices who underwent operation within 8 hours of admission to the emergency department. Of 153 patients who underwent operation 10 or more years ago, 45 (29 percent) have survived from 10 to 22 years and their current status is known. On admission, 40 percent of the long-term survivors had jaundice, 44 percent had ascites, 13 percent had encephalopathy (with an additional 9 percent with a history of encephalopathy), 29 percent had severe muscle wasting, and 82 percent had a hyperdynamic state. There were 9 Child's class A patients, 33 Child's class B patients, and 3 Child's class C patients. At operation, all patients had portal hypertension which was reduced by the shunt to a mean corrected free portal pressure of 18 mm saline solution. The emergency portacaval shunt procedure permanently controlled variceal bleeding. None of the patients bled again from varices, and the shunt remained patent throughout life in every patient. Encephalopathy did not affect 91 percent of the patients, but was a recurrent problem in 9 percent, usually related to the use of alcohol. Lifelong abstinence from alcohol occurred in 58 percent of the long-term survivors, but 11 percent resumed regular drinking and 31 percent consumed alcohol occasionally. Liver function declined compared with preoperative function in only 18 percent of the patients, almost always because of alcohol use. Ten years after operation, 73 percent of the patients were in excellent or good condition, and 68 percent were gainfully employed or engaged in full-time housework. Comparison of the 10 to 22 year survivors with our early group of 180 patients reported previously and our recent group of 84 patients showed no significant differences in preoperative or operative data. The single factor that appeared to influence long-term survival was resumption of regular use of alcohol. We conclude that the emergency portacaval shunt procedure, by preventing hemorrhage from varices, results in prolonged survival and an acceptable quality of life for a substantial number of patients with advanced alcoholic cirrhosis.

Topics: Adult; Aged; Alcohol Drinking; Coma; Emergencies; Esophageal and Gastric Varices; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Portacaval Shunt, Surgical; Postoperative Complications; Prospective Studies; Quality of Life; Time Factors; Vasopressins

Topics: Acute Disease; Adult; Aged; Embolization, Therapeutic; Emergencies; Female; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Male; Middle Aged; Radiography; Stomach; Vasopressins

Many factors may contribute to producing a shock state within the surgical environment. The classic causes of shock--hypovolemia, cardiac failure, and sepsis--occur commonly in the operating room. Additionally, concurrent surgery and anesthesia may contribute to produce clinical shock. Surgery may produce hypovolemia from "third space" loss and/or from blood loss. Some anesthetic drugs, by inhibiting the autonomic nervous system, impair the body's ability to compensate for hypovolemia, cardiac failure, or sepsis. Other entities such as tension pneumothorax, drug allergy, or mechanical factors produced by surgical exposure may contribute to hemodynamic compromise of the patient. Shock that occurs outside the surgical suite may also be produced by a variety of insults. One or more factors may contribute to inadequate tissue perfusion, thus making diagnosis of the cause(s) of shock a clinical challenge. Presented in this review is an anesthesiologist's approach to shock on a macrocirculatory level. Two important concepts are vital to this approach. First, one must act immediately to restore adequate perfusion to the brain and heart when confronted with a patient in shock. This is possible without knowing the specific cause(s) of the poor perfusion. Second, a rapid, accurate diagnosis of the cause(s) must be made if the patient is slow to respond to the initial therapy. Through the use of pulmonary artery catheterization, the factors producing any given shock state may be identified, and appropriate therapy may be instituted and monitored.

Topics: Anesthesia, General; Anesthetics; Emergencies; Fluid Therapy; Heart; Hemodynamics; Humans; Intraoperative Complications; Male; Middle Aged; Shock; Vasopressins

Haemorrhages in the course of cirrhosis and portal hypertension are surgical emergencies. Nevertheless medical treatment may be necessary both to revive the patient and temporarily to check the haemorrhaging itself. Some views are presented on the use of drugs, both those already in clinical use and others at the experimental stage, which appear to be effective in the treatment of haemorrhaging in portal hypertension (Vasopressin, glypressin, prostaglandin, somatostatin, propranolol, cimetidine and ranitidine).

Topics: Cimetidine; Emergencies; Hemorrhage; Humans; Liver Cirrhosis; Lypressin; Propranolol; Prostaglandins; Ranitidine; Somatostatin; Terlipressin; Vasopressins

Topics: Angioplasty, Balloon; Diagnosis, Differential; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Intubation, Gastrointestinal; Liver Cirrhosis; Portacaval Shunt, Surgical; Prognosis; Sclerosing Solutions; Vasopressins

For the initial control of haemorrhage from oesophageal varices, two methods of vasopressin administration have been compared--the conventional bolus of 20 units and a low dose infusion of 0.4 units per minute. Twenty patients bleeding from oesophageal varices, confirmed by endoscopy, were allocated into either treatment group (10 in each). Vasopressin infusion stopped bleeding in 86 per cent of the episodes in contrast to 12.5 per cent (P less than 0.01) with bolus doses. Balloon tamponade with a Sengstaken-Blakemore tube was used to control bleeding in only 2 episodes in patients on infusion and in 10 episodes in patients on bolus doses of vasopressin (P less than 0.05). Our study confirms that low dose vasopressin infusion in more effective in controlling bleeding from oesophageal varices than conventional bolus doses.

Topics: Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intravenous; Male; Middle Aged; Vasopressins

The cirrhotic patient with acute bleeding from esophageal varices has less than a 50% chance of leaving the hospital alive; the outlook for survival is so poor that even desperate measures are worthwhile. Some traditional nonsurgical methods for the control of the bleeding are either ineffective at worst or temporary at best. Balloon tamponade is not recommended at all, but intravenously administered vasopressin may be helpful in allowing the necessary diagnostic investigations to be completed. Most important at this stage are the measures necessary to improve the general status of the patient--restoration of blood volume with fresh blood, prevention of ammonia intoxication, support of the liver, correction of metabolic alkalosis and treatment of the hyperdynamic state with digitalis and cardiotonic drugs. Controlling the bleeding is not the greatest problem--the greatest problem is achieving survival of a critically ill patient who undergoes a formidable operation (e.g., variceal ligation stops the bleeding, but is itself an operation of considerable magnitude). In our hands emergency shunting is the best treatment providing a definitive procedure with the highest 10-year survival rate and the lowest complication rate.

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Infusions, Intra-Arterial; Infusions, Parenteral; Ligation; Liver Cirrhosis; Mesenteric Arteries; Methods; Portacaval Shunt, Surgical; Vasopressins

Topics: Adult; Aged; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemostasis; Heparin; Humans; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Topics: Acute Disease; Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Methods; Middle Aged; Vasopressins

Topics: Adolescent; Adult; Aged; Alcoholism; Child; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Liver Function Tests; Male; Middle Aged; Portacaval Shunt, Surgical; Postoperative Complications; Vasopressins

Topics: Emergencies; Heart Arrest; Heart Massage; Histamine H1 Antagonists; Humans; Hypotension; Infusions, Parenteral; Podiatry; Seizures; Spasm; Tachycardia; Vasopressins; Vocal Cord Paralysis

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis; Hepatitis; Humans; Liver Cirrhosis; Portacaval Shunt, Surgical; Vasopressins