Characteristics and Outcomes Among Patients With Early Venous Thromboembolic Events After Lung Transplant

BACKGROUND

Despite several previous studies reporting a high frequency of venous thromboembolism (VTE) after lung transplant (LT), few actionable risk factors have been identified. There are limited data regarding the practice patterns of anticoagulation use among patients with LT.

METHODS

All adult patients with single or bilateral LT between 2012 and 2016 were included (n = 324; mean age, 56.3 ± 13.3 years; male, 61.1%). Demographic, clinical, and laboratory variables before and after LT were recorded. Follow-up data included survival up to 3 years post-transplant. Development of VTE during the first 30 days after LT was the primary outcome variable.

RESULTS

The overall incidence of VTE during the first 30 days after LT was 29.9% (n = 97), among which the majority were upper extremity thromboses. Female sex, personal history of VTE, hospitalization at the time of transplant, and use of 3 or more central venous catheters during index hospitalization were independently associated with VTE. The use of anticoagulants was independently associated with a reduced risk of VTE. Despite increased morbidity, the development of VTE was not associated with worse post-transplant survival.

CONCLUSIONS

A significant proportion of patients develop early VTE after LT. Limiting the number of central catheters to < 3 during the post-transplant period, along with the early institution of thromboprophylaxis, may lower the risk of VTE.

Intravenous magnesium reduces the rate of glucose disposal in lactating sheep

Magnesium deficiency is generally associated with an impaired ability to dispose of glucose. In order to test whether or not increasing the peripheral free Mg concentration ([Mg(2+)]) would enhance glucose disposal, we have carried out glucose infusions in sheep with and without simultaneous infusion of Mg. Basal plasma glucose levels were higher in lactating sheep ('lactators') than in non-lactating sheep (controls) (P < 0.05). The glucose disposal rate (K(G)) with no added Mg was greater in lactators than controls (P < 0.05). When Mg was added to the infusate, K(G) in lactators was reduced (P < 0.005). Infusion of Mg depressed basal insulin levels in controls and lactators (P < 0.0001 for both). The insulin response to the intravenous glucose tolerance test (IVGTT) was lower in lactators compared with controls (P < 0.0001); however, after correcting for the reduced basal insulin level when Mg was included during the IVGTT, there was no difference between the two groups. We conclude that intravenous Mg at the doses used in this study leads to a decrease in basal insulin secretion, and that increasing serum [Mg(2+)] reduces glucose disposal in lactating sheep.

Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries

BACKGROUND

Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury.

PATIENTS AND METHODS

Hemodynamically stable patients admitted to a level I trauma center with blunt or penetrating injury to the lower chest or abdomen underwent VATS and subsequent celiotomy under the same general anesthetic. Intraoperative thoracoscopic findings were blinded to the abdominal surgeons.

RESULTS

Twenty-six patients were enrolled in the study over a 12-month period. Diaphragmatic injuries were identified in 8 patients (31%). Videothoracoscopy identified all eight injuries in these patients. Six of the 8 patients (75%) with diaphragmatic injuries sustained associated injury to intrathoracic or intra-abdominal organs. There was no mortality and no procedure-related morbidity. There were no missed injuries in patients who underwent VATS.

CONCLUSIONS

Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.

Duplex scanning of central vascular access sites in burn patients

Seventy-one burned patients requiring intensive care unit management underwent 570 central venous and 167 femoral arterial catheterizations. These patients were surveyed by repeated physical examinations and duplex scans for vascular-related complications. Catheter sites were rotated every 3 days. No arterial thrombi or occlusions were noted. Fourteen patients (19.6%) had 19 positive venous duplex scans. Five patients (7%) had symptomatic deep venous thrombosis (DVT) and nine (12.6%) had asymptomatic DVT. Mean number of venous cannulations before a positive scan was 4.3 (range 1 to 17). All five symptomatic patients had DVT that originated in the lower extremities. No patient had clinical evidence of a pulmonary embolus, or limb morbidity resulting from the DVT. Follow-up duplex scans in the five asymptomatic and three symptomatic patients showed complete resolution in each case. This study demonstrates the high incidence and natural history of central DVT in a group of critically ill burn patients.