Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources).

Amnion membrane improves results in treating neurogenic thoracic outlet syndrome.

A patient with neurogenic thoracic outlet syndrome was initially treated with scalenectomy, first rib resection, and wrapping of the brachial plexus (BP) with amnion membrane (AM) to prevent postoperative adhesions. Twelve months later, at reoperation for recurrent symptoms, the AM was observed to be intact. The BP had no scar tissue around it.

Pectoralis Minor Syndrome: Subclavicular Brachial Plexus Compression.

The diagnosis of brachial plexus compression-either neurogenic thoracic outlet syndrome (NTOS) or neurogenic pectoralis minor syndrome (NPMS)-is based on old fashioned history and physical examination. Tests, such as scalene muscle and pectoralis minor muscle blocks are employed to confirm a diagnosis suspected on clinical findings. Electrodiagnostic studies can confirm a diagnosis of nerve compression, but cannot establish it.

Thoracic outlet and pectoralis minor syndromes.

Compression of the neurovascular bundle to the upper extremity can occur above or below the clavicle; thoracic outlet syndrome (TOS) is above the clavicle and pectoralis minor syndrome is below. More than 90% of cases involve the brachial plexus, 5% involve venous obstruction, and 1% are associate with arterial obstruction. The clinical presentation, including symptoms, physical examination, pathology, etiology, and treatment differences among neurogenic, venous, and arterial TOS syndromes.

Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome.

The supraclavicular approach to scalenectomy and first rib resection has been modified since the original description in 1985. The incision is 1 to 2 cm above the clavicle, 1 cm lateral to the midline, and 5 to 7 cm long. Subplatysmal skin flaps are created.

Neurogenic thoracic outlet and pectoralis minor syndromes in children.

Brachial plexus compression (BPC) occurs above the clavicle as neurogenic thoracic outlet syndrome (NTOS) and below as neurogenic pectoralis minor syndrome (NPMS). It was recently noted that 75% of the adults seen for NTOS also had NPMS and in some this was the only diagnosis. This is also true in children but has not yet been reported.

Nitroprusside and nitroglycerine in patients with posttraumatic pulmonary failure.

Pulmonary artery pressure is frequently elevated in patients with post-traumatic pulmonary dysfunction. To ascertain whether or not this increase is reversible and what effects such reversal would have on gas exchange, the vasodilators nitroprusside and nitroglycerine were administered to 11 such patients. Pulmonary hemodynamics an gas exchange were observed.

Further experience with the saphenous vein used in situ for arterial bypass.

Ongoing experience with use of the saphenous vein in situ as in infrainguinal arterial bypass is presented. One hundred eighty-three bypasses were performed for limb-threatening ischemia, 92 of which were to the popliteal artery, either isolated or in continuity with one or more tibial vessels, and 91 bypasses were carried to single tibial vessels below the termination of the popliteal artery. The results were analyzed by the life table method and show an overall patency rate of 89.

A system to measure functional residual capacity in critically ill patients.

The use of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) in spontaneously breathing, intubated patients has prompted the development of new procedures for measuring functional residual capacity (FRC). The authors have developed a system for measuring FRC by the multiple breath nitrogen washout technique, which is suitable for use on intubated patients breathing with CPAP, IMV, or intermittent positive pressure ventilation (CONTROL) and on nonintubated patients. This system uses a pair of synchronized volume ventilators to permit a step change in inspired N2 fraction while providing therapeutic ventilatory support.

Increased creatinine clearance following cryoprecipitate infusion in trauma and surgical patients with decreased renal function.

Deficiency of opsonic alpha 2 surface binding (SB) glycoprotein (cold-insoluble globulin, plasma fibrinectin) is related to depressed reticulendothelial function as well as to multiple organ failure after tissue injury and sepsis. Cryoprecipitate (250 ml), extracted from 10 units of human plasma, was infused over 60 minutes into 11 hypo-opsonemic patients with decreased renal function. Cardiac output, mean arterial pressure, creatinine clearance, and limb blood flow were measured before and at intervals of 14 to 20, 35 to 44, and 60 to 66 hours following cryoprecipitate infusion.

Detrimental effects of removing end-expiratory pressure prior to endotracheal extubation.

Patients recovering from acute respiratory insufficiency are usually not extubated until they can ventilate adequately while breathing spontaneously at ambient end-expiratory pressure (T-tube). It is hypothesized that this period of T-tube breathing might be detrimental to gas exchange since the endotracheal tube abolishes the expiratory retard produced by the glottis and thereby inhibits the patient's ability to maintain adequate functional residual capacity (FRC). To test this hypothesis, pulmonary function of 17 patients was compared during T-tube breathing and Continuous Positive Airway Pressure (CPAP) and after extubation.

Cardiovascular hemodynamics after opsonic alpha-2-surface binding glycoprotein therapy in injured patients.

Depression of reticuloendothelial (RE) phagocytic function has been clearly documented following trauma and operation. This phagocytic failure is mediated in part by depletion of an opsonic glycoprotein. Depletion of this opsonic protein may result in prolonged blood retention of potentially harmful particulates that may interfere with the microcirculation and may possibly result in altered organ function.