Severe Hemodynamic Deterioration Research Articles

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia.

The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia. Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133-146 mEq/L). Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 +/- 5.8 ng/mL/h; PAC: 217 +/- 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 +/- 1.1 ng/mL/h; PAC: 95 +/- 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 +/- 0.5 to 128 +/- 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 +/- 1 to 135 +/- 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients. These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia

OBJECTIVE: The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia. METHODS: Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133–146 mEq/L). RESULTS: Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 ± 5.8 ng/mL/h; PAC: 217 ± 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 ± 1.1 ng/mL/h; PAC: 95 ± 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 ± 0.5 to 128 ± 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 ± 1 to 135 ± 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients. CONCLUSIONS: These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Lethal Postoperative Coronary Artery Spasm

Background. Coronary artery spasm in the immediate postoperative period after a coronary operation is recognized infrequently. Its severity is variable and manifestations unpredictable. The diagnosis is usually made by an awareness of the possibility and thereafter by exclusion of other causes of myocardial ischemia. An opportunity for a positive diagnosis is rarely available. Methods. The case reports of 3 patients with similar presentations of ischemic heart disease and with severe manifestations of coronary artery spasm in the postoperative period are presented. Results. All 3 patients were women aged 55 to 60 years. All had single-vessel coronary artery disease involving the left anterior descending artery and underwent a left internal mammary artery bypass graft. Severe manifestations of myocardial ischemia of abrupt onset developed approximately 7 hours postoperatively in each patient. One patient died of severe hemodynamic deterioration from which resuscitation was unsuccessful. Another sustained a large anterior myocardial infarction despite graft patency. The third patient was supported by an intraaortic balloon pump and made a full recovery. Conclusions. The early diagnosis of coronary artery spasm is achieved by an awareness of the condition. The institution of early appropriate management may prevent its consequences.

A NEW DEVICE FOR OXYGENATION AND DRUG ADMINISTRATION BY TRANSTRACHEAL JET VENTILATION

S203 Introduction: The incidence of the potentially life-threatening "cannot intubate, cannot ventilate" situation is approximately 1/10.000 anesthetics [1]. Percutaneous transtracheal jet ventilation (TTJV) is a widely accepted, effective treatment to restore adequate arterial oxygenation. Unfortunately, the equipment required for "conventional" TTJV is often not immediately available in emergency situations and demands regular maintenance. These systems bear a high risk of barotrauma in cases of treating emergency respiratory distress and complete upper airway obstruction. Alternative, mostly self-assembled transtracheal systems (e.g. oxygen insufflation by squeezing a bag connected to a transtracheal needle (or iv-catheter) by a cutted barrel of a 2-ml-syringe and a tubus connector [2]) fail to achieve effective oxygenation albeit with a lower risk for barotrauma. A new device ("flow-modulator") is introduced allowing oxygenation and drug administration into the patient's lungs by manually controlled, jet-ventilation-like, pulsed gas flow. Methods: The device [3] consists of a short, non-compliant tube (1) with several openings (2) located at opposite sites in front of a syringe connector (3). The device is connected between a transtracheal needle (or iv-catheter) and an oxygen supply delivering oxygen at a rate of at least 15 liters/minute. Intermittent closing and releasing leads to a jet-ventilation-like, pulsed flow. The ratio of the transtracheal needle's (or iv-catheter's) cross-section and the total cross-section of the non-closed openings of the device determines the effective gas flow to the patient (e.g. with a ratio of 1 to 3, 25% of the total gas flow reaches the patient's lungs). Successive closing of openings with equal diameters induces an exponential gas flow increase to the patient's lungs, whereas a linear gas flow profile is achievable with different (decreasing) diameters. Besides, effective jet-nebulizing by injecting a liquid drug through the syringe connector is possible. Currently, the efficacy of the device is examined in an animal model approved by the Institutional Animal Investigation Committee. (Figure 1)Figure 1Results: The closure of all openings and subsequent high gas flow to the patient is only achievable by an intentional digital maneuver. Total release of the openings ensures prompt, quantitative gas discharge to the atmosphere thus minimizing the risk of barotrauma even in case of upper airway obstruction. The construction of the device is characterized by the absence of any mechanical parts. Maintenance is not required. This includes a maximum of system-immanent safety. Malfunction is excluded - a barotrauma can only occur following a physician's fault. First data suggest sufficient oxygenation with concomitant moderate hypercapnia and respiratory acidosis. In no case barotrauma or severe hemodynamic deterioration were observed. Discussion: The device ("flow-modulator") allows safe, variable, manually controlled oxygen-flow into the patient's lungs assuring sufficient oxygenation with moderately impaired ventilation. In addition, drugs (e.g. epinephrine) can be nebulized, reaching even more peripheral tracheobronchial areas. This small device, easy to understand and safely to handle, may become a beneficial tool in the management of the difficult airway - since it fits the smallest pocket even "on the road".

Management of Tricuspid Valve Disease in Patients Undergoing Double Valve Replacement

The management of mild tricuspid valve disease associated with left-sided valve lesions remains controversial. Between January 1985 and September 1995, 87 patients underwent combined double (aortic and mitral) valve replacement and tricuspid valve repair at the Shanghai Chest Hospital. The early mortality was 16.1%. Predictors of early mortality were found to be New York Heart Association functional class IV and right ventricular systolic pressure of 65 mm Hg or more, by multivariable regression analysis. The mean follow-up was 4.6 years. Cumulative 3-year and 5-year survival rates in patients discharged from hospital were 80% ± 4% and 63% ± 7%. Late mortality was due to sudden death (18.7%), myocardial infarction (6.5%), and cerebral embolism or hemorrhage (31.2%). Of 48 patients still alive, 45 are in New York Heart Association functional class I or II. None of them has mild or moderate tricuspid regurgitation. Based on these results, we recommend early surgical treatment prior to the appearance of severe hemodynamic deterioration and we propose a policy of liberal indication for tricuspid annuloplasty for mild functional tricuspid insufficiency at the initial double valve replacement.

Effects of the Pringle Maneuver on Hemodynamics during Laparoscopic Liver Resection in the Pig

The Pringle maneuver (PM) is recognized in conventional liver surgery as a method of controlling bleeding. To determine the hemodynamic effects of the PM during pneumoperitoneum (PP) for laparoscopic liver resection, we measure hemodynamic and blood gas changes in 7 healthy pigs. All variables were recorded 5 min before and 10 and 30 min after employing PP or PM and 10 min after discontinuation of PM. After the induction of PP, cardiac index and arterial carbon dioxide tension significantly increased, accompanied by a significant decrease in pH. After the beginning of PM, cardiac index and mean arterial and central venous pressures decreased significantly, whereas the heart rate rose markedly. After discontinuation of the PM, the systemic vascular resistance index decreased, and the heart rate remained elevated. These results demonstrate severe hemodynamic deterioration with PP and a subsequent PM. The latter should, therefore, be considered only as a last resort for the control of bleeding during laparoscopic liver surgery.

Coronary reoperation: Results of adding an internal mammary artery graft to a stenotic vein graft

Although it is desirable at coronary reoperation to replace a stenotic vein graft to the left anterior descending coronary artery (LAD) with an internal mammary artery (IMA) graft, previous reports have shown that if the stenotic vein graft is removed, that strategy can be complicated by severe hemodynamic deterioration and increased perioperative mortality. We report the results for 90 patients in whom an IMA was used to graft a completely obstructed LAD with the stenotic vein graft left intact. For 10 patients, reoperation involved only an IMA-LAD graft, and in 80 patients, a second IMA, veins, or both were used to graft other vessels. There were no hospital deaths. One patient had a perioperative myocardial infarction. Follow-up at a mean postoperative interval of 58 months documented 11 late deaths (eight cardiac related) and actuarial 5-year survival of 88%. Twenty-two patients underwent coronary angiography at a mean postoperative interval of 48 months. The IMA-LAD graft was found to be perfectly patent in 20 and obstructed in 2. The strategy of adding an IMA graft to the LAD and leaving a stenotic vein graft intact has been associated with a low risk of perioperative myocardial infarction, the late clinical results are favorable, and repeat angiography indicates that serious competitive flow from the stenotic vein graft is uncommon.

Acute Myocardial Infarction Complicating the Clinical Course of Dilated Cardiomyopathy in Childhood

An acute myocardial infarction occurred in a 6-year-old child with dilated cardiomyopathy. This caused severe hemodynamic deterioration that led to a fatal outcome. Autopsy revealed diffuse myocardial atrophy without cell infiltrate, normal epicardial coronary arteries, and a massive healed anteroapical infarction. Coronary embolism or spasm could not be ruled out as the cause of the infarction.

Studies of myocardial protection in the immature heart: IV. Improved tolerance of immature myocardium to hypoxia and ischemia by intravenous metabolic support

Thirteen immature puppies (2 to 4 kg) underwent 1 hour of acute hypoxia (oxygen tension 25 to 30 mm Hg), followed by 45 minutes of normothermic global ischemia on total vented bypass with normal blood reperfusion. Ventricular function was assessed by inscribing Starling function curves and measuring stroke work indices before hypoxia and after reperfusion. Seven puppies (control) received normal saline infusion at 4 ml/kg/hr. Six other puppies received a 4 ml/kg/hr intravenous infusion of glutamate/aspartate, glucose-insulin-potassium, mercaptopropionyl glycine, carnitine, and catalase during hypoxia and reperfusion. In control hearts, acute hypoxia depleted myocardial glutamate and aspartate by 52% (p less than 0.05 versus prehypoxia) and 48% (p less than 0.05 versus prehypoxia) and caused severe hemodynamic deterioration (55% decrease of stroke work index) (p less than 0.05 versus prehypoxia); three of seven (43%) required premature institution of bypass. Postischemic left ventricular function recovered to only 40% of control levels (p less than 0.05 versus prehypoxia). In contrast, intravenous metabolic infusions maintained tissue glutamate (p less than 0.05 versus control group) and aspartate (p less than 0.05 versus control group) in treated hearts during hypoxia and allowed cardiac index to rise 20% (p less than 0.05 versus prehypoxia); all treated hearts tolerated 1 hour of hypoxia, and stroke work recovered 70% (p less than 0.05 versus control group) of stroke work index after subsequent ischemia. Impaired tolerance of immature hearts to acute hypoxia and subsequent ischemia is due to substrate depletion. This impairment can be reduced by intravenous metabolic support during hypoxia and reperfusion and leads to improved recovery of postischemic function.

Upper Limit Ventricular Stimulation in Respiratory Rate Responsive Pacing due to Electrocautery

Transient programmed upper limit stimulation (150 bpm) was observed during repetitively utilized electrocautery in the beginning of an open-heart surgical procedure in a patient with a minute ventilation rate responsive ventricular pacemaker. This tachycardia caused severe hemodynamic deterioration, and was also initiated by internal heart massage and manual ventilation. Considering the recommendations of the manufacturer, this series of serious events could have been prevented, when reprogramming to the inhibited mode had been executed in anticipation of the operation.

Deleterious effects of intravenous verapamil in Wolff-Parkinson-White patients and atrial fibrillation

Three patients presented to the emergency room with atrial fibrillation and fast ventricular response with wide preexcited QRS complexes (Wolff-Parkinson-White syndrome). All three patients received intravenous verapamil (5-10 mg). The first patient developed ventricular fibrillation requiring several defibrillations; the second patient developed severe hemodynamic deterioration requiring urgent cardioversion; in the third patient a marked increment in the ventricular response was noted, however, there was no hemodynamic impairment. Verapamil may cause detrimental results when given to patients with the Wolff-Parkinson-White syndrome and atrial fibrillation. Its administration should therefore be considered as an absolute contraindication in these patients.

Hemodynamics of Protamine Administration

Protamine administration for heparin reversal after cardiopulmonary bypass on occasion is associated with mild to severe hemodynamic deterioration. The route of administration may modify these reactions. A prospective randomized study was done in 68 patients undergoing isolated coronary artery bypass grafting. The route of protamine administration was randomized in a balanced fashion between right atrium, left atrium, and aorta. The preoperative and operative characteristics of the three groups were similar. Hemodynamic measurements were recorded before cannulation, after removal of the venous drainage catheter, and 1 minute, 5 minutes, and 10 minutes after protamine administration. Hypotension occurred in 11 patients with no significant difference among the three groups. The hypotension was immediate in three patients in whom route of administration was the aorta. The overall hemodynamic changes observed for the three treatment groups were not significantly different An analysis for type II error indicated that it was unlikely that an important difference had been missed. We conclude that the route of administration does not affect the hemodynamic changes associated with protamine administration. We did not observe a case of severe hemodynamic deterioration, so that we cannot assess the effect of route of administration on the severity of an anaphylactic reaction.

Hemodynamics of protamine administration: Comparison of right atrial, left atrial, and aortic injections

Protamine administration for heparin reversal after cardiopulmonary bypass on occasion is associated with mild to severe hemodynamic deterioration. The route of administration may modify these reactions. A prospective randomized study was done in 68 patients undergoing isolated coronary artery bypass grafting. The route of protamine administration was randomized in a balanced fashion between right atrium, left atrium, and aorta. The preoperative and operative characteristics of the three groups were similar. Hemodynamic measurements were recorded before cannulation, after removal of the venous drainage catheter, and 1 minute, 5 minutes, and 10 minutes after protamine administration. Hypotension occurred in 11 patients with no significant difference among the three groups. The hypotension was immediate in three patients in whom route of administration was the aorta. The overall hemodynamic changes observed for the three treatment groups were not significantly different. An analysis for type II error indicated that it was unlikely that an important difference had been missed. We conclude that the route of administration does not affect the hemodynamic changes associated with protamine administration. We did not observe a case of severe hemodynamic deterioration, so that we cannot assess the effect of route of administration on the severity of an anaphylactic reaction.

Percutaneous transluminal coronary angioplasty in patients with prior myocardial infarction: Angioplasty at a distance from the prior infarct zone

Patients undergoing coronary angioplasty who have had a prior transmural myocardial infarction in the distribution of a contralateral coronary artery are considered a high-risk group because of potentially severe left ventricular dysfunction if an ischemic complication occurs. The purpose of this study was to evaluate the safety and efficacy of coronary angioplasty in 28 patients with prior myocardial infarction remote from the artery undergoing dilatation. Prior myocardial infarction was defined by the presence of pathologic Q waves on ECG or segmental akinesis on ventriculography. Angioplasty was successful in 30 of 33 lesions (91%) and in 25 of 28 patients (89%). Mean stenosis diameter was reduced from 91% ± 7% to 28% ± 16%; mean translesional gradient after angioplasty was 6 ± 5 mm Hg. No patient developed severe hemodynamic deterioration from transient coronary occlusion during balloon inflation or from an acute ischemic complication. Three patients underwent coronary artery bypass surgery after unsuccessful angioplasty. There were no new Q wave infarctions or deaths. The results of coronary angioplasty in patients with prior infarction were compared with those of 203 patients without prior remote infarction. Primary success and occurrence of major complications were comparable in both groups. At a mean follow-up of 12 ± 6 months, 18 of the 25 patients (72%) who underwent initially successful dilatation have remained symptom free with angioplasty alone. Therefore, coronary angioplasty is a suitable therapeutic procedure in carefully selected patients with angina pectoris and prior myocardial infarction at a distance from the site of angioplasty.

Role of Coronary Graft Flow Measurement During Reoperations for Early Graft Failure After Off-Pump Coronary Revascularization

Doppler-based techniques of coronary graft flow measurement are frequently used, especially during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), to exclude graft dysfunction resulting from technical errors. Nevertheless, early graft failure in the immediate postoperative period continues to affect a small percentage of patients who may require emergent reoperation as a result of severe hemodynamic deterioration. In this setting, in which coronary angiography is infrequently an option, expeditious intraoperative assessment of previously constructed coronary grafts may be performed by using the Doppler-based technique Transit Time Flow Measurement (TTFM). As a result, the hemodynamic values obtained during reoperations may guide the operative strategy. In this study we report on eight patients who underwent “off-pump” CABG and necessitated early reintervention as a result of presumed graft dysfunction. In these patients, graft dysfunction was confirmed or excluded by using intraoperatively the TTFM technique, comparing newly obtained flow hemodynamic variables with those recorded as a baseline during primary operations.

Delayed Closure of the Median Sternotomy Incision

Attempts to close a median sternotomy incision in the patient with profound cardiac or pulmonary dysfunction following a cardiac surgical procedure can result in severe hemodynamic deterioration. Delayed sternal closure in this setting may be a lifesaving technique. A method is described for delayed sternal closure that employs a temporary impermeable rubber patch sutured to the presternal fascia.

Extensive myocardial salvage and reversal of cardiogenic shock after reperfusion of the left main coronary artery by intravenous streptokinase

of an artery supplying a large segment of the remaining functional myocardium may result in severe hemodynamic deterioration. Emergency surgical therapy in such patients may be associated with unacceptable morbidity and mortality rates. Therefore, the presence of previous LV injury is an important consideration in the decision to pursue angioplasty or elective CABG in the patient with multivessel CAD. In summary, findings are described in 4 patients with previous inferior or lateral wall MI in whom acute ischemia developed in the distribution of the left anterior descending coronary artery after attempted angioplasty. All 4 patients had severe hemodynamic decompensation refractory to intraaortic balloon pumping and pharmacologic support. Prompt CABG resulted in satisfactory salvage of LV function in all patients; however, morbidity related to the period of profound hypotension before institution of cardiopulmonary bypass was significant and 1 patient died early.

Delayed Postoperative Cardiac Tamponade Mimicking Severe Tricuspid Valve Stenosis

A patient developed acute, severe hemodynamic deterioration five days after an aortic valve replacement. Cardiac catheterization revealed a markedly elevated right atrial pressure but a normal right ventricular end-diastolic pressure. Angiography revealed an extrinsic mass causing compression of the right atrium and the tricuspid anulus. A large clot overlying the right atrium and ventricle was found at emergency surgery. Postoperative cardiac tamponade may result in an atypical hemodynamic presentation when there is selective compression of one chamber or of a valve anulus.

The Medtronic-Hall prosthesis in multiple valve replacement--first results.

From January 1981 to September 1982, 107 patients have been operated on for valve replacement with the Medtronic-Hall (M-H) prosthesis. Thirty-four of them have had multiple valve replacements and they are the subject of this paper. In 2 cases there were tricuspid replacement, and in 9 other patients some type of tricuspid annuloplasty was performed. There were 2 hospital deaths (5.8%) and one late death. No thromboembolic episodes were recorded in this series of patients. In 2 instances a periprosthetic leak was detected. One of these was in a woman with an aortic and mitral valve replacement due to bacterial endocarditis. In this patient a diastolic aortic murmur was registered 4 months after the operation without hemodynamic repercussion. The other patient had endocarditis with positive blood cultures (S. epidermidis) one year after the operation and showed severe hemodynamic deterioration. The patient was re-operated on and the mitral prosthesis was replaced by another with the same characteristics. The patient is doing well. A constant but slight degree of hemolysis was found in every patient in the group.

The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome

Echocardiographic studies were performed on 134 consecutive patients with idiopathic mitral valve prolapse syndrome. Fifteen patients (11.2%) were noted to have ruptured chordae tendineae on M-mode examination and in 12 of them the diagnosis was confirmed by bidimensional studies. Only four patients were referred for surgery as a result of severe mitral regurgitation. At operation one patient was found to have rupture of the anterior mitral chorda and the other three had posterior mitral chordal rupture. Eleven patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome does not always result in severe hemodynamic deterioration and may go undetected unless a high index of suspicion is maintained. Serial echocardiographic studies may reveal the natural history of this condition in asymptomatic patients.