Stable Hemodynamic Parameters Research Articles

Catheter-Based Reperfusion Treatment of Pulmonary Embolism

Case Presentation: A 76-year-old man with a history of hemicolectomy for colon cancer 10 days previously was admitted because of syncope and severe shortness of breath. On physical examination, the patient was hemodynamically unstable, with a systolic arterial pressure of 80 mm Hg, a heart rate of 124 beats per minute, and distended jugular veins. He was agitated and unable to speak full sentences. His respiratory rate was 28 breaths per minute, and oxygen saturation was 80% on room air. Contrast-enhanced computed tomography showed a filling defect of the left main pulmonary artery, complete occlusion of the left lower lobe pulmonary artery, nonobstructive filling defects of the right lower lobe pulmonary artery, and right ventricular enlargement (right-to-left ventricular dimension ratio of 1.4) (Figure 1). The hemodynamic situation remained unchanged after initiation of treatment with oxygen, intravenous unfractionated heparin, and normal saline. Figure 1. Contrast-enhanced chest computed tomogram from the first case. Left, Complete occlusion of the left lower lobe pulmonary artery (large arrow) and nonobstructive filling defect in the right lower lobe pulmonary artery (small arrow). Right, The subannular right-to-left ventricular dimension ratio was obtained from the reconstructed 4-chamber view.1 Right (47.3 mm) and left (33.9 mm) ventricular dimensions were measured perpendicular to the interventricular septum and 1 cm above the atrioventricular annulus plane. The right-to-left ventricular dimension ratio was calculated as 1.4. Case Presentation: A 55-year-old woman suddenly developed acute shortness of breath 3 weeks after resection of a meningioma. On physical examination, the patient appeared hemodynamically stable, with a systolic arterial pressure of 100 mm Hg, a heart rate of 96 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 89% while receiving 3 L of oxygen via face mask. A contrast-enhanced computed tomography confirmed subtotal filling defects in both main pulmonary …

Silent myocardial ischaemia in diabetic patients after general anaesthesia with 24 h intravenous opioids or with epidural analgesia

ObjectiveTo evaluate the effect of general anaesthesia with either continuous i.v. opioids (G/O) or thoracic epidural analgesia (G/EP) on postoperative transient myocardial ischaemia (TMI) in type 2 diabetic patients undergoing open cholecystectomy.MethodologyThis randomised controlled study was conducted on 50 patients with D.M. Patients were divided into G/O group or G/EP group. All patients had negative stress exercise test and at least two cardiac risks preoperatively. Epidural analgesia was established by 15 ml of ropivacaine 0.2% with fentanyl 2 μg/ml followed by 5–8 ml/h of ropivacaine 0.1% with fentanyl 1 μg for 24 h postoperatively. Both studied groups received same general anaesthesia. Continuous i.v. fentanyl 100 μg/h was given intraoperatively in group G/O followed by i.v. morphine PCA. Primary outcome measured postoperative TMI using 24 h continuous ST segment analysis, endothelin-1(ET-1), troponin T, creatine kinase MB (CK-MB), and CKMB/CK preoperatively, 8 h and 24 h postoperatively. Second outcome measured dynamic stress (perioperative heart rate, blood pressure and postoperative pain).ResultsEndothelin-1 was above cutoff level preoperatively and rose up dramatically postoperatively in both studied groups. G/EP attenuated ET-1 elevation than G/O. Troponin T and CK-MB did not rise postoperatively in both studied groups. Postoperative CK-MB/ CK ratio was higher than 10% in 12 and eight patients in group G/O and G/EP, respectively. Twelve cardiac ischaemic events were noticed in four patients in group G/O and four events in two patients in group G/EP without significant difference in total duration of ischaemia between groups. G/EP lowered HR more significantly intraoperatively and gave better pain control for 4 h postoperatively. In conclusion, D.M was associated with high ET-1 level. Upper abdominal surgery increased ET-1 release. G/EP attenuated ET-1 release more than G/O and produced more stable haemodynamic parameters and less postoperative pain. No superior cardioprotective effect was noticed in G/EP over G/O.

The Effect of Intrathecal Bupivacaine Plus Sufentanil on Intraoperative Hemodynamics During Elective Coronary Artery Bypass Surgery

Introduction: Intrathecal opioids have been used for many patients undergoing surgical operations to improve clinical outcomes. Cardiopulmonary bypass in patients undergoing coronary artery bypass graft surgery carries a number of drawbacks, namely hemodynamic derangements. Several methods have been used to suppress this state; among them is sympathetic blockade by neuraxial anesthesia. This study assesses the effect of intrathecal adjuvant bupivacaine plus sufentanil on intraoperative hemodynamic changes in elective coronary artery bypass surgery. Methods: In a double-blind, randomized, placebo-controlled clinical trials, 80 patients scheduled for elective CABG were randomly assigned into 2 groups. One group received intrathecal sufentanil (S) and the other group received the same dose of sufentanil plus supplemental bupivacaine (SB). All the patients were similar regarding other items. Hemodynamic and clinical outcomes including blood pressure values were measured during and after the operation. Results: There were more stable hemodynamic parameters in the SB group. Also, the SB group patients were extubated sooner than the other patient group. Discussion: The administration of intrathecal sufentanil plus bupivacaine seems to keep the hemodynamic status of the patients more stable than intrathecal sufentanil alone.

Calcificaciones valvulares cardíacas y alteraciones del metabolismo óseo-mineral, a propósito de un caso

We present the case of a 44-year-old man under replacement therapy with hemodialysis since 1995 and stable hemodynamic and analytical parameters for more than 11 years. Vascular calcifications followed the expected course for this type of patient. In September 2007, after an episode of clinical hyperthyroidism and secondary atrial fibrillation with rapid ventricular response, warfarin treatment was started. Impairment in bone and mineral metabolism disorders in chronic kidney disease (BMM -CKD) biochemical parameters was also observed, with elevated intact parathyroid hormone (PTHi) and phosphorus levels. Despite treatment intensification, these parameters were not adequately controlled for more than 1 year. During this period, vascular calcifications rapidly progressed, with severe consequences to the aortic valve, leading to surgical valvular substitution. Other factors were probably involved in the poor and torpid clinical course of this patient, such as a poor control of BMM-CKD parameters and warfarin treatment. These factors may have been intensified by hemodynamic alterations.

Incarcerated Gastro-thorax: a rare and delayed presentation of diaphragmatic injury due to multiple stab wounds.

Diaphragmatic injuries due to thoraco-abdominal penetrating trauma may often go unnoticed at the initial admission, especially in patients who are asymptomatic, with stable hemodynamic and respiratory parameters. Such occult diaphragmatic perforations can result in latent morbidity and mortality due to delayed trans-diaphragmatic herniation of the abdominal viscera leading to incarceration, strangulation and perforation. Here we report a case of an initially asymptomatic patient who had sustained multiple truncal stab injuries and presented two months later with a trans-thoracic incarceration of the stomach which was accurately diagnosed and successfully repaired at the time of surgery. This case report highlights the importance of exploring thoraco-abdominal penetrating injuries even in the absence initial clinical and radiological signs, so as to promptly identify occult and isolated diaphragmatic perforations and prevent delayed catastrophes. The clinical features, radiological findings, diagnostic difficulties and surgical options are discussed along with review of relevant literature.

Validation of the normal, freely moving Göttingen minipig for pharmacological safety testing

Introduction The objective of this study was to use a newly established cardiovascular model using freely moving minipigs to document the hemodynamic and electrocardiographic effects of known pharmacological agents. The data generated are to serve as the basis of pharmacological drug safety evaluations using this new model. Methods 6 Göttingen minipigs were equipped with a radiotelemetry system (ITS). Following a recovery period, aortic pressure (AP), left ventricular pressure (LVP), lead II of the ECG and body temperature were continuously recorded throughout an 8 h monitoring period following oral administration of one of the test agents or vehicle. Notocord HEM 4.2 software was used for data acquisition. One known hERG blocker (moxifloxacin (30, 100 or 300 mg/kg)) and one non-selective beta-adrenoreceptor antagonist (propranolol (3, 10 or 20 mg/kg)) were tested in the model using a cross-over study design in 6 pigs. Results We obtained high signal quality and found stable hemodynamic parameters with low intrinsic heart rates in the Göttingen minipig under resting, pre-treatment conditions. After oral dosing of moxifloxacin, a substantial, dose-dependent increase in the QT-interval duration could be shown, as anticipated for this agent. After propranolol administration, a decrease in HR and left ventricular dP/dt was detected as expected for a beta-adrenoceptor blocking agent. Discussion The present data demonstrate that using this model in conscious, chronically instrumented Göttingen minipigs, a cross-over study with six animals was sensitive enough to detect a dose-dependent QT prolongation when moxifloxacin was administered in oral doses leading to clinically relevant plasma drug concentrations. Additionally, we could demonstrate the expected propranolol-induced effects on heart rate and myocardial contractility, despite the low intrinsic resting heart rates in these minipigs. These data support the use of the Göttingen minipig as a sensitive cardiovascular and electrocardiographic model for the testing of new pharmaceutical agents.

Oxidative Stress Implication After Prolonged Storage Donor Heart with Blood Versus Crystalloid Cardioplegia and Reperfusion Versus Static Storage

Several factors are known to limit cardiac transplantation, such as number of donors, quality of cardiac graft preservation, and ischemia-reperfusion injury. Some mechanisms of reperfusion injury are now recognized; they include oxygen free radical (OFR), white blood cells activation, changes in calcium influx, alteration of microvascular blood flow, and sympathetic activation. The goal of this study was to assess the effects of two types of cardioplegia with long-term storage, either static or continuous perfusion, in 30 isolated sheep hearts as a model for heart transplantation. We examined myocardial function, histology, ischemic damage, and markers of oxidative stress. Two types of cardioplegia and storage conditions using a Langendorff reperfusion were studied in a combined approach: crystalloid (CP) [groups I and III] or cold oxygenated autologous blood (BC) [groups II and IV], immediate storage during 8h in profound hypothermia (groups I and II), or reperfused with crystalloid (group III), or blood cardioplegia (group IV). All perfusate samples were drawn from the coronary sinus. Lactate levels increased progressively in groups I, II, and IV, but not in group III, as no significant elevation was shown [90 min: 13.6+/-1.7 versus 5.2+/-1.0 mmol/L (P<0.01)]. Arrhythmias were more frequent when using BC (n=5) than CP (n=0). For plasma thiobarbituric acid-reactive substances (TBARS) levels a significant difference was found between group III and the other groups since 15 to 90 min (P<0.05). Vitamin E concentration decreased significantly from 5 min for groups II and IV, 15 min for group I, and 30 min for group III, with a significant difference between groups II and IV (P<0.05) but not between groups I and III. CP followed by a reperfusion with the same solution showed a significantly lower ischemic injury and OFR production, less frequent ventricular arrhythmias while stable hemodynamic parameters carried on. However, this protocol did not act on the early postoperative contractile function.

Isolated pulmonary Langerhans cell histiocytosis

A 45-year-old female was hospitalized for evaluation of chronic cough and exercise intolerance of 2-months duration. Her past medical history was significant for smoking (20 pack years) and diverticulosis. Initial assessment revealed stable haemodynamic parameters with bilateral wheeze and crackles. Complete blood count and basic metabolic profile were unremarkable. A chest radiograph (Figure 1a) demonstrated bilateral reticular infiltrative pattern in middle lobes predominantly. Arterial …

Minimal access mediastinal surgery: One or two lung ventilation?

BACKGROUND:Minimal access mediastinal surgery (MAMS) is usually performed under general anaesthesia with double lumen tubes (DLT). The aim of this study is to evaluate two lung ventilation through single lumen tubes (SLT) during thoracoscopic sympathectomy for hyperhidrosis and thoracoscopic thymectomy for myasthenia gravis.METHODS:In this prospective non-randomized study, MAMS was performed in 58 patients with hyperhidrosis and 42 patients with myasthenia gravis, from January 2002 to December 2008. Patients were intubated with a DLT or SLT, 50 patients in each group. In the DLT group, endobronchial tubes were placed using the traditional blind approach and one lung ventilation was confirmed clinically. In the SLT group, the hemithorax was insufflated with CO2 in conjunction with two-lung anaesthesia. All the patients were evaluated for haemodynamic stability, oxygen saturation of haemoglobin (Spo2), end-tidal Pco2 (ETPco2), times required for intubation and surgery, satisfaction of surgeon with regard to exposure and postoperative complications.RESULTS:In the SLT group, all the patients had stable haemodynamic and ventilation parameters. In the DLT group, haemodynamic instability occurred in two, decrease in Spo2 in four and increase in ETPco2 in three patients. One patient in the DLT group developed vocal cord granuloma two months later. Time required for surgery and the surgeon's opinion with regard to exposure were similar for both groups.CONCLUSION:Thoracoscopic surgery when used in cases where a well-collapsed lung may not be essential, since surgery is not performed on the lung itself, does not require DLT. SLT is safe in MAMS. It provides good surgical exposure and decreases the cost, time and undesirable complications of DLT.

Severe Aortic Stenosis: Combined Lumbar Plexus, Sciatic and Iliohypogastric Nerve Block with 0.25% Levobupivacaine for Reduction of Hip Fracture

The potential advantages of 0.25% concentration of levobupivacaine in performing lumbar plexus with sciatic and iliohypogastric nerve block in patients with aortic stenosis is emphasized in this case report. A 48-yr old male patient who was scheduled for hip fracture surgery had severe aortic stenosis with aortic valve gradient of 85 mmHg. Anesthesia plan was combined lumbar plexus, sciatic and iliohypogastric nerve block with a total of 60 mL, 0.25% levobupivacaine. After performing the blocks, the patient underwent successful and uneventful hip reduction surgery except requiring only sedation medications. The patient had sufficient anesthesia and remained hemodynamically stable without the use of vasoconstrictive medication during the operation. We thought that combined lumbar plexus, sciatic and iliohypogastric nerve block with 0.25% levobupivacaine provides stable hemodynamic parameters with adequate anesthesia for hip fracture surgery in patient with severe aortic stenosis.

Hem-o-lok Clip Dislodgment Causing Death of the Donor After Laparoscopic Living Donor Nephrectomy

The self-locking Hem-o-lok vascular clips (Weck Closure Systems, Research Triangle Park, NC) are widely used to control medium and large size vessels in various laparoscopic procedures (1). The self-locking mechanism ensuring adequate closure has made the Hem-o-lok clips popular mainly in laparoscopic donor nephrectomy (LDN) where the relatively short vascular stump remains with the donor (2). Another advantage is cost saving in comparison with the endovascular staplers. The following case report of late clip dislodgement with subsequent donor death has led to the recall in 2005 of the clip manufacturer not to use this clip in LDN (3), and indeed recent reports validated our observation (4). Despite that alert, these clips are still widely used in LDN in the United States (5) and Asia (6). This has prompted us to report that fatal case in the transplant literature. Case Presentation A kidney donation from an unrelated 34-year-old healthy man to his friend was approved by the Israel Transplant Center. Hand-assisted left donor nephrectomy was performed through a transperitoneal approach, whereby both the renal artery and vein were cut after the application of two Hem-o-lok clips to each vessel. The videotape of the procedure showed the two clips on the renal artery before the vessel was cut and again on the renal arterial stump at the end of the procedure. The patient was extubated in the operating room and observed for another 3 hr in the recovery room where he was fully conscious with stable hemodynamic parameters and passing adequate amount of urine. The hemoglobin level at discharge from recovery was 11.2 g/L. At 10 p.m., 12 hr after surgery, on the ward the patient developed a sudden drop of blood pressure associated with loss of consciousness. Hemoglobin level measured during resuscitation was 6 g/L. Resuscitative efforts on the floor were unsuccessful, and the patient was transferred to the operating theater. On arrival at the theater, his carotid pulse was impalpable and both pupils were dilated. On explorative laparotomy through a midline incision, the left renal arterial stump was found opened and both clips could not be visualized. Suture of the arterial stump with infusion of blood products could not reverse his condition, and the patient succumbed to uncontrolled hemorrhagic shock. At postmortem examination, the two closed Hem-o-lok clips were found beside the opened renal artery stump although the two clips on the vein were in satisfactory position. The remaining length of the arterial stump measured 5 mm. Having the videotape showing the two clips on the arterial stump and the finding in the postmortem examination of the two locked clips lying nearby the arterial stump suggest delayed clip dislodgment as the mechanism to explain the hemorrhagic shock in our patient. The Hem-o-lok clip has angled arms designed purposely to leave a little space between the two arms to prevent a full closure, which might damage the vessel. It is our assumption that pain-related adrenergic stimuli associated with temporary elevated blood pressure caused clip dislodgment from the elastic arterial stump. Further reason for failure of these clips is the small amount of tissue that occasionally gets inside the locking mechanism, and thereby interfering with it. The short arterial stump when using the Endo-GIA stapler (Ethicon Endosurgery, Johnson & Johnson, Cincinnati, OH) device may be of a problem in some cases. Other options to maintain enough arterial length such as the use of articulate Endo-TA (Ethicon Endosurgery, Johnson & Johnson, Cincinnati, OH) (5) or the combined use of a Hem-o-lock clip with a regular titanium clip applied distally should be carefully studied (7). Yoram Dekel Department of Urology Rabin Medical Center Beilinson Hospital Petach-Tiqwa, affiliated with Sackler Medical School Tel-Aviv University, Israel Eytan Mor Department of Transplantation Rabin Medical Center Beilinson Hospital Petach-Tiqwa, affiliated with Sackler Medical School Tel-Aviv University, Israel

Effect of preoperative skull block on pediatric moyamoya disease

Stable hemodynamics, normocapnia, and adequate pain relief are considered important factors in the reduction of neurological complications in pediatric patients undergoing encephaloduroarteriomyosynangiosis (EDAMS) operations for the treatment of moyamoya disease. A preoperative skull block may reduce hemodynamic fluctuations and hypo- or hyperventilation due to emergence delirium or oversedation and provide adequate pain relief, thereby reducing postoperative morbidity. Pediatric patients (age 3-13 years) undergoing EDAMS surgery for moyamoya disease were randomly divided into a nerve block (NB) group (18 cases) or control group (21 cases). The treatment group patients received a preoperative NB (0.25% 5-8 ml bupivacaine mixed with 20-40 mg methylprednisolone) targeting the supraorbital, supratrochlear, auriculotemporal, and posterior auricular nerves. Patients in the control group did not receive NB. General anesthesia with sevoflurane was induced in both groups. In the NB group, stable hemodynamic parameters were obtained with a lower sevoflurane concentration than in the control group. For delirious awakening, the odds ratio in the control group was 4.9 compared with the NB group. Pain and analgesic requirement were higher in the control patients than in the NB-treated patients during the postanesthesia care unit stay. However, the arterial CO(2) tension in the postanesthesia care unit did not differ between the 2 groups. The odds ratio in the control group for the rate of morbidity (cerebral infarction and reversible ischemic neurological deficits) during the first 24 hours following the operation was 3.2 compared with the NB group. The use of skull block during EDAMS surgery provided easy hemodynamic control, calm awakening, and better pain relief and may be related to the reduced postoperative morbidity.

Evaluation of cardiovascular and ECG parameters in the normal, freely moving Göttingen Minipig

Introduction The objective of this study was to evaluate the normal cardiovascular and ECG parameters in freely moving minipigs and to use these data as the basis of pharmacological drug safety evaluation. Methods 7 Göttingen Minipigs were equipped with radiotelemetry transmitters (ITS). Aortic pressure (AP), left ventricular pressure (LVP), lead II of the ECG and body temperature were continuously monitored. Notocord HEM 4.2 software was used for data acquisition. Power calculations for the various parameters were done to assess appropriate sample sizes. Results We obtained excellent signal quality and found stable hemodynamic parameters with a low intrinsic heart rate in the Göttingen Minipig. After oral dosing of vehicle, the hemodynamic parameters returned quickly to baseline values indicating that the procedure was well tolerated. The heart rate dependency of the QT interval had to be corrected individually. A sufficient power could be achieved with a sample size of 4 due to the low variability of the parameters measured. Discussion These are, to our knowledge, the first data documenting the course of systemic arterial and ventricular hemodynamic parameters in the freely moving Göttingen Minipig over 24 h. As such, they may serve as a basis for future studies in which drug effects are studied in these animals.

THE “OLIGOANALGESIA PROBLEM” IN THE EMERGENCY CARE

Pain is a common occurrence in trauma victims that provokes harmful effects on the body. However, there is a gap in the literature about this problem, which is still underevaluated and undertreated in Brazil, especially concerning the use of opioids. To estimate pain intensity and the use of analgesia in traffic accident victims. A prospective study, involving 100 accident victims (traffic accidents), who were interviewed at 2 separate posttraumatic moments, in a reference hospital of the city of São Paulo. All the medications used for these victims were recorded. All patients displayed a Glasgow Coma Scale (ECGl) of 15, had stable hemodynamic parameters, and were brought directly from the scene of the accident. Pain of moderate and severe intensity (in 90% of cases) was the most noted. After a 3-hour period, a significant number of patients with pain (48%) continued without analgesia, and few opioids were used. Pain is a common event associated with trauma. It is still undertreated and underevaluated in Brazil, and the use of opioids for admittedly very severe pain is not frequently employed in the Emergency Service even in hemodynamically stable patients and with a Glasgow Coma Scale of 15.

Erste Ergebnisse einer prospektiven Studie über nichtchirurgisches Management von Milzverletzungen durch stumpfes Bauchtrauma

BACKGROUND: After it was recognized that splenectomy puts patients at lifelong risk of septic complications, splenic conservation or conservative treatment after blunt abdominal trauma received increasing attention. The aim of our prospective, multicenter study was to evaluate which patients with splenic injury most benefit from non-operative treatment. METHODS: Patients were recruited prospectively from 4 surgical centers in Austria from 2003 onward. Inclusion criteria were age of at least 16 years, stable hemodynamic parameters after blunt abdominal trauma with splenic injury, and conservative treatment. After 15 months, 25 patients with a median age of 38 years entered the study (8 females, 17 males). The patients were classified according to the severity of the splenic lesion and treated conservatively according to a standardized regime. RESULTS: Conservative management was possible in 21 patients while 4 required surgery. Failure of conservative treatment was due to incidentally high dosed heparin therapy in three patients, while one patient with grade-IVb injury receiving a normal dose of prophylactic heparin treatment required splenorraphy 36 hours after the trauma. CONCLUSIONS: Preliminary results suggest that nonoperative management is a safe and effective treatment for splenic trauma.

Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity

Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity. Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed. Sixty-three patients (2.1%) developed anastomotic leaks (open, 2.1%; laparoscopic, 2.1%) at a median of 3 days (range 0 to 28 days) after Roux-en-Y gastric bypass. Symptoms and signs included tachycardia (72%), fever (63%), or abdominal pain (54%). Upper gastrointestinal series and CT demonstrated leaks in only 17 of 56 (30%) and 28 of 50 (56%) patients, respectively; when done jointly, both studies were negative in 30% of patients. The 68 anastomotic leaks occurred at the gastrojejunostomy (49%), excluded stomach (25%), jejunojejunostomy (13%), gastric pouch (9%), and uncertain location (4%). Forty patients (63%) required 58 reoperations for drainage of intraabdominal collections (55%), repair of anastomotic defects (34%), or revision of the leaking anastomosis (11%), with an overall morbidity of 53% and mortality of 10%. Nonoperative treatment was successful in 23 of 26 patients, with an overall morbidity of 61% and no mortality (p=NS versus operative). Operative treatment was more common in patients with hypotension or oliguria (p < 0.01). Lack of specificity in clinical presentation and imaging studies make diagnosing anastomotic leaks challenging, so operative exploration should be part of the diagnostic algorithm. Nonoperative treatment is safe and effective in a subset of patients who exhibit stable hemodynamic parameters and are known to have controlled leaks.

Evaluation of furosemide regimens in neonates treated with extracorporeal membrane oxygenation

IntroductionLoop diuretics are the most frequently used diuretics in patients treated with extracorporeal membrane oxygenation (ECMO). In patients after cardiopulmonary bypass (CPB) surgery, the use of continuous furosemide infusion is increasingly documented. Because ECMO and CPB are 'comparable' procedures, continuous furosemide infusion is used in newborns on ECMO. We report on the use of continuous intravenous furosemide in neonates treated with ECMO.MethodsThis was a retrospective observational study in neonates treated with continuous intravenous furosemide during ECMO.ResultsThirty-one patients were included in the study. A median of 25 (9–149) hours after the start of ECMO, continuous furosemide therapy was started at a median rate of 0.08 (0.02–0.17) mg/kg per hour. The continuous furosemide dose was not changed in the individual patient. Seven patients received a furosemide bolus prior to, and five patients received additional loop diuretics during, the continuous infusion. Urine production before continuous furosemide therapy was not significantly different between patients who received a furosemide bolus prior to the infusion and those who did not receive this bolus (P = 0.2879). Although a positive effect of the 'loading' bolus was observed in urine output in the first 24 hours, there was no statistically significant difference in urine output (P = 0.0961) or in time (P = 0.1976) to reach a urine output of 6 ml/kg per hour between patients. After 24 hours, urine production remained a median of 6.2 ml/kg per hour irrespective of furosemide boluses. The forced diuresis was well tolerated as illustrated by stable haemodynamic parameters and a decrease in ECMO flow and vasopressor score over the observation period.ConclusionThis is the first report on continuous intravenous furosemide therapy in newborns treated with ECMO. The furosemide regimens used in this study varied widely in continuous and intermittent doses. However, all regimens achieved adequate urine output. An advantage of continuous, over intermittent, intravenous furosemide could not be documented. Furosemide dosing regimens should be developed for neonates treated with ECMO. In addition, therapeutic drug-monitoring studies are required to prevent furosemide toxicity because so far no data are available on serum furosemide levels in neonates treated with ECMO.

Robotic-assisted endoscopic thoracic aortic anastomosis in juvenile lambs.

Advances in robotic technology have enabled a wider range of applications for minimally invasive techniques in cardiac surgery, including mitral valve repair and coronary artery bypass grafting. With increased technical sophistication, robotic-assisted techniques can be developed for the endoscopic repair of certain congenital cardiac lesions. The purpose of this study was to assess the feasibility of closed chest thoracic aortic anastomosis in a juvenile ovine model. Lambs, aged 45 to 55 days, underwent surgery that was performed using the da Vinci robotic surgical system. Using 3 ports, the surgeon dissected the descending thoracic aorta and mobilized it free from attachments, using single-lung ventilation and CO2 insufflation. Snares were introduced through 2 stab wounds for aortic occlusion proximally and distally. In 4 lambs, the aorta was completely transected and reanastomosed using interrupted nitinol sutures. One lamb underwent longitudinal aortotomy, and patch aortoplasty was performed with the placement of a Gore-Tex patch. Snares were released and the animals were recovered once hemodynamically stable. Animals were sacrificed at 6 to 12 hours after surgery and the descending aorta was harvested. Burst-pressure testing was performed on the anastomoses. All 5 lambs survived the procedure with stabilization of hemodynamic parameters following surgery. The mean aortic clamp time was 47 +/- 17 minutes, and the anastomosis was completed in 26 +/- 5 minutes. The mean burst pressure was 163 +/- 9 mm Hg. Endoscopic thoracic aortic anastomosis can be performed safely and with adequate exposure in a juvenile large-animal model using computer-assisted surgical techniques. With further refinements, these approaches could be applied to the repair of congenital anomalies of the aorta, including interrupted aortic arch and aortic coarctation.

Fatal Intraoperative Anaphylaxis Related to Aprotinin after Local Application of Fibrin Glue

To the Editor:—We report a case of intraoperative fatal anaphylaxis. The chronology of the event and the subsequent evaluation strongly point to a role of the aprotinin contained in the fibrin glue locally applied to the operating field.This letter is accompanied by an Editorial View. Please see: Moss J: Allergic to anesthetics. Anesthesiology 2003; 99:521-3.A 52-yr-old man underwent surgery for a painful lumbar disc herniation. His past medical history included a rhinoplasty, and his only other medical problem was a glaucoma treated with carteolol. After premedication with hydroxyzine 100 mg, anesthesia was induced with midazolam, propofol, and rocuronium and maintained with sufentanil and desflurane. No event occurred for 2 h until application of 0.2 ml of fibrin glue (Tissucol® Kit 500 U/ml; Baxter, Maurepas, France) on a dural tear. Blood pressure decreased immediately (60 mmHg), accompanied by a bronchospasm and a skin rash. The anesthetic agents were discontinued. The patient received hydroxyethyl-starch and intravenous epinephrine, but cardiac arrest developed. Cardiac massage was started and was soon followed by defibrillation. Stabilization of hemodynamic parameters was achieved with epinephrine infusion (epinephrine 3 mg/h). Right heart and pulmonary artery catheterism performed in the intensive care unit showed a low cardiac output with low left and right filling pressure. Despite intensive inotropic support, the patient died 48 h later from multiorgan failure.The plasma levels of histamine and tryptase were increased 2 h after initial symptoms, confirming anaphylaxis. Antiaprotinin immunoglobulin (Ig) E and antiquaternary ammoniums immunoglobulins were identified in the preoperative serum of the patient (table 1).No drugs other than those cited above had been given during the 2 h preceding the shock, except for Tissucol®. The chronology does not point to a role of neuromuscular blocking agents, because a 2-h interval had elapsed between the injection of rocuronium and the shock. Our patient had specific IgE against quaternary ammoniums (detected on his preoperative stored plasma), but this has little predictive value because antiquaternary ammoniums IgE are present in 10% of the population without allergic reaction to neuromuscular blocking agents. 1An allergic reaction to latex may occur at any time during surgery, but the negativity of antilatex IgE in the preoperative serum does not support this hypothesis in our case. The chronology of events and the presence of antiaprotinin IgE in the preoperative serum strongly argue in favor of an allergic mechanism induced by fibrin glue.Fibrin glue is effective for hemostasis and sealing of tissue wounds but has been associated with severe anaphylactic reactions. 2Since 1990, Tissucol® has been composed of human coagulation factors and bovine aprotinin. The aprotinin role is to delay the destruction of the glue by fibrinolysis. None of the allergic cases following exposure to fibrin glue related to human coagulation factors. Bovine aprotinin was therefore held responsible. 3More than 100 cases of allergy to intravenous aprotinin have been published, essentially after reexposure to the drug. 4,5In our patient, the antiaprotinin IgE level was moderately positive, indicating previous sensitization. Cases of allergy after local application of the product are rare, and our case is the first related death reported. A case similar to ours was described after neurosurgery with local injection of fibrin glue for closure of a liquor fistula, which resulted only in a generalized skin rash. 6After further enquiry, we discovered that fibrin glue had been applied during the previous rhinoplasty 5 yr before. It has been demonstrated in cardiovascular surgery that locally given aprotinin results in a 10% 12-month prevalence of IgG antibodies. 7On the other hand, it has been observed in cardiovascular surgery that even a careful research of exposure history is not very sensitive to identify patients with aprotinin-specific antibodies. 8In case of known previous exposure to aprotinin, a preoperative allergologic workup is usually performed. However, the predictive value of the tests (prick-test, specific antiaprotinin IgG or IgE) has not been studied for aprotinin local application. Because the prevalence of reactions to aprotinin is higher in patients with a reexposure interval less than 6 months, such a short interval should be considered a relative contraindication to fibrin glue application. 5This is the first report of a fatal case of intraoperative anaphylactic shock related to local aprotinin. Because the preoperative questioning to investigate previous exposure to fibrin glue is difficult, and because an allergologic workup cannot be performed in every patient, the liberal use of fibrin glue must be weighed in relation to the risk of allergy.

Prolonged function of extracorporeal hDAF transgenic pig livers perfused with human blood.

The development of genetically modified pigs has renewed interest in the use of porcine liver perfusion in the treatment of acute liver failure. A previously developed model of extracorporeal perfusion has been used to test the function of porcine livers transgenic for human decay accelerating factor when perfused with fresh, whole, human blood. Three experimental groups were studied: alloperfusions (normal pig livers perfused with pig blood) and xenoperfusions of both unmodified and transgenic pig livers with human blood. All livers were perfused for up to 72 hr. Alloperfusion resulted in the maintenance of good function and histological structure. Stable hemodynamic, synthetic, and metabolic parameters were demonstrated in both unmodified and transgenic liver xenoperfusions; hyperacute rejection was not seen. In both groups, however, the measured parameters of liver function deteriorated toward the end of the 72 hr perfusion period; deterioration was more marked in the nontransgenic group. Xenoperfusions were characterized by a progressive and marked decrease in hematocrit of the circulating blood. Histologically, patchy necrosis was noted in both groups and more retained erythrocytes were seen in the sinusoids of nontransgenic livers, but no other consistent differences were apparent. These studies have demonstrated that porcine liver xenoperfusions can be performed for prolonged periods while maintaining good liver function. The use of organs from animals transgenic for a human complement regulator protein confers improvement in some measures of liver function. This preclinical model provides evidence that extracorporeal liver xenoperfusion may be effective in temporary liver support for patients in acute liver failure.