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THE EFFECT OF CONTINUOUS POSITIVE AIRWAY PRESSURE ON BLOOD PRESSURE VARIABILITY

CLINICAL OUTCOME OF PATIENTS TREATED WITH INTRAVENOUS UROKINASE FOR ACUTE MYOCARDIAL INFARCTION

T Torok , A Kardos, L Rudas, D Paprika

OBJECTIVES: Although the increased heart rate variability in healthy subjects in association with continuous positive airway pressure is well known, the underlying mechanism is not well understood. The carotid arterial baroreceptor stimulation due to greater blood pressure variability and the augmented mechanical effects of forced breathing on venous return can play important role in this phenomenon. METHODS AND DESIGN: To test our theory we have studied nine healthy volunteers mean age was 22 yrs, range (19-24 ), applying patterned breathing 6/min, and continuous positive airway pressure 10 cm of water. ECG and finger blood pressure (Finapres 2300 ) was continuously recorded. STATISTICAL ANALYSES AND RESULTS: The oscillation amplitude of R-R intervals were analysed as well as the time and frequency domain indexes of heart rate variability. The oscillation amplitude and the same frequency domain components of systolic blood pressure were also calculated. The forced deep breathing caused significant increase in heart rate variability as indicated by time and frequency domain analysis of R-R intervals.( LF HRV ms 2 : spontaneous: 777.4±526.1, deep breathing 6828±5468) The application of CPAP in the same rhythm during deep breathing resulted in further enhancement in heart rate variability.( LF HRV ms 2 : 9052±4533) The analysis of the same frequency domain components of systolic blood pressure showed marked elevation of the total and low frequency power during metronome breathing.( LF BPV mmHg 2: spontaneous:8.24f6.22, deep breathing: 16.22±9.77) Applying CPAP with the same breathing pattern elicited further significant increment in systolic blood pressure fluctuation.(LF 13PV mmHg 2 :deep breathing+ CPAP:27, l 1±9.85) CONCLUSION: Our findings indicate that forced deep breathing results in enhanced systolic blood pressure oscillation. For the accentuated systolic blood pressure fluctuation the mechanical effect, exerted by active breathing with CPAP on the venous return toward the right atrium could be responsible. Medical Intensive Care Unit, Albert Szent-Gyorgyi Medical University, Szeged, Koranyi fasor 7-H 6723,

H Keller N Seltzer, A Weimer, H Meaning, P Ulrich, *U Staedt, *W Kirschstein

Only few studies have previously evaluated intravenous urokinase as thrombolytic therapy for acute myocardial infarction (AMI). In 266 patients (81 % men, 19 % women, mean age 60 ± 12 years) the major clinical outcomes were evaluated retrospectively after treatment with intravenous urokinase for AMI (41 % anterior MI, 51 % posterior MI, 10,9 % non-Q-wave MI). Inclusion criteria for thrombolytic therapy were chest pain for more than 20 min, onset of chest-discomfort 5 6 hours, ST-segment elevation of > 0,1 mV in at least 2 of 3 inferior leads or ST-segment elevation >_ 2 mV at least in 2 of 6 precordial leads. Patients older than 75 years were not excluded. The time-interval between the beginning of chest pain and the thrombolytic therapy administration was in 41,5 % of patients within 2 hours and 39,4 % within 4 hours. A total of 2 million U urokinase was infused over a 30 min period and an additional million U urokinase in patients who had clinical signs of a persistent ischemia (chest pain). All patients recieved intravenous heparin and aspirin 325 mg (orally). In 27 patients (10,2 %) minor bleeding without clinical consequence was observed. No life-threating bleeding (intracranial, gastrointestinal, bleeding necessitating emergency transfusion) was documen-ted. During the course of the hospitalization 39,5 % of patients had sympto-matic myocardial ischemia or during exercise stress testing. 25 patients underwent coronary angioplasty. 34 pattentg needed elective coronary artery bypass surgery within 3-6 month. The reinfarction rate was 5,5 % during hospital stay. 61 % of patients had diagnostic coronary angiography within a 6 month period. In these patients the patency of the infarct-related vessel was 63 %. 3,1 % of patients died during the first day, 4,3 % during the first 7 days, 5,5 % during the first 35 days and 7,5 % during the first 6 month. The use of intravenous urokinase in patients with acute myocardial infarction ist associated with a low incidence of bleeding complications and a succsess rate comparable to other thrombolytic regimes. Kreiskrankenhaus Rastatt and *I. Med. Klink, Klinikum Mannheim Universitat Heidelberg, Engelstr. 39, D-76437 Rastatt, Germany

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STUDY TO INVESTIGATE THE EFFECT OF DOBUTAMINE ON THE RELATIONSHIP BETWEEN CARDIAC INDEX AND INTRATHORACIC BLOOD VOLUME INDEX

TYPE II PHOSPHOLIPASE A2 LEVELS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION (AMI) T Kasai ±, S Endol, N Arakawat, N Satot, T Suzukil, S Taniguchil, K Inada2 , K Hiramori 3

OBJECTIVE: 'COLD' system measurements of intrathoracic blood volume index(ITBVI) may reflect myocardial preload more closely than either central venous pressure(CVP) or pulmonary artery occlusion pressure (PAOPI. With the system, ITBVI is calculated as the product of thermodilution cardiac index(CI) and mean transit timelMTt) of indocyanine green dye(ICG). Under euvolaemic conditions, any increase in Cl resulting from improved myocardial contractility should be balanced by a corresponding reduction in MTt, leaving ITBVI unchanged. There is a theoretical concern however, that a spurious rise in ITBVI may be observed in these circumstances, due to its mathematical dependence on Cl. The objective of this study, therefore, was to determine whether 'COLD' measurements of Cl and ITBVI are coupled when Cl is increased using a dobutamine infusion in euvolaemic patients. DESIGN: Case series. SUBJECTS: Twelve stable, ventilated, intensive care patients, who were being monitored with the 'COLD' system and receiving inotropic support with dobutamine. METHOD: In each patient, 3 baseline measurements'of thermodilution Cl and ITBVI were made with the 'COLD' system. The rate of dobutamine infusion was then increased, over a period of 20-30 minutes, until either a CI value 20% above the baseline or a dobutamine dose of 30 Ngm/kg/ min was reached. At this point, 3 further measurements of Cl and ITBVI were made. No intravenous fluids, other than maintenance fluids and drug infusions, were given during the study period. RESULTS AND STATISTICAL ANALYSIS: The mean increase in Cl was 31.7%, whilst the mean increase in ITBVI was only 2.84%. When (minus change in log MTt) is plotted against (change in logCl) the points do not deviate significantly from the line of identity. The mean value of (change in logCl + change in logMTt) is 0.011 (SD = 0.028, 95% confidence interval _ -0.007 to + 0.029). Antilog values for the confidence interval are 98.4% to 107%. CONCLUSION: Under euvolaemic conditions, increasing Cl by infusing dobutamine does not produce a corresponding increase in ITBVI. This implies that ITBVI may indeed be a useful Cl-independent measure of preload.

In the acute stage of AMI, we evaluated the association between type II Phospholipase A2 (type II PLA2), and the severity of the disease or the pathologic condition after reperfusion and its clinical importance. The subjects were 15 patients with AMI within 6 hours after the onset. Cardiac failure was observed in 5 patients but not in the other 10 (5 showing reperfusion and 5 not showing reperfusion). Blood was collected via the peripheral vein at the time of admission and 12, 24, 36, 48, and 72 hours after the onset, and the type II PLC concentration was determined by RIA (Shionogi & Co., Ltd., Japan). The blood type II PLA2 concentration in the acute stage of myocardial infarction was high at the time of admission and gradually increased, reaching a peak 48 hours after the onset. The blood type II PLA2 concentration was higher in the patients with myocardial failure than in those without this complication. The blood type II PLA2 concentration tended to increase after reperfusion in the group treated by reperfusion compared with the group not treated by reperfusion. A positive correlation was observed between the peak type II PLA2 concentration and peak CK. The blood type II PLA2 concentration in the acute stage of myocardial infarction seems to reflect the severity of the disease and can be a parameter of the degree of myocardial damage associated with myocardial ischemia and reperfusion.

A McLuckie , R J Beale, D Bihari

Department of Intensive Care, Guy's Hospital, London SE1 9RT, UK

'Critical Care and Emergency Center2Dept. of Bacteriology, 3 2nd Dept. of Internal Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka 020, Japan.

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145 IMPROVED ELIMINATION OF IMIPRAMINE IN CARDIOGENIC SHOCK

1MTH A CARDIOPULMONARY BYPASS IN AN ANIMAL MODEL W Schmidt , I Meineke, M Nottrott, I Frerichs, S Muller, G Hellige

OBJECTIVES: The tricyclic antidepressant (TCA) imipramine (IMI) is known to cause cardiotoxicity at plasma concentrations (CONC) well above 1µg/ml. Whether the use of cardiac assist devices with or without secondary detoxification methods (e.g. hemoperfusion) in severe acute TCA overdose is appropriate or not is open to debate. We studied the pharmacokinetics of IMI in sheep (S) in order to evaluate the usefulness of a cardiopulmonary bypass support (CPB) in the management of near lethal toxicity (NLT) situations. METHODS: 10 anaesthetized S [42-104 kg] were artery-venously cannulated [A. fem. com. / V. jug. ext. = 17- / 21-French] and connected to CPB [Per Cart""]. Catheters were placed into the aortic arch for blood pressure (BP) and in the pulmonary artery for cardiac output (CO) measurements [thermodilution]. BP and electrocardiogram were recorded continuously. Arterial blood samples were collected at predetermined time points and the plasma was used for the analytical determination of IMI and its metabolite desmethylMl by an HPLC method with UV detection. On average S received 0.54 mg/kg/min IMI infusion until they experienced NLT, defined as BP <_ 40 mmHg and CO < 1.5 I/min for 5 min. Then S were given CPB-support for five runs of 30 min duration each followed by 5 min weaning (W1-5). Finally the S were observed for another 120 min whilst spontaneous circulation (SC). RESULTS: Main data of control, IMI shock (IMIS), W and SC. n=10S start IMIS W1 W2' W3' W4 W5 SC-* 108 104 77 93 87 94 97 115 HR b m 87 41 48 65 68 74 BP mmHg 90 31 5.7 4.9 5.1 5.5 5.9 1.4 2.9 4.6 COI /min 205 30 65 100 135 170 Time min 0 -360 All S developed a cardiogenic shock (CS) within 30 min after receiving IMI and were able to completely overcome CO decrease, hypotension, dysrhythmias and conduction delays within 170 min by CPB-treatment. During the infusion of IMI CONC between 5 and 10 µg/ml were reached. After cessation of the infusion CONC fell more rapidly with CPB. CONC below 0.5µg/ml were reached within 50 min, without CPB after 150 min. CONCLUSION: The use of a CPB can aid in the elimination of IMI in an acute overdose situation and allows to overcome CS. If such a technique is employed it should be continued for a sufficient period of time in order to avoid a rebound effect due to redistribution of drug from the periphery after the CPB is stopped. Stadtische Kliraken Kassel, Mbrtchebergstralle 41-43, 34125 Kassel, Germany

Baseline Hemodynamic Variables Predict Augmentation of Coronary Flow Velocity by Aortic Counterpulsation M Zehetgruber, G Mundigler, G Christ, C Merhaut, U Klaar, C Kratochwill, S Hofmann, P iosuzonek OBJECTIVES: Augmentation of coronary blood flow by intraaortic balloon counterpulsation (IABP) ranges from 5-100%. These variable effects on coronary blood flow might be attributed to multiple factors such as baseline hemodynamic variables and severity of coronary artery disease. We therefore examined if these parameters were related to the extent of coronary blood flow augmentation by IABP. DESIGN, SUBJECTS: 20 patients (65±11years) with angiographically documented coronary artery LAD disease were treated with IABP because of acute myocardial infarction (n=12) with cardiogenic shock (n=8), or post cardiopulmonary bypass (n=5). METHODS: Coronary blood flow velocity was recorded by transesophageal Doppler echocardiography in the proximal LAD. Coronary flow velocity time integral (VTI) and hemodynamic variables were measured with (+) and without (-) IABP. Flow velocity augmentation was calculated as VTI+IVTI-. RESULTS AND STATISTICAL ANALYSIS: Parameter

+ IABP

-IABP

p

0.0001 15±10 0.0002 90±25 0.001 63±16 0.0001 50±17 0.0001 21+6 0.01 2.7±1.32.4±1.3 Cardiac index (CI)[I/min/m2] By univariate analysis, coronary flow velocity augmentation correlated with baseline CI (R:-0.61, p<0.005), PCWP (R:0.51, p<0.02), APsys (R:-0.52, p<0.02), APdia (R:-0.57, p<0.01) and APmean (R:-0.54, p<0.02). Severity of LAD stenosis showed no correlation to coronary flow augmentation. According to multivariate analysis, baseline Cl was the strongest predictor of coronary flow augmentation. CONCLUSION: Augmentation of coronary flow by IABP is significantly more effective in patients with poor hemodynamic status and is independent from stenosis severity. A low cardiac output is the best predictor of coronary flow augmentation. If cardiac output measurements are not available, baseline blood pressure may also predict the expected benefit of IABP on coronary flow augmentation. VTI [mm] Syst. arterial pressure(APsys)[mmHg] Mean arterial pressure(APmean)[mmHg] Diast. arterial pressure (APdia)[mmHg] Wedge pressure(PCWP)[mmHg]

23±13 82±23 69±13 83±15 19±5

Intensive Care Unit, Dept. of Cardiology. University of Vienna ,A-1090

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155 INVASIVE EVALUATION OF PULMONARY CAPILLARY WEDGE PRESSURE BY TRANSTHORACIC ECHOGRAPHY DURING MECHANICAL VENTILATION

B io E De Sio A, * Sibilio G, Papa A, Golia D, * Grassia V, * Bove G. BJECTIVES: The relationship of the left and right atrium pressures and plumes leads to specific movements of the mteratnal septum during each phase the cardiac cycle well studied either by transthoracic echocardiography (TTE) d transesophageal echography (TEE) (1,2). The evaluation of the behaviour of he septum during the mesosystole, mainly depending on the pressure gradients, could fottrnish a non invasive semiquantltative method to measure the left atrial pressure (LAP). DESIGN: Comparison of the left (PCWP) and right (CVP) atrial pressure and interatrial septum (lAS) morphology. SUBJECTS: 15 acute respiratory failure patients submitted to mechanical ventilation and invasive hemodynau»c monitoring by baloon-tipped flow directed pulmonary artery catheter. METHODS: The values of CVP and PCWP were collected during tele-expiratory phase (peep 2 - 8 emH2O) and compared to the morphology of IAS during mesosystole evaluated by transthoracic echography using a subcostal view. RESULTS: The transthoracic approach allowed a thechnically valid study in 10 patients: in 4 patients presenting a PCWP < 18 mmHg the TTE demonstrated a protrusion of the IAS in the left atrium while in 6 patients with a PCWP > 18 mmHg the IAS showed a more flat shape through the cardiac cycle with a curvature toward the right atrium and no movements during mesosystole. CONCLUSION: The study of the movements of the interatrial septum, allowing to get informations on the pressures of the left atrium, could further extend the indications to the use of transthoracic echocardiography in the hemodynamic monitoring of the critically ill patients. REFERENCES: 1) Kusumoto FM et al. J Am Coll Cardiol 1993; 21: 721-8. 2) Yonezawa F et al J Cardiol 1987; 17:617-23.

Intensive Care Unit, * Dept. Of Cardiology, Hasp. S.Maria delle Grazie - 80072 Porzuoh (NA) - Italy

PROSTHETIC HEART VALVETHROMBOSIS: THE IMPORTANCE OF PREVIOUS SYSTEMIC EMBOLISM? F Suarez , M Corrales, *R RSbago, P Gonzalez-Arenas, R Morales,

Sanchez J, *J Fraile, *M Rey, *J Martinell.

OBJECTIVES: Prosthetic heart valve thrombosis (PVT) is a serious and potencially lethal complication. The aim of the study was to determine the clinical features and adequacy of anticoagulation of pts with left-sided PVT. METHODS: We studied 97 consecutive pts with 112 PVT; 74 female and 23 male; mean age 51.5±9.6 years. Diagnosis of PVT were based on noninvasive techniques (auscultatory findings, fluoroscopy and/or Doppler echocardiography); cardiac catheterization was also performed in 35/97 pts. RESULTS: There were 97 pts with 112 PVT (106 mechanical and 6 bioprostheses); 48/112 mitral PVT, 42/112 aortic PVT and 11/112 mitroaortic PVT. The interval between implantation and PVT was 5.88±5.16 years. On admission, 85/97 pts were in heart failure (15/85 cardiogenic shock, 25/85 acute pulmonary edema and 45/85 congestive heart failure), 15/97 pts had angina and 16/97 pts experienced systemic embolization (11/16 cerebral, 3/16 peripheral, 2/16 coronary). In 32/97 pts, systemic embolism was also reported 2.66±2.5 years before PVT: 30/32 cerebral, 5/32 peripheral and 1/32 coronary artery embolism; 40.6% experienced recurrent episodes. Level of anticoagulation was judged to be inadequate in 52/73 pts with mechanical PVT (71.2%) in whom prothrombin time was available at the time of hospital admission. Fibrinolytic treatment was attempted in 13/97 pts (Oct-89 to March -93) and 84/97 were treated surgically: prosthetic thrombus was seen in 67/84 pts, and isolated prosthetic pannus in 17/84 pts. CONCLUSIONS: Overall hospital mortality of pts with left-sided PVT was 14%. In 80% of pts, PVT was due to a thrombotic occlusive mechanism. Anticoagulation was considered inadequate in 71%. Systemic embolisms were observed in 33% of pts before PVT (94% cerebral embolism); it should alert about the possibility of PVT in the future and surgical treatment should be always considered. Intensive Care Unit and *Cardiovascular Department, Fundacidn Jimenez Dfaz, 28040 Madrid, Spain.

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LOW CARDIAC OUTPUT SYNDROME (LOS) IN LISTED TRANSPLANT CANDIDATES (TC) : DECISION BETWEEN AN INTENSIFIED DRUGI THERAPY AND A LEFT VENTRICULAR ASSIST DEVICE (LAD) P -N Niederst , K.-P. Mellwig, H.K. Schmidt, U.Gleichmann, R.Korfer*

ACUTE AORTIC DISSECTION TYPE STANFORD A: INCIDENCE, DIAGNOSTIC PROCESS AND CLINICAL COURSE IN 1870 CONSECUTIVE PATIENTS OF AN INTENSIVE CARE UNIT

OBJECTIVES: An acute LOS may abruptly bring TC in a life-threatening hemodynamic situation. After managing the acute complications a decision must be made whether a LAD will be necessary or an intensified drug therapy is successful to obtain a subsequent discharge from the intensive care unit (ICU). DESIGN AND SUBJECTS: From 4/94 to 3/96 24 patients (PTS) (2 female, 22 male, mean age 53±9 years), waiting for heart transplantation (HTX), were admitted to our ICU with an acute LOS. We assessed retrospectively the hemodynamic data and the dose of catecholamines (CAT) and phosphodiesteraseinhibitor (PDT). METHODS : All PTS received a pulmonary artery catheter for continuous hemodynamic monitoring: cardiac index (CI) and systemic vascular resistance (SVR) were measured with the method of thermodilution; mean arterial pressure (MAP), pulmon-' ary artery mean pressure (PAPM) pulmonary capillary wedge pressure (PCWP) were registrated with the corresponding drug dose. RESULTS AND STATISTICAL ANALYSIS: In all 24 patients the acute LOS could be managed.: After 48h the CI rose from 1,8±0,3 to 2,6±0,5 Umin/m 2 , the PCWP declined from 29±6 to 1,8±7 mmHg and the SVR from 1510±430 to 1100±240 dynes s cm - ', by using 4,0±2,7 9g/kg/min dobutamine, 2,3±3,3 9g/kg/min dopamine and 3,6±2 µg/kg/min amrinone/enoximone. Despite of a high dose of CAT (7,3±4,6 tg/kg/min dobutamine and 7,3±4,6 9g/kg/min dopamine) and of PDI (6,8±3,2 µg/kg/min amrinone/enoximone) 12/24 patients suffered from therapyresistant LOS: CI 1,9±03 1/mm/m 2 , PCWP 26±4 mmHg, MAP 58±8 mmHg, SVR 1040+210 dynes s cm. LAD was implanted 27±13d after admission, HTX was performed within 57±47d in 10/12 PTS, 2/12 died before HTX. The other 12 PTS could be discharged after 23±20d, 8 PTS were transplanted within 69+60d, 3/12 are still waiting for HTX, I patient died . Before discharge from ICU we registrated a CI of 2,7±07 l/min/m 2 , a PCWP of 18+9 mmHg ,a MAP of 80±8 mmHg and a SVR of 1110±240 dynes s cm 5 ; a minority of PTS still needed Ito 2 pg/kg/min CATor PDI. CONCLUSION:The acute LOS could be initially managed in all 24 PTS with an adequate dosage of CAT and PDI according to continuously registrated hemodynamic parameter. If it was not possible to decrease the PCWP and to stabilize or increase the MAP (after normalizing of the SVR) despite of high drug dosage a LAD (12/24 PTS) was necessary. 50% of the PTS could be discharged and an elective HTX became possible.

U Janssens , J-G Ochs, HG Klues, P. Hanrath OBJECTIVES: Without treatment acute aortic dissection type Stanford A (AD type A) has a mortality of 50% within the first 48 hours. We assessed the incidence, diagnostic process and clinical course of AD type A in 1870 consecutive patients (pts) of an intensive care unit. DESIGN: Retrospective analysis. METHODS: The pts with AD type A were reviewed with regard to clinical features, time between onset of symptoms and exact diagnosis, diagnostic procedures and mortality. SUBJECTS: Consecutive sample of all patients with diagnosis of acute aortic dissection type A admitted to the intensive care unit between 1/94 and 3/95. RESULTS: 15/1870 pts (0.8%) had AD type A, (12 male, 3 female, age 31-70 [54.8 + 2.6]). Time from first onset of symptoms to final diagnosis ranged from 20 minutes - 20 days. Within 24 hours AD type A was diagnosed in 9/15 pts (early diagnosis [ED]), after 24 hours late diagnosis [LD])in 6/15 pts (7+2.7 days). Transesophageal echocardiography (TEE) showed AD type A in 15/15 pts. Additional transthoracic echocardiography (TTE) in 5/15 and computed tomography in 4/15 pts confirmed diagnosis of AD. Nuclear magnetic resonance tomography was not performed. After exact determination of type and extent of AD all pts were transferred as , soon as possible for immediate operation. 5/15 (33.3%) pts died, 2 pts just before, I during and 2 soon after surgical treatment (3 pts in the group with ED, 2 pts in the group with LD). CONCLUSION: TEE plays a pivotal role in diagnosing the type and extent of acute aortic dissection (specifity and sensivity 100%). ED within 24 hrs was established in only 60% of all pts, but delay in diagnosis did not result in an increasing mortality. Overall mortality was 33.3%. Medical Clinic 1, RWTH Aachen, Pauwelsstr.30, D-52057 Aachen, Germany

Kardiologische Klinik, *Klinik fiir Thorax- and Kardiovaskularchirurgie Herz- and Diabeteszentrum NRW, Universitatsklinik der Ruhr-Universitat Bochum, Georgstrale 11, 32545 Bad Oeynhausen, Germany

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Factors influencing the hemodynamics of heart donors. S. Di Bartolomeo, M. Bertolissi, G. Nardi, A. De Monte.

USEFUL OR USELESS: SEQUENTIAL LACTATE LEVELS FOLLOWING CORRECTION OF COMPLEX CONGENITAL HEART DISEASE. T Sajjanhar, SM Tibbv M Hatherill, D Anderson, IA Murdoch.

3JECTIVES:To assess the factors influencing the degree of hemodynam ipairment of the brain-dead cardiac donor(CD) patients. DESIG ttrospective study. MATH.AND METH.:From 1985 to 1995 at o stitution 53CD patients underwent brain death assessment.Tl - ocedure lasted 12 hours in 35 cases and 6 hours in 18 cases for ange occurring in the law. All patients were monitored with E.C.( vasive blood pressure (BP), central venous pressure (CVP), urina ttput,SPO2,EtCO2.An echocardiogram was performed by a cardiologi: e reviewed the charts and recorded every hour the above mentiom trameters together with the adrenergic drug dosage and the flu dance. We recorded also the demografic data, the cause of admission, ti me from admission to ICU to brain-death. The hemodynamic status w aded in 4 levels according to the following table. Then we compared t] groups for age (years),ICU lengbt of stay(hours), group of pathology A BPs>90mmHg in all recordings with no adrenergic drugs or dopamine at< 25/kg/min R idem with dopamine >2 and10y/k /min or another adrenergic drug added D BPs<90 mmttg in at least one recording (non traumatic nt, traumatic t, traumatic with thoracic trauma tt), mea CVP(mmHg), fluid balance (F.B. ml/kg/hour) and echocardiogram (norms n, abnormal an). We used the one way analysis of variance to compar numerical data and the chi square test for nominal data. The significanc level was 0.05. RESULTS (+sd) : table below. No differences were found AGE ICU stay PATHOL. CVP F.B. ECHO An=18 28 + 9 92 ± 95 9nt;6t;3tt 10.42 + 3.9 2.6 + 2.8 lln;6an Bn=25 30 + 13 127 + 237 lOnt;8t;7tt 10.03+3.7 3 + 2.3 17n;7an Cn=3 25 + 15 102 + 52 Int;2t 10.60±2.8 2.7 + 0.5 2n;lan Dn=7 28+10 1nt;2t;3tt 53±30 11.2+2.62 4+3.9 5n;2an among the groups. CONCLUSION : In brain dead CD patients the degree of hemodynamic instability and vasopressor needs cannot be anticipated on the basis of age, pathology, length of ICU stay and echocardiographic ardiac function and is not related to mean CVP and fluid administration. Department of ICU 2nd - S.Maria della Misericordia Hospital 33100 Udine - ITALY - Head Dr. F.Giordano.

Introduction. Recently, an initial serum lactate level of > 4.5 mmol/I in children following cardiopulmonary bypass, for complex congenital heart disease (CHD), was found to predict mortality'. We hypothesised that sequential measurement of lactate levels might be more informative. Patient & Methods. We examined serial lactate measurements in 80 children, median age 7 months (Interquartile range 0.42 - 32.5 months) admitted to the paediatric intensive care (PICU) following cardiac surgery for complex CHD. Initial lactate measurements were taken within 15 minutes of arrival in the PICU and subsequently 4-6 his and 12-18 hrs later. Outcome and length of stay (LOS) were recorded. Data were assumed non-parametric and analysed by repeated measures ANOVA and unpaired t-tests. Results. Data in the table are medians plus interquartile ranges. Lactate levels were significantly elevated initially (p< 0.009) and at 12-18 hrs (p< 0.04) in the non-survivors (NS). A significant fall in lactate levels, with time, was noted only in survivors (S: p < 0.001). Using an initial lactate level of> 4.5 mmol/I sensitivity and specificity for (NS) was 50% and 73%, respectively with a very low positive predictive va l ue for (NS) of 16.7%. 4-6 hrs

12-18 hrs

1.2

( 0.9, 2.0)

1.1 (0.8, 1.6)

4.5 (3.4,9.2)

1.9 (0.9,6.4)

1.6 (1.3,4.4)

0.009

0.32

0.04

Lactate (mmol/I)

Initial

Survivors (n=72)

2.2 (1.5, 4.6)

Non-Survivors (n=8)

p value

e ian LOS for(S)wa4 days.ChiId,in who staye longer than 4 days ha significantly raised initial median lactate levels (4.63 vs 1.86: p< 0.0001). Conclusion. Measurement of an initial serum lactate level following surgery for CHD may usefully predict LOS but is of little positive predictive value for PICU mortality. Sequential lactate measurements do not improve prediction. References. 1) Siegal LB, et al: Crit Care Med 1995; 23:( Suppl 1) A205. Paediatric Intensive Care Unit, Guy's Hospital, London. SE 1 9RT.

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THE DIAGNOSTIC VALUE OF TRANSESOPIIAGEAL ECHOCARIIOGRAPHY IN PATIENTS WITH MASSIVE PULMONARY EMBOLISM AND SHOCK

ENDOCARDITIS - AN OFTEN UNDERESTIMATED PROBLEM IN INTENSIVE CARE UNITS T Welte I , J Molting', MS Jepsen 2 , G Claus', H Klein'

B. Krivec. G. Voga, I. Zurat1, k Skale, R. Pare2nik, M. Podbregar OBJECTIVES: To determine the incidence of central thrombemboli and applicability of transesophageal echocardiography (TEE) in selected patients with massive pulmonary embolism (MPE) and circulatory shock. DESIGN: Open, uncontrolled study in the setting of intensive care unit. SUBJECTS: 13 consecutive patients with clinically suspected MPE and circulatory shock with high central venous pressure. METHODS: TEE was performed as an initial diagnostic method. Pulmonary scintigraphy was designed as next diagnostic method in case of negative finding for central thrombemboli. Thermodilution pulmonary catheter was inserted in 12/13 patients. RESULTS: 1 patient died before the diagnostic evaluation was completed. In others circulatory shock was confirmed (systolic artery pressure less than 90 mm Hg, cardiac index 1,8 +/- 0,5 litre/min/m 2 , mean pulmonary artery pressure 42 mmHg +/- 9,9mmHg, central venous pressure 16,2 +/- 4,9 nunHg, serum lactate 7,3 +/- 5,6 mmol/litre). Central thrombemboli were demonstrated in the right pulmonary artery in 12 patients_ Mobile, hypoechogenic masses (4pts.) or immobile and hyperechogenic structures (7 pts.), or both (lpt.) were differentiated. 1 patient without central thrombemboli exhibited diminished echographic contrast flow in right pulmonary artery. Extensive right - sided perfusion defects were found by pulmonary scintigraphy. Additional findings such as spontaneous contrast in right atrium, ventricle or pulmonary artery and intracardiac thrombi were also demonstrated. CONCLUSION: There seems lobe high incidence of central thrombemboli in patients with massive pulmonary embolism and shock. For them, TEE constitutes a rapid, safe and effective diagnostic tool. Department for Intensive Internal Medicine, General Hospital Celje, Oblakova 5, 3000 Ce1je, Slovenia

OBJECTIVES: Diagnosis of acute endocarditis is often missed, early diagnosis and correct treatment, however, are necessary to prevent fatal clinical outcome. We report upon the incidence of endocarditis in the coronary and surgery ICU of our hospital within a period of 8 months. Among 1111 patients (pts) treated within this time frame 26 pts (2.3%) had acute endocarditis. Only 13 (50%) pts, however, came with a correct diagnosis. The remainder 50% were diagnosed as sepsis or septic shock. Initial clinical symptoms in all pts were fever without other signs of infection and a new heart murmur. The correct diagnosis was achieved by transesophageal echocardiography (TEE). Nine pus had mitral valve endocarditis (mve), 7 pts aortic valve endocarditis (ave), 2 pts tricuspid valve endocarditis (tve), 2 pts mve and ave and one pt the and ave, one pt mve and septic ventricular septal defect, 4 pus had the and infection of the pacemaker system in addition with either mve (2 pt) or ave (1 pt). RESULTS: All pts where treated with the intention to abolish the infection by sufficient antibiotic therapy prior to valve replacement. In 6 pts valve replacement was unnecessary due to successful antibiotic regime whereas 7 pus needed valve replacement and left the hospital symptome free. In three cases continous preoperative antibiotic treatment is still necessary whereas in one pt there was reentrance of endocarditis of the replaced aortic valve. Eight pts were inoperable due to concomittant other clinical problems like liver cirrhosis, stroke or both. Five of the 8 inoperable pts died within 3 weeks after confirmation of acute endocarditis and 3 pts continue to have severe valve insufficiency. One pt died intraoperatively. CONCLUSION: Endocarditis is a not rarely occuring and often missed diagnosis and goes along with major complications during intensive care treatment. On the contrary early and correct diagnosis can be achieved by TEE and microbiological techniques. Need for valve replacement is unpredictable in the early course of endocarditis and is mainly determined by successful antibiotic treatment. Early TEE in pts with fever of unknown origin is mandatory in order to assess endocarditis. Division of Cardiology and Pneumology t and Division of Cardiothoracic surgery 2 , Otto-von-Guericke-University Magdeburg, D-39120 Magdeburg, Leipziger Str. 44, Germany

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CARDIAC TROPONIN I DOES NOT INCREASE AFTER CARDIOVERSION

LEFT VENTRICULAR DIASTOLIC FUNCTION DURING ASSISTED VENTILATION IN COPD PATIENT.

E Bonnefov. P Chevalier, G Kirkorian, J Guidolet, A marchand, D Bouchayer, PBertMarcaz, P Touboul.

G Cionella, M Dambrosio, N DiVenere*, N Brienza, M Conte, S M Maggiore, A M Leone, A Brienza.

OBJECTIVES : To assess cardiac damage after cardioversion, we used cardiac Troponin I (cTnl), a new highly specific cardiac biological marker. It is highly effective to discriminate myocardial and muscular injuries. PATIENTS : 28 patients (8 women, 20 men, n .sn age 64j1Oyears) with elective cardioversion of supraventricular tachycardia. METHODS : All the patients gave their informed consent We measured serum cTnI, myoglobin, total CK, CkMB mass, 1 hOO, 2H00, 3h00, 4h00, 8h00, 12h00 and 24h00 after cardioversion. Serum cTnI was measured using a sandwich immunoenzymologic assay. RESULTS : Cumulative energy was below 370 joules (J) in 17 pts, between 370 and 900 J in 8 pts and 1020 J in 3 pts. In all but 3 patients cTnl remained below 0,3 NG/ml which is the detection limit of the assay. In these 3 patients, cTnl ranged between 0.3 and 0.9 NG/mi which remains within the normal range (0.3-1 NG/ml). There was no correlation between cTnl and number of cardioversion, neither between cTnl and energy of cardioversion. Myoglobin and CK increased to abnormal levels in 11 patients and reached myocardial infarction like values in 5 patients. CKMB increased to modest levels with CK and myoglobin. There was a close relation between the increase of CK and myoglobin, and the number of shocks and the total energy delivered. CONCLUSION : Cardioversion in clinical setting does not induce elevation of cTnl. Increase in CK, CKMB and myoglobin may be solely due to muscular lesions and is closely related to the cumulative energy delivered.

Normal LV diastolic function is expressed by an E/A ratio >1. All four patients showed a LV diastolic dysfu fiction, that was more evident during the f-tube step (20% reduction of E/A compaied to PS PEEP). Moreover, in T-tube an increase in HR and LV preload was observed. Thus, in COPD patients with PF.EPi in increase in LVp associated with a worsening of IV diastolic function might jccui during Ttube spontaneous breathing, contributing to weaning impairment.

Intensive Care Unit, Hbpital Cardiologique, Lyon 69000, France.

*Institute of Cardiology, Policlinico, Bari, Italy

Several studies have suggested that influences of lung mechanics on cardiac function can impair weaning from mechanical ventilation in COID patients who meet standard weaning criteria. Left ventricular (LV) preload (LVp) and diastolic function were studied by transthoracic bidimensional Doppler-echocardiography during three ventilatory steps applied in random order in four preliminary COPD patients: a) T-tube trial; b) pressure support (PS) set in order to obtain a Tidal Volume (TV) of 8-10 ml/Kg bw; c) same level of PS plus a PEEP level equal to 80% of flow-limited intrinsic PEEP (PEEPi). LVp was assessed bN measuring the transmitral flow and the diamter of the mitral orifice; LV diastolic function was evaluated by the ratio between early filling (E) and late filling (A) peak velocities, normalized for heart rate (lilt) T-Tubc TV (ml) 207± 134 RR (b/min) 23±9 TVITi 69.6+38.3 HR (b/min) 98,20 LVp(1/min) 15.7+4.4 E/A 0.70-1)14 Data arc presented as mean ±SD.

PS 305±111 20±10 430.6±116.4 77*13 9.74_3 0,81_0,04

PS+PEEP 277,±.70 21=5 321.2171.1 79±16 9.47.±3 0,89^0,0t

Intensive Care Unit, Policlinico, Bari, 70124 Piazza G Cesare, Iraly

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MYOCARDIAL STUNNING IN CARBON MONOXIDE POISONING K Vandewoude, J. Poelaert, D. Vogelaers, R. Blanca Garcia, W. Buylaert, C. Roosens, F. Colardyn.

Insertion of Automatic Implantable Cardioverters-Defibrilators and postoperative Cardiac Function.

Objective and Methods: Myocardial stunning is defined as fully reversible temporary regional or global contractile dysfunction, after a short episode of ischemia or hypoxia, without myocardial necrosis. We studied hemodynamic (cardiac index - Cl) and ultrasonographic parameters for left ventricular (LV) diastolic (IVRT = isovolumetric relaxation time, E/A = early versus atrial component of diastolic filling) and systolic (ejection fraction = EF) function, in patients (pts) following carbon monoxide (CO) poisoning complicated by cardiogenic shock. Results: Hemodynamic and ultrasonographic data upon admission (t 1 ) and 48-72 hrs later (t 2 ) are summarized for 4 patients (pts) without previous ischemic heart disease. All pts were treated by mechanical ventilation and early hvoerbaric oxvaen theraDv (HBO). (19y) HC (24y) LS (48y) Pt. (56y) CE WL t1 t2 t2 t1 t2 t1 t1 t2 62% 21.4% 47.5% COHb 51% 3.0 4.9 3.1 2.8 4.7 3.3 Cl 11 13 6 0 15 15 PCW 24.0 15.7 15.9 19.1 13.3 13.4 17.6 LVEDA 17.9 12.4 10.9 6.5 9.9 13.8 10.4 3.2 LVESA 12.2 0.18 0.59 0.48 0.48 0.21 0.33 0.46 0.76 EF 80 165 65 95 60 90 90 IVRT 80 1.27 1.1 1.25 1.27 0.71 3.86 .96 E/A 0.90 0 0 0 0 0 5 0 DOBU 15 0 0 0 0 300 160 ADR 0 0 CUHB = carboxyhemoglobin (7o); UI (Umm. ml); -'UW = pulmonary capillary wedge pressure (mm Hg); LVEDA/ESA = LV end-diastolic/-systolic area; DOBU - dobutamine (µg/kg.min);ADR = adrenaline (ng/kg.min). Myocardial necrosis was excluded by serial enzyme assay, ECG and absence of regional hypo- or akinesia on late echocardiography. Conclusion: In spite of early reoxygenation, severe but reversible systolic and diastolic LV dysfunction was documented, indicating stunning in severe CO poisoning.

Objectives: Insertion of Automatic Implantable CardiovertersDefibrilators(AICD) necessitates multiple inductions of ventricular fibrillation (VF) and multiple defibrilations during intraoperative testing of the device. VF and DC coutershock are both known to induce cardiomyocyte dysfunction. We postulated the operation would after cardiac function. Design: Prospective, non randomized, non blinded. Subjects: 15 consecutive patients undergoing insertion of AICD. Methods: General anesthesia was standardized (high dose opioid). The Defibrilation electrodes were all intravascular. No patient required a thoracotomy for insertion of an epicardial electrode. We recorded before the operation: the left ventricular ejection fraction, the preoperative haemodynamic values as measured after induction of anaesthesia with a hermodilution pulmonary artery catheter. We recorded during the operation and testing of the device: the total duration of VF, the total number of joules imposed on the heart during defibrilations. We recorded during the first postoperative day: the values of cardiac enzymes (plasma CPK-MB), the haemodynamic values, the incidence of low cardiac output and the necessity for inotropic support. We evaluated whether the postoperative cardiac status could be correlated to intraoperative fibrillation/defibrillation or whether it was correlated to preoperative cardiac status. Results :Total duration of VF varied from 41 to 244 seconds. Total imposed joules varied from 45 to 329 J. There was no correlation between fibrillation/defibrillation and postoperative CPK-MB values. There was no correlation between fibrillation/defibrillation and postoperative haemodynamic values, incidence of low cardiac output or necessity of inotropes. No single preoperative test was an good independent predictor of adverse postoperative cardiac events. By discriminant analysis the preoperative pulmonary wedge pressure, mean pulmonary artery pressure, heart rate and low ejection fraction (<0.35), when combined, did predict the necessity for postoperative use of inotropes (p=0.035) Conclusion: AICD insertion in itself seems inocuous with respect to postoperative cardiac function. Postoperative cardiac dysfunction can be correlated to preoperative cardiac status.

Depts. of Intensive Care and of Emergency Medicine, University Hospital Gent, De Pintelaan 185, 9000 GENT - BELGIUM

Department of Anaesthesiology, Brugmann Hospital, 4 PI Van Gehuchten, 1020 Brussels,Belgium

M Mattvs, L Dumont, JF Annaert, C Mardirosoff, J Goldstein, T Verbeet, J

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A PLACEBO-CONTROLLED, RANDOMIZED, DOUBLE-BLIND STUDY OF INTRAVENOUS ENALAPRILAT EFFICACY AND SAFETY IN ACUTE CARDIOGENIC PULMONARY EDEMA D. Annane, E. B811issant, E. Pussard, R. Asmar, F. Lacombe, E. Lanata, O. Madonna, M. Safar, J.F. Giudicelli, J.C. Raphael, Ph. Gajdos.

ADENOSINE FOR DIFFERENTIAL DIAGNOSIS OF TACHYARRHYTHMIAS IN THE EARLY POST OPERATIVE PERIOD

BACKGROUND AND OBJECTIVE: Converting enzyme inhibitors meet most of the criteria required to be used in acute pulmonary edema (APE). However, they could also induce deleterious effects on renal function and electrolytes. The purpose of the study was to evaluate the efficacy and safety of a single intravenous 2h-infusion of enalaprilat (1 mg) after an APE. METHODS AND RESULTS: This was a placebo-controlled, randomized and double-blind study performed in 20 congestive heart failure (III-IV NYHA) patients. Systemic and regional hemodynamic parameters, biological parameters and blood gases were measured before and repeatedly after the onset of infusion. As compared to placebo, enalaprilat decreased pulmonary capillary wedge pressure (37 vs -10%, p=0.001), diastolic and mean systemic (-21 vs 0%, p=0.009 -18 vs -1%, p=0.026) and pulmonary (-21 vs -8%, p=0.040 ; -18 vs -9%, p=0.046) blood pressures, brachial and renal resistances (-44 vs -14%, p=0.017 ; -22 vs -2%, p=0.0I4), increased brachial and renal blood flows (+77 vs +8%, p=0.036 ; +12 vs 0%, p=0.043), arterial oxygen tension (+2 vs -16%, p=0.041) and saturation (+1 vs -2%, p=O.045) and fmally tended to decrease rate pressure product (-19 vs -7%, p=0.076), to increase brachial artery diameter (+13 vs 0%, p=0.081) and to improve intrapulmonary shunt (-18 vs +16%, p=0.080). Enalaprilat did not affect cardiac output, and carotid and hepato-splanchnic hemodynamics. CONCLUSIONS: Early administration of enalaprilat is effective and well-tolerated in APE. Service de R6animation M6dicale (Universite Paris V), Hopital Raymond Poincare, 104 boulevard Raymond Poincare, 92380 Garches cedex, France.

N.A.Haas, F. Uhlemann, I. Daehnert, F. Berger, B. Stiller, S. Dittrich, I. Schulze-Neick, P. Ewert, P.E. Lange OBJECTIVES: After surgical correction of congenital heart defects tachyarrhythmias might compromise the hemodynamic function in the instable patients. We evaluated the short acting Adenosine for its diagnostic use to distinguish between different forms of tachyarrhythmias. METHODS: During January 1995 and December 1995 we used Adenosine as drug of first choice in patients with tachyarrhythmias whose cause could not be differentiated by routine 12 leads electrocardiogram. In 45 patients Adenosine was given 70 times intravenously in a dose of 0,05 up to 0,2 mg/kgbw. RESULTS: We detected atrial tachycardia of diffemt origin and were able to classify the specific arrythmia in all the patients Atrial flutter was pesent in 17 episodes, ectopic atrial tachycardia in 8, preexcitation syndromes in 11, AV-nodal tachycardia in 21 patients, sinus tachycardia in 12 and finally atrial fibrillation in 1 patient. During administration of Adenosine, no severe adverse hemodynamic effects were observed. CONCLUSIONS: Adenosine proved to be a very helpful tool in the differential diagnosis of tachyarrhythmias in the early postoperative period. Therefore we believe that Adenosine can be recommended as drug of first choice in all tachyar hythmic patients where the diagnosis of the underlying arrhythmia is unclear. Department of Congenital Heart Defects, German Heart Center, Augustenburger Platz 1, 13353 Berlin, Germany.

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HEMODYNAMIC CHANGES AFTER TRANSPORT FROM OPERATION THEATRE TO POSTOPERATIVE CARE AFTER CARDIAC SURGERY. CJM. Langenbere H. Pietersen, G Geskes, A Wagenmakers., P Soeters. University Hospital Maastricht, P. Debeyelaan 25, 6202 AZ, 'l'he Netherlands OBJECTIVES : To study coronary sinus flow in relation to perioperative hemodynamic changes in patients undergoing a coronary artery bypass graft operation ( CABG)DESIGN: prospective descriptive perioperative study in CABG patients, in a university hospital. SUBJECTS: n= 18 CABG patients, NY! IA Ill-IV, two and three vessel disease, ventricular ejection fraction 50%. METHODS: Standard premedication, anesthesia and extra corporal circulation with moderate hypothennia. After induction of anesthesia a Swan Ganz and coronary sinus catheters were inserted. No inotropic drugs were used. Measurements : before incision (TI), after removal of aortic clamp (X-oll) 20 min. (T2), 50 min. (T3), 2 hours (T4),), 6 hours ('15). Pressure measurements were performed with the pressure modules at zero level 5 cm below midsternal reference point. RESULTS AN!) S'I'A'11STICAI, ANALYSIS; values : mean ± sem

RELATIONSHIP OF ANTICOAGULATION LEVEL AND INCIDENCE OF RESTENOSIS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION UNDERGOING PRIMARY PTCA M Kunert, H Stolzenburg, L Scheuble, K Emmerich, LJ Ulbricht, I Krakau, H GOlker

'I'!

PCWP

I beJi re incision 9,8 _ 1

Sc.Flow

SIR! ...

....

E_ C1

--

12,9 f .... 1,1 ^...112 ........ 1 12_......... 2582r222 2,26i 0,17 . ... _...... `- ...... _...........

2 20min..F-OF)+9,9}0,6 13 t 0,7

145 1 10: 15741-94 t 3,121 0,16

3 ; 50"x-OFF

*11,7 , l l &14,6-1- 0,4 #154.............. + 1.i, 17931/26 .......i 82,761 ......- 0,1

4 2/ix-OFF

5,7= 0,6 : 8,5 t 0,5

--

5 6 h x-OFh ..... ; _ 6,4 0,5 8,6 1 0, 7

--

-

_ --

1281 13' 22611148 2,31 -;_...... 0,12 .. 1461 11 1898,112 ; 2,96w 0,2

Statistical analysis : W i lcoxon-Mann whitney for paired samples.* l'3-T44 p <(),03,& T3 vs 14 p
OBJECTIVES: To examine the degree of heparinanticoagulation level during primary percutaneous coronary angioplasty (PICA) and its effect on the incidence of restenosis after primary PICA for acute myocardial infarction. BACKGROUND: Supposed antiproliferative heparin effects. DESIGN: a retrospective clinical study. SUBJECTS & METHODS: 45 patients with acute myocardial infarction (34 m_,11 f.,61±11y.) were divided in two groups according to their heparin-anticoagulation level (aPTT,PT, Behring,FRG ;HR-ACT,HemoTec,Medtronic,FRG) during primary PICA: group I with high anticoagulation level (ACT>350 sec_), group II with low anticoagulation level (ACT<300 sec.). The incidence of restenosis (NHLBI IV) was, obtained angiographically 3 months after primary PTCA. RESULTS (mean values ± 1 SEM) ACT aPTT PT Restenosis (sec.) (sec_) (%) (%) group I 397 >180 12 29,6 ± 6 (n=27) ±95 (8/27) group II 272 >180 25 30,0 (n=18) ±31 ±15 (6/18) <0,05 p-value <0,05 n_s. CONCLUSION: There is no relationship between degree of heparin-anticoagulation level during primary PICA and the incidence of restenosis 3 months after PICA. Med.Clinic B (Cardiology) Heart Centre

Wuppertal University Witten-Hmrdwcke, FP(_

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EFFECTS OF VASODILATORS ON PULMONARY VASCULAR IMPEDANCE AFTER OCCLUSION OF THE MAIN RIGHT PULMONARY ARTERY IN DOGS M. Maggiorini , S. Brimioulle, P. Lejeune, M. Delcroix, F. Vermeulen, J. Stephanazzi, R. Naeije

DEVELOPMENT OF LEFT VENTRICULAR FUNCTION 3 MONTHS AFTER PRIMARY PTCA FOR ACUTE MYOCARDIAL INFARCTION M Kunert, H Stolzenburg, L Scheuble, K Emmerich, LJ Ulbricht, I Krakau, H Gulker

Objectives: Acute occlusion of the main left or right pulmonary artery

OBJECTIVES: to assess changes of global and regional left ventricular function in myocardial infarction treated by primary PICA. SUBJECTS & METHODS: In 40 patients with acute myocardial infarction (30 m_,10 f.,60±1Oy.) and successful primary PICA (TIMI flow III) left ventricular function was measured angiographically using biplane ejection fraction (EF) and regional wall motion (RWM) before primary PICA (EF-1,RWM-1) and after 3 months (EF-2,RWM-2). Regional left ventricular function analysis included assessment of regional wall motion in the infarct-area (RWMMI)and non-infarcted-area (RWM-N-AMI) according to the infarct related artery (RCA,LAD). RESULTS (mean values ± 1 SEM) (%) EF-1 EF-2 RWM-1 RWM-2 RWM-1 RWM-2 (AMI) (AMI) (N-AMI) (N-AMI) Ant_ 53 59 24 35 33 37 MI ±17 ±19 ±14 ±14 ±15 ±13 [LAD (n=15),Restenosis = 33% (5/15)] Inf. 65 64 30 42 40 29 MI ± 9 ±10 ±13 ± 8 ±11 ±12 [RCA (n=25),Restenosis = 24% (6/25)] Striking improvement of global left ventricular function after anterior MI is mainly result of improved regional function in the infarct-area after PTCA. Unaltered EF after inferior MI can be explained by initial anterior hyperkinesis or right ventricular infarction.

during thorax surgery loads the right ventricle abruptly. We investigated the effects of sodium-nitroprusside (SNP) and prostaglandine El (PGE1) on pulmonary vascular impedance (PVZ) after occlusion of the main right pulmonary artery (r-Pa) in dogs. Methods: PVZ spectra were obtained in 9 anesthetized and ventilated (Fi02 0.4) dogs. After baseline measurements the r-Pa was occluded using the balloon of a Swan-Ganz catheter positioned for this purpose in the r-Pa. After occlusion, effects of SNP and PGEI on PVZ were studied. The dosage of both vasodilators was adjusted to reduce mean systemic arterial pressure by 20%. Results: Flow (Q) matched PVZ data (mean±SEM) are shown in the tabl e. Q (l.min - l.m 2 ) Ppa(mmHg)

r-Pa occluded Baseline Occlusion SNP PGE1

2.7±0.1 13±1

Zo (dyn.sec.cm -5 ) 402±25 83±8 Zl (dyn.sec.cm -5 ) 71±9 Zc (dyn.sec.cm - s) Wt (mW) 111±6

Wosc%

29±3

2.7±0.1 18±1 *

558±34 * 141±10 * 115±15 * 164±7*

33±3

2.7±0.1 17±1*

2.8±0.1 17±1*

32±3

35±3 *

523±35 * 520±34 * 115±9 *f 131±9 * 113±12 * 121±12 * 151±8* 177±17 *

[Z o = 0 Hz impedance {Z); ZI = first harmonic Z; Zr = characteristic Z; Wtot ='total hydraulic work; Wosc% = Oscillatory work in % of the Wt; * p at least <0.05

compared to baseline; f <0.05 iNo and SNP vs. embolism]. Conclusions: Lower low-frequency impedance during SNP-infusion and

a higher proportion of power wasted in oscillations during PGE1-infusion at the same pressure and flow suggest that intravenous nitric oxide donors decrease hydraulic load to the right ventricle after acute occlusion of the main right pulmonary artery more efficiently. Laboratory of Cardiovascular and Respiratory Physiology, Erasme University Hospital, B-1070 Brussels, Belgium

Med.Clinic B (Cardiology) Heart Centre Wuppertal, University Witten-Herdecke, FRG

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ALTERATIONS IN HAEMODYNAMIC AND ACID-BASE BALANCE SEEN WITH ETHOMIDATE, PROPOFOL AND MIDAZOLAM IN ELECTIVE CARDIO VERSION. MJ Broch , V Valentin, B Murcia, E Bartual, A Malaga, LL Miralles, F Valls.

A NEW INFUSION REGIME FOR THE ULTRA SHORT-ACTING BETA-BLOCKING AGENT ESMOLOL IN CRITICAL CARE PATIENTS HG Stuehlinger. D Seidler, U Hollenstein', K Janata, M Muellner, W Loeffler, G Gamper, A Bur, R Malzer, AN Laggner. Dept. of Emergency Medicine, 'Department of Internal Medicine I, University of Vienna, Vienna, Austria

OBJECTIVES: Propofol (P) and Midazolam (M) are widely used in Elective Cardioversion (EC), although they are know to produce hypotension with sometimes may be severe and damaging. Other drugs, such as Ethomidate (E), which do not cause this are also available. Our hypothesis for this study was that P and M cause at least a 15% reduction in the systolic blood pressure (SBP) as compared to E (a=0.05 and 6 0.80), and have no advantages over the latter. MATERIAL AND METHODS: A prospective, randomized, single blind study was made of 38 consecutive patients with drug resistant supraventricular tachyarrhythmias, who were suitable for EC. E, P and M were used as sedatives. The dosage given was: E (0.2 mg/Kg), P (1 mg/Kg) and M (0.05 mg/Kg). The intravenous route of administration was used. Initially 50% of the calculated dose was given, followed by boluses of 25% at 60 second intervals, until the patient showed spontaneous lid drop and no longer responded to verbal commands. There was continuous monitoring of BP, heart rate (HR), and respiratory rate (RR). An ECG and routine laboratory tests were done at the start of the procedure. BP, HR, RR and arterial blood gases (pH, paCO2, paO2, HCO3) were determined at their basal level, post-induction, postcardioversion, on waking, and 30- 60 minutes later. The ANOVA test was used for overall comparison of the groups. When the result was positive, the StudentNewman-Keuls test for paired groups with a significance level <0.05 was done. RESULTS: There were 13 patients in group E, 13 in P and 12 in M. There were no significant differences in the basal state of the different groups. 1°.Post-induction: there was a significant fall in SBP (as %): E=0.3 as compared with P=22 and M=15; diastolic BP (%): E=2 vs P=17, M=4 vs P=17; mean BP (%): E=3 vs P=18. 2°.The fall in SBP was still significant on wakening and 30 minutes later. 3°.There were no significant differences between the three groups with respect to HR, RR, Pa02 or acid-base balance, although there was a slight drop in paO2 in group E. 4°.The time taken for induction (minutes) was: E=4 vs M=14 (p<0.05), P=6 vs M=14 (p<0.05). 5°.The time taken to waken (minutes) was: E=18 vs M=54 (p<0.05), P=17 vs M=54 (p<0.05). 6°. The commonest complication seen was transient shivering and myoclonus in group E, but this was slight and not statistically significant. 7°.Amnesia was partial in 9% of patients, all of whom had received P. CONCLUSIONS: By contrast with the significant fall in BP seen in groups P and M, in group E this parameter was unchanged, and in this group induction and waking times were less. Since the transient complications seen are minor and uncommon, and E also gives the best cost-benefit ratio, this may be the drug of choice for EC. Intensive Care Unit,Dr.Peset Hospital, Av.Gaspar Aguilar 90,46017 Valencia, Spain

In this study we have evaluated our new bolus /infusion regimen for esmolol, an ultra short-acting B-blocker. Because of the wide array of side effects of Bblockers ( bradycardia, hypotension, acute left heart failure and cardiogenic shock) a mode of application allowing fast reaction to the patient's clinical course is crucial. With most 8- blockers currently available for intravenous use patients' heart rate can either not be reduced efficiently or undesired bradycardia or hypotesion occurs. Because of its pharmacological properties esmolol is the 8- blocker of choice in the critical care setting. However, there are numerous reports of severe adverse effects, probably caused by inappropriate dosage and administration. The aim of our study was to show that esmolol can be administered safely. We administered esmolol to 81 patients with acute MCI: a bolus of 100 mg, injected over 5 minutes, followed by a continous infusion via infusion pump at an initial rate of 200 mg/h (4 ml/h). According to clinical necessity the dose was increased in 4 ml steps until a target heart rate of 65/min was reached and maintained. In 39 patients (48%) this heart rate could be achieved fast and maintained over a period of 12-24 It without difficulty. In 7 patients (9%) the study maximum dose of 1000 mg/h did not lower the heart rate to 65/min. 13 patients (16%) had to be taken off the 13-blocker therapy because of bradycardia, hypotension and left heart failure. In all of these patients side effects subsided within 8±3 minutes after cessation of the infusion. In 22 patients (27%) the target heart rate was not reached partly due to errors of esmolol administration. We conclude that in the critical care patient esmolol as used in our bolus/infusion regimen is a fast acting and easily managable drug because of pharmacokinetic characteristics. As opposed to many reports in the literatur no severe side effects occured. All documented episodes of bradycardia and hypotension could be corrected within minutes. Emergency Department, University of Vienna 1090 Vienna, Waehringer Giirtel 18 -20, Austria

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INDICATOR-DILUTION USING HEAVY WATER AND ICG FOR THE ESTIMATION OF LUNGWATER IN CARDIAC SURGICAL PATIENTS

EFFICACY AND SAFETY OF NITROPRUSSIDE AND URAPIDIL IN HYPERTENSIVE EMERGENCIES MM Hirschl , M Binder, H Herkner, A Bur, AN Laggner

CJ Wallin, B Sideno, J Vaage, LG Leksell OBJECTIVES: To estimate lungwater (LW), central bloodvolume (CBV) and cardiac output (CO) in connection to coronary artery bypass grafting (CABG). DESIGN: Prospective, bedside, clinical study. SUBJECTS: The study was approved by the Ethical Committee of the Karolinska Hospital and approved consent was obtained from the patients. Six male patients ( mean age 71, range 65 to 79) scheduled for CABG surgery were studied. METHODS: Fentanyl (4 - 10 ug/kg) and thiopental (1-2 mg/kg) were used for the induction of anaesthesia while additional fentanyl in combination with isoflurane were used for the maintenance of anaesthesia. Before induction of anaesthesia a radial arte line was introduced while after induction a central venous line was introduced into the right internal jugular vein. The oxygenator was primed with 2100 mL of crystalloid, bloodcardioplegia was used. The previously described optical double indicatordilution equipment (QDOT Inc, Flourtown, PA, USA) connected to an IBM PC) using heavy water and indocyaninegreen as indicators was used (1). The indicatorsolution was made of 0.25 mL/mL of 2 H 2 O, 0.75 mL/mL of H 2 O and ICG 4.17 mg/mL. At each data collection period a 5 mL bolus injection of the indicatorsolution was administered via the central venous line, while blood drawn from the radial artery (32 mL/min) was simultaneously passing the optical cell of the indicatordilution equipment. Values for CO, CBV and LW were presented on the video of the PC within 75 s. Data was collected at points (Dcp) after induction of anaesthesia (I), at admittance to the recovery room on mechanical ventilation (II), after four hours of mechanical ventilation (III) and awake the following morning (IV). RESULTS AND STATISTICAL ANALYSES: Cardiac index (CI), CBV index (CBVI) and LW index (LWI) are presented in the table as mean ± SD. Cl mL/kg CBVI mL/kg WI mL/kg Dcp I 1.75 1 0.23 22.41 4.9 351 0.35 DcpII 1.5410.19 17.2±5.3 03±0.6 Dcp III 2.0710.31 22.218.0 6±0.42 Dcp IV 2.04±0.28 19.613.6 : 3.23 ±0.38 CONCLUSION: It is commonly believed that cardiac surgery with cardioplegia and the use of crystalloid priming of the oxygenator will augment LW. This was not confirmed in the present pilot study were an optical doubleindicator dilution method was used. 1. Wallin CJ, Leksell LG. J Appl Physiol (1994) 76(5):1868-1875

OBJECTIVES: To compare efficacy and safety of urapidil and sodium nitroprusside in patients with hypertensive emergencies. DESIGN: randomized, prospective clinical study. SUBJECTS: 60 patients with hypertensive emergencies, i.e. systolic blood pressure (SBP)>200 mmHg and/or diastolic blood pressure (DBP) > 110 mmHg and evidence of end-organ damage were included. METHODS: After a resting period of 15 minutes patients were randomized either to urapidil (URA) or sodium nitroprusside (NTP) treatment. URA (n=35) was administered as intravenous bolus (12.5 mg) every 15 minutes until response to treatment or a maximum total dosage of 75 mg. NTP (n=25) was started at a rate of 0.5 µg/kg/min and increased in increments of 0.5 pg/kg/min until response to treatment or a maximum infusion rate of4 µg/kg/min. Primary response to treatment was defined as SBP reduction below 180 mmHg and DBP reduction below 95 mmHg within 90 minutes after start of treatment. In the group of responders blood pressure was evaluated until 240 minutes after start of treatment. In these patients NTP infusion was maintained for 30 minutes and then tapered down by I pg/kg/min every 10 minutes until cessation of infusion. Recent elevation of SBP above 185 mmHg and/or DBP above 100 mmHg during the next 150 minutes was considered as secondary therapeutic failure. RESULTS: Primary response was achieved by 82%(URA) and 100% (NTP) of all patients. Secondary therapeutic failure was observed in 20% (NTP) and 3% (URA) of all patients. Thus, overall response 240 minutes after start of treatment was similiar for both drugs (URA: 80%: NTP: 74%; p=0.51). Reduction of SBP and DBP was more pronounced in patients receiving nitroprusside compared to those treated with urapidil (SBP: -55 mmHg vs. -48 mmHg; p<0.05; DBP: - 29 mmHg vs. -22 mmHg; p<0.05). Side effects were significantly more often in the NTP group than in the URA group (23% vs. 9%; p=0.03). CONCLUSION: Both drugs are equally effective in the treatment of hypertensive emergencies. However, due to the lower frequency of side effects urapidil may represent a reasonable alternative to nitroprusside. Department of Emergency Medicine,Wdhringer Gurtel 18-20 A-1090 Vienna, Austria

S 287

561

599

IMPROVEMENT OF VENTRICULAR FUNCTION AND GASTRIC TONOMETRY IN SURVIVORS DURING EARLY SEPSIS. F Turani , C Ceraso , A Lironcurti , P Senesi , C Leonardis, AF Sabato

EFFECTS OF CONTINUOUS POSITIVE AIRWAY PRESSURE ON SYSTOLIC AND DIASTOLIC LEFT VENTRICULAR FUNCTION IN PATIENTS WITH LEFT VENTRICULAR FAILURE A Rovira. L Oussedlk, C Carnbray, C Gimeno, M Cerdd

OBJECTIVES:Depressiou of myocardial function is well described in septic shock , but only a few clinical studies correlate haemodynamic and metabolic data in early sepsis. Aim of this study is to evaluate the relationship betwween improvement in myocardial function and metabolic data in survivors from sepsis. METHODS: The study included 20 patients with sepsis as defined by Bone criteria. Each patient was monitored with a volumetric Swan Ganz catheter ( Swan Ganz Tbermodiluition Eiecton Fraction \ volumetric catheter model 93 A-431 H-7.5 f) and an arterial catheter.Gastric touometry ( phi) was studied by a nasogastric tonometer ( Tonometric Inc , Bethesda, Md) Hemodynamic,oxygen derived variables ,plasma lactate , phi were obtained at the time of study admission (TO) and after 12 (T 1) , 24 hours (T 2) and 36 hours (T 3) . Data are expressed as mean ± SD. An unpaired Student's t-test was used to compare differences between groups. RESULTS : In the table are renorted the main realty at T 3. Parameters Survivors Non survivor H.R. Maria 91±4 117±14 a MAP mm\h 84±4.5 68±15 a CI L\min\m2 4.3±2.6 3.9±1.4 REF% 36±10 39±6 EDVIml\min\m2 129±27 93±43 DO2Iml\min\m2 709±238 425±207a V021ml\min\m2 213±182 121361 LACTATEmmo1V 1.04±0.1 2.93±1 phi 7.38±.1 7.29±0.1 SVRI 1546±159 1090±533 a LVSWIg.mJm2 58±23 24±4 ap<0.05;l p < 0.01 CONCLUSION Data of this study show: 1) LVSWI , HR and SVRI improve in survivors 2) Lactate and phi return to normal value only in survivors . Early improvement of ventricular function in sepsis may prevent gastrointestinal failure and mof.

OBJECTIVES: To asses the effects of non Invasive Continuous Positive Airway Pressure (CPAP) on systolic and diastolic ventricular function among patients with left ventricular failure. DESIGN: Autocontroled Intervention study. SUBJECTS: Nine patients with heart pathology, with no valvular disease, admitted to ICU because of left ventricular failure. METHODS: We studied systolic and diastolic ventricular function Indexes by Doppler ultrasound at baseline, after non invasive CPAP levels of 7.5, 15 cm H2O and alter CPAP. RESULTS AND STATISTICAL ANALYSES: Five men and four women were Included In the study, with a mean age of 65(1 8.8). The main pathology was Ischemic heart disease (67% of the patients). When the study was carried out four patients were already In Killip I, and the rest In Killlp II. At baseline, average blood pressure was 127(119)1 71(±13); mean respiratory frequency was 22 (t4) and mean ventricular frequency 81(±10). The ecographic indexes are shown in Table 1. Varlable(mean*SD)

BasdiM

CPAP 7.5

CPAP 16

Cardiac Index(l.minhn2)

2.9210.65

3.1610.85

3.0810.89" 2.80±0.82

E/A ratio

1.09±0.62

1.1630.65

1.58±0.59

W,Icwton test between Baseline Fable 1. Ecograpnic indexes.

Post CPAP 1.0310.60

and CPAP15, =0.07.

CONCLUSION: We observe a modest Improvement, basically on respiratory frequency and SatO2, and an effect of CPAP on ventricular function. Beneficial effects of CPAP may be due to an Improvement both in lung and left ventricular functions.

Intensive Care Unit, Consorci de ('Hospital de Is Creu Rojal, L' Hospitalet de LLobtegat 08906, Spain.

ICU S.Eugenio Hospital, P.zza Umanesimo 100 - 00144 ROMA, Italy

575

610

SUBTRATE UPTAKE DURING AND AFTER ROUTINE CORONARY ARTERY BYPASS SURGERY (CABG) ' Pietersen HG , Langenberg CJM, Geskes G, Wagenmakers AIM, Lange de S, Soeters PB. OBJECTIVES: study of myocardial metabolism in relation to global myocardial ischaemia. DESIGN: prospective perioperative study. SUBJECTS: 18 patients CABG patients, age mean: 63 range (41-75) NYHA IIIIV, Left venricular ejection fraction > 50%, no concomittant metabolic disorders, scheduled for CABG operation. METHODS: Patients received lorazepam 60 sg.kg ' oral premedication and high dose sufentanil anesthesia. Preoperatively coronary sinus (cs) and Swan Ganz catheters were inserted via the right internal jugular vein. Arterial (art) and cs blood, cs bloodflow and haemodynamic data were taken before incision(T1), 1520 min. (T2), 50 min. (T3) 2 hours (T4) and 6 hours (T5) after release of the aortic clamp. St. Thomas' solution was used for cardioplegia, with moderate (28°C) hypothermia during bypass. Flux was defined as arterio-venous concentration difference x cs flow. RESULTS AND STATISTICAL ANALYSIS: Means are given ± SEM,Wilcoxon matched-pairs signed-ranks tests were used, P values < 0.05 were considered significant. tTl vs T5 P <0.05. lactate uptake, and Free Fatty Acid (FFA) uptake were significant at all time points. Glucose was significant at T2 only. For FFA and lactate Ti was compared versus T3 and TS. Haemodynamic data remained

COMPARATIVE MORTALITY BETWEEN MEN AND WOMEN IN ACUTE MYOCARDIAL INFARCTION: CORRELATION WITH AGE AND RISK FACTORS. W.A. Sanchez* , A. Lesmes*, M. Guerrero*, E. Vigil**, F. Ortega*, F. Lucena*. *Intensive Care Unit. **Documentation. Hospital de Valme. Sevilla. Spain. OBJECTIVE: Evaluate the influence of risk factor and age in the differences of hospital mortality between sexes. SETTING: Health area of 365000 inhabitants, rural dominance, low economic level. 550 beds in University Hospital. 14 beds (coronary/medical/surgical) intensive care unit. In the past five year: 927 admission/year. DESIGN: Retrospective five years study. Since January 1 th 1991 to December 31th 1995. We included all the patients admitted into hospital. METHODS: We use Hospital and Unit database, where general, administrative, diagnosis and therapeutic procedures are enclosed by ICD-9CM. Total admission/discharges, sex, age, Ischemic cardiopathy (IC), Acute myocardial infarction (AMI), Diabetes (DM), Hypertension (H) and dead, were checked. RESULTS: 103.664 admissions (59.150 women and 44.514 men) of 69.003 patients. 1.411 patients had 1.626 AMI, of these 737 had prior IC, 401 DM, 591 H, 1080 these three risk factor. 331 patients admitted with AMI had not any of these. The following table summarizes the data in hospital mortality.

-

within normal values.

Time Ti T2 T3 T4 T5 FFA flux 5.36±9.1 4.8±3.7 3.3±4.6 6.5±6.8 11.6±8.3 f µmol/min 36.6±7.3 Lactate flux 37.1±6,8 25.7±5.9 12.3±7.9 21.7±4.5 pmol/min 28±8.4 1.2±11.5 Glucose flux -10±12 21.2±7.2 1.8±4.3 umol/min Discussion: Myocardial ischaemia is believed to cause alterations in oxidative metabolism with decreased FFA uptake and lactate release. However in this patient group significant FFA and lactate uptake was observed in the immediately postoperative period.These data demostrate that global ischaemia caused by aortic crossclamping has only moderate effects on myocardial metabolism. H.G. Pietersen, MD, Dept. of Surgery, University Hospital Maastricht PO box 8500 6202 AZ Maastricht, The Netherlands

Years

10-39 40-49 50-59 60-69

70-79

80-89

>90

Total

269

192

31

820

w hospital

36

M hospital

136

84

174

345

376

182

16

1358

W AMUdead

2/0

11/1

33/1

130/16

170//27

68/9

3/0

411154

M AM1/Dead

32/0

125/3

220/9

308/21

236/38

69/14

4/0

987/85

(W: Women. M: Men.)

31

48

172

The mean mortality was 8.61% for men, and 13,13% for

women. (We show and probe more data in communication). CONCLUSIONS:

1)In our experience, as well as literature, women have more hospital mortality than men. These data are significant even in five years and only one hospital study. 2) Despite other authors, in our cases the age is not the cause for this sex difference.

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658

EVALUATION OF ADDITIONAL RESISTANCE IMPOSED BY LARYNGEAL MASK AIRWAY

PROJECT FOR THE FREEZING OF DONOR HEARTS: A PROMISING EXPERIMENTAL STUDY.

ER Righini, R Alvisi, E Marangoni and G Gritti Istituto di Anestesiologia e Rianimazione - University degl Studi di Ferrara.

J Perez-Bemal; E. Gutierrez; R. Hinojosa; A. Hemandez; J.M. Borrego; J. Cerro; D. Rinc6n; A. Ord6iiez.

The Laryngeal Mask Airway (LMA) was first described in 1983 by Brain Recently, the use of the LMA has been suggested in various respiratory

INTRODUCTION: The development of myocardial protection methods has been one of the most important advances in cardiological investigation in recent years. The technique for the adequate preservation of the organ under optimum functional and metabolic conditions for more than 4 to 5 hours (the shortest period required for the performance of a heart transplantation) has not yet been found. To overcome this handicap, a method of myocardial protection able to preserve the heart for a longer time is necessary. For this purpose, the stoppage of the metabolic activity of the heart is imperative. Nowadays, freezing is the only method that secures the attainment of these aims; low temperatures inhibit molecular activity, allowing the conservation of frozen myocytes for years. When freezing organs like the heart, the different hydration degree of the extracellular and the cellular components of the organs poses some unresolved problems due to the appearance of ice crystals and the irreversible cell damages it implies. OBJECTIVES: To demonstrate thatfreezing donor hearts is a useful method for the stoppage of its metabolic activity without causing irreversible damages and to conserve integral its cardiac function. To demonstrate that the administration of cryoprotective substances during the preservation process allows the functional recuperation of the organ during the unfreezing process. MATERIALS AND METHODS: 8 New Zealand rabbits were anesthetized and heparinized to undergo a cardiectomy. Then the heart was connected through an aortic cannula to a Langendorff system. A first study of the basal morphological and hemodynamical parameters was performed. Then the cryoprotective formula used by our research group (polyethilenglicol) was infused through an aortic cannula. The heart was then kept frozen at 2°C for 2 hours inside an isothermal container. The heart underwent a controlled unfreezing process; the unfreezing parameters were studied. RESULTS: Despite a moderate morphological damage (electron microscopy), an adequate electric and functional recuperation was achieved in all the 8 hearts studied. The poliethilenglicol allowed low temperatures to be reached while impeding the solidification of the organ. The formation of a ice crystals inside the tissues decreased and the dehydration function of the polyethylenglicol inhibited the cell crack after the unfreezing. CONCLUSIONS: Freezing a donor heart at -2°C after the perfusion of a cryoprotective substance and reperfusion its after a controlled unfreezing guarantees an acceptable functional response of the organ. The freezing of donor organs open new horizons for the Banks of Organs for Transplantations.

conditions ranging from spontaneous breathing to controlled mechanical ventilation (CMV) Despite that, little is known on the interaction of the LMA with the patient's respiratory system. We compared the additional inspiratory laryngeal mask airway resistance (RLMA) measured in vitro during simulated ventilation and in vivo in 5 anaesthetized patients for whom a LMA size 3 was appropriate.

Measurements and results: RLMA was studied in vitro and in vivo during mechanical ventilation with costant-square wave inspiratory flow (VI) using a different range of inspiratory flows. After differential pressure across the mask was measured, a second order polynomial was used to describe the pressure-flow relationship. The Rohrer coefficients Kl and K2 were

calculated for in vitro and_in vivo series of data and RLMA in vitro and in vivo were calculated for VI= 0,5; 0,75 and 11's - ', respectively. Differential pressure (P'LMA) variations along the LMA length were calculated under in vitro and in vivo conditions, for Vl= 0,75 l•s -1 , by withdrawing the distal pressure measuring catheter tip from the initial position to the LMA patient edge. Calculated RLMA in vitro and in vivo were 0,11 vs 0,22 kPa•1 -1 •s for VI= 0,5 1•s - '; 0,14 vs 0,31 kPa'1 - I•s for Vr 0,75 l's - ';0,17 vs 0,41 kPa•l - "•s

in vitro and in vivo were 0,13 vs 0,25 kPa when the distal catheter tip was in the basal position; 0,07 vs 0,08

for VI= 1 1•s - ', respectively. Mean P'LMA

kPa when it was 10 mm upstream the vertical bars; 0,04 vs 0,04 kPa,

respectively, when it was in the middle tract of the LMA tube. Conclusions:

In vivo positioning of the LMA significantly increases RLMA

because of the configurational changes occurring when the LMA is in situ: when precise evaluation of inspiratory load is required, the measurement of RLMA requires laryngeal airway pressure recording.

U. Cuidados Intensivos. Hospital Universitario Virgen del Rocio. 41013 Sevilla. Spain.

657

660

INTENSIVE MEDICINE AND THE INVESTIGATION OF THE CORONARY PHYSIOPATHOLOGY. THE ROLE OF THE HYPDXIA IN THE BLOCKADE OF THE CALCIUM STREAMS IN THE CORONARY ARTERIES.

POSTOPERATIVE VENTRICULAR FUNCTION AND OPTIMAL MYOCARDIAL PRESERVATION TEMPERATURE DURING HEART TRANSPLANTATION. AN EXPERIMENTAL STUDY.

A Orddnez; A. Hernandez; J. Perez-Bernal; R. Hinojosa: J.M. Borrego; A. Franco; J. Lopez-Barneo.

J. Perez-Bernal; J. Cerro; R. Hinoiosa; A. Hernandez; J.M. Borrego; E. Gutierrez; R.Martin; A.Ord6riez.

INTRODUCTION: In the ICU, we work with ischemic and hypoxic myocardial territories everyday, specially during the process ischemia/reperfusion of the acute coronary disease. Thus, the ICU specialist is very concerned in the investigation of the coronary physiopathology. One of the main autoregulation mechanism of the coronary flow ifs the hypoxia/ischemia. This coronary vascular behaviour is more relevant in cases of ischemic cardiopathy and ischemia/reperfusion syndrome. Whereas the molecular mechanisms responsible for the vascular regulation in the systemic vascularization are well-defined (hypoxemia= blockade of the calcium streams=decrease of calcium inside the flat muscular fibre=muscular relaxation=vasodilation) in the coronary circulation it remains unknown. OBJECTIVES: To demonstrate that the molecular mechanism regulating the vascular tonus at the systemic level behaves in the same way in the coronary vascular bed. MATERIALS AND METHODS: The investigation was carried out at,the experimental surgery unit of our hospital. We isolate myocytes of the muscular layer in the descending anterior coronary arteries of Large White pigs using an enzymatic method. They myocytes were kept active inside an oxygenated nutritious solution (Krebs solution). After provoking an hypoxia, the currents of calcium and potassium channels were assessed in basal situation and using the Patch-Clamp technique. RESULTS: In normoxic conditions(P02<140mmHg) the intensity or maximal extent of the current of the calcium channels (Ica++) was 50-80pA. When the myocytes of the coronary artery were exposed to an hypoxic atmosphere P02=20-40mmHg) the calcium current was inhibited in a few seconds. We observed that the inhibition of the coronary calcium channels went back to the normal situation when the normoxyc atmosphere is reestablished.The potassium currents (IK) were not affected by the hypoxia. CONCLUSIONS: We have demonstrated that at a molecular physiopathology level, the mechanism of response of the vascular torus with regard to the hypoxia are similar to that produced in the systemic circulation. The selective inhibition of the calcium channels by the hypoxia may be one of the most important mechanisms in the redistribution of the coronary flow in situations of ischemia. In experiments to be developed, we are studying whether the response of the coronary artery in cases of hypoxia of the myocyte is different depending on the territory of the coronary artery studied or the myocardial pathology.

INTRODUCTION: The preservation of the donor heart to achieve a long time of anoxia is the most important challenge of cardiologic investigation. The functional recuperation of the myocardium after reperfusion both in heart surgery and heart transplantation is vital for the viability of the organ and survival of patients. Nowadays, the maximum time for the performance of an adequate myocardial protection is only of four to five hours of anoxia. This poses problems when having to extend the time of ischemia (i.e.: when the donor heart has to be obtained in remote geographical centers). Although the optimum temperature for the preservation of the donor heart has not yet been determined, the most common technique used is hypothermia. OBJECTIVES: To determinate the optimum temperature for heart preservation during the time of ischemia of the heart to be transplanted. MATERIALS AND METHODS: 30 New Zealand rabbits were used as experimental models. Experiments were divided in six groups of five experiments each. Different preservation temperatures were used in each group (5°,10°,15°,20°,25° and 35°C). A cardiectomy was performed following a cardioplegic stop. The organ was preserved by immersion for two hours at all the five different temperatures. To assess functionality, the preserved organ was connected to a system of controlled reperfusion in vitro (Langendorff system). In all groups the time and type of stoppage, gaining of weight of the organ, time of appearance of the electric and mechanical activity after the reperfusion and the hemodynamic parameters of systolic-diastolic ventricular function were studied. RESULTS: Myocardial edema and diastolic aortic pressures increases significantly when the myocardial conservation surpass 15°C. Longer times for electric recuperation corresponded to the extreme temperatures observed (5 ° and 35° C). The fastest electric recuperation (3936.3 sec) occurred at 10°C. The appearance of mechanical activity able of generating Peak Pressures of Isovolumetric Development appeared in the 10°C group (mean:64.8t3.5mmHg; p <0.05). CONCLUSION: The myocardial edema and its negative hemodynamic repercussions are related to heart preservation temperature higher than 15°C. Optimum preservation temperatures of a heart in ischemia as assessed by the ventricular function after an implantation was 10°C.

U. Cuidados Intensivos. Hospital Universitario Virgen del Rocio. 41013 Sevilla. Spain

U. Cuidados Intensivos. Hospital Universitario Virgen del Rocio. 41013 Sevilla. Spain

S 289 668

733

DOES HAEMODILUTION AFFECT PERIOPERATIVE CARDIAC TROPONINE I RELEASE DURING CARDIAC SURGERY. M Saussine , CL Sany , B Calvet ,D Raison , JM Frapier..

OUTCOME OF PATIENTS AFTER CARDIAC ARREST (CA) DURING ANAESTHESIA

Introduction : The aim of this prospective study is to evaluate if, in cardiac surgery , postoperative anemia increases myocardial damage. Methods : 31 patients age (65.t9years) undergoing coronary artery bypass (CABG) and 20 patients age (69:14 years) undergoing aortic valve replacement (AVR) for aortic stenosis were studied . Surgery and anaesthesia mananagement were standardized Exclusion criteria were emergency and preoperative hemoglobine level (HB) less than 11 gm /1 . Blood samples to HB measurements were collected pre operatively , at the end of cardioplegia infusion , just after decanulation and at the arrival in the intensive care unit. Myocardial damage was evaluated with measurement of cardiac troponine I (TNI ) a specific marker of myocardial injury and also the more sensitive to detect microinfarction . TNI was assayed by an immunoassay on the Baxter Stratus analyser preoperatively 12 h and 24 h after the arrival in the intensive care unit.Linear regression and Student t test were used when appropriate . Results : We found at any time no relationship between HB and TNI in the CABG group . However a significant relationship between HB at the decanulation and TNI was demonstrated (r= 0.672)(p < 0.0012 ) in AVR group The HB level at decanulation in patients with TNI level >12 µg in AVR group is significantly lower (7,1±1.2gmvs9,22._1.3 gm) (p<0.003 ). Conclusions : This study suggest in AVR for first time an association between anemia due to haemodilution and myocardial injury . Explanation may be the vulnerability to ischaemia of the hypertrophied heart due to aortic stenosis . The results obtained in the CABG group are similar of previous reports . References : CIIN CFIEM ,40/7 1291-1295.1994. I THORAC CARDIOVASC SURG . 93 . 741-754. 1987

V. Vasilkov, A.

Safronov,

V. Marinchev.

OBJECTIVE: The aim of this study was evaluate patients outcome and effectivity of resuscitation after CA during anaesthesia. The main goal was identify factor that the most influence that

CA.

METHODS: We made retrospective study on

data

of anaesthesia

6000 surgery patients (45% - emergency).

The most common causes of CA were prolonged arterial hypotension (systolic AP < 90 mm Hg) during anaesthesia. We registered 117 patients with prolonged arterial hypotension and 22 patients developed CA. Resuscitation was successful in 7 patients from 22 patients only. But 5 patients died in the first hospital month and 2 patients survived. RESULTS:

CONCLUSION: 1) Prolonged arterial hypotension is the main cause of CA (20.2%) during anaesthesia. 2) Resuscitation was successful in 30%, but 9.1% patients survived. Institute for Postgraduate Medical Training, Stasova street,

8. Penza 440060, Russia.

Departement d'anesthesie - reanimation B.Hopital Arnaud de Villeneuve 34295 Montpellier France

735

689 LUNG WATER IN PATIENTS TREATED FOR ACUTE CONGESTIVE HEART FAILURE OR ACUTE MYOCARDIAL INFARCTION

C-J Wallin, A Olsson, R Nordlander, LG Leksell

OBJECTIVES: To measure lung water and water balance in patients with acute congestive heart failure (CI-IF) or acute myocardial infarction (AMI). DESIGN: Patients were studied 12 and 36 hours after admittance to an intensive care unit, during routine clinical management, and compared to a control group. SUBJECTS: Six patients with AMI, and six patients with acute CHF were studied. 18 cardiac healthy patients served as controls. No patient had a pulmonary disease. METHODS: Cardiac output and lung water were measured using the heavy water indocyanine green double indicator dilution method. RESULTS AND STATISTICAL ANALYSES: In the CHF group PCWP was 10(8) and 8(3) mmHg and CI 2.1(0.3) and 2.0(0.3) L /min/m 2 the first and second day respectively. In response to reduction in weight (- 2.1(1.7) kg, P < 0.05) the elevated lung water decreased to a normal level during the observation period (Fig). In the AMI group PCWP was 8(3) and 7(3) mmHg and CI was 2.4(0.4) and 2.2(0.4) L/min/m 2 the first and second day. Despite the reduction in weight (-1.3(0.4) kg, P < 0.001) lung water was unaffected (Fig.). Values are means (SD). One way ANOVA, P = 0.003.

An * indicates a P value less than 0.05 for a difference from control group using Duncans comparison post hoc test.

CONCLUSIONS: In the CHF group lung water was reduced in accordance with a hydrostatic mechanism. In the AMI group the constantly elevated lung water suggests a resetting of the Starling equation due to increased pulmonary microvascular permeability. Dept Anaesth Int Care, Karolinska Hospital, S-171 76 Stockholm, Sweden

Assessment of Coronary Flow Velocities during the Use of lntraaortic Balloon Pump after Cardiac Surgery

AC Rodrigues, A Moraes, F Galas, V Angelim, C Medeiros, JO Auler Jr, G Bellotti, F Pilleggi Instituto do Coragio - Sao Paulo University Medical School - Brazil The beneficial effects of intraaortic balloon pump (IABP) either by diminishing afterload or by augmenting coronary blood flow are well established. The aim of this study is to analyze whether hemodynamic variations produced by IABP may predict changes in the coronary flow velocities as measured by transesophageal echo (TEE) Doppler. Methods: Coronary flow velocity was measured by TEE, with the Doppler at the left main or left anterior coronary artery, in 15 patients (7 females, mean age of 64 yrs), who needed IABP immediately after cardiac surgery. All patients had flow velocity measurements [peak diastolic velocity (PDV) and mean diastolic velocity (MDV)] and hemodynamic variables I cardiac index (Cl), pulmonary wedge pressure (PW), mean blood pressure (MBP)] and heart rate (HR) simultaneously measured during IABP pumping 1:1, and after 15 minutes off counterpulsation. Results: Optimal tracings were obtained in 12 patients (80%). Results (shown below as meantsd) were compared by paired t-test and linear regression analysis was used to test correlation between the degree of hemodvnamic and coronary flow velocity chances. PDV* MDV * HR MBP CI " PW mmHg I/min/m 2 mmHg cm/sec cm/sec bpm 51±28 83113 79±44 3.96*1 19±5.3 BIA 1:1 106118 38±23 84±19 53±33 3.6±0.9 20±5.3 BIA Off 110±17 * p < 0.05 Conclusion: IABP significantly augments coronary flow velocities while producing hemodynamic changes. However, such changes do not occur proportionally; discrete hemodymanic variations may occur in the setting of important increase in the coronary flow velocities. TEE may optimize IABP use, therefore.

S 290

737 EFFECTS OF NITRIC OXIDE ON PULMONARY CIRCULATION AFTER CARDIAC SURGERY F R.B.G.Galas.; J

O.0 Auler Jr.; M.J.Carmona,E. R.R.Messias

Introduction: Pulmonary hypertension is frequent after cardiac surgery and is commonly treated with intravenous vasodilators. One undesirable effect of these drugs is oxygenation disturbances. Recently inhaled nitric oxide (NO), even in small quantities, has been proposed to decrease pulmonary hypertension without negatively interfering in oxygenation. The aim of this study was to investigate the effects of NO in patients with moderate pulmonary hypertension after cardiac surgery. Methods: Seventeen extubated adult patients (11 male and 5 female) with Swan-Ganz catheters were observed during three thirty minute intervals (baseline, 30 minutes, discontinuation). At the end of each interval, hemodynamic measurements and gas collection was carried out. Results: Statistical analysis was performed using Profile analysis where significance was p<0.005. The data are provided below: SPAP mmHg

BASELINE

NO

AFTER NO

42.82+14.8 37.29 + 14.03 42.12±16.3 MPAP mmHg 31.59+ 10.5 28.44+11.9 31.06+_ 10.7 PVRI(dyn.s I cm'.m 2 ) 276.30+ 104.7 209.86+ 125.9 288.79+129.1 SVRI (dyn.s -1 cm''.m 2 ) 1810.76+678.0 1892.29+996.4 1819.24+ 834.9 PVR/SVR 0.16+0.008 0.13+0.08 0.17+0.08 TPG mmHg 13.82+ 7.9 11.00+ 7.3 13.82+7.1 SPAS' systolic pulmonary artery pressure;MPAP mean pulmonary artery pressure;PVRI pulmonary vascular resistance indez;SVRI systemic vascular resistance index;PVR/SVR ratio; TPG transputmonary gradient Conclusions: Inhaled nitric oxide at a concentration of 30 p.p.m. promoted an important and selective vasodilator effect in the pulmonary vasculature without causing any significant alterations in the systemic circulation and tissue oxygenation. InvflW o do Coral -au - Sao Paulo I lnrversi v Medical School. A, or Eno,, C. Aguis,.44 Sao Paulo Brazil CEP 05403000

796 NITRIC OXIDE (NO) INHALATION AS A SUPPORT OF RIGHT VENTRICULAR FUNCTION IN PATIENTS WITH IMPLANTED LEFT VENTRICULAR ASSIST DEVICES (LVAD) F. Wagner , M. Dandel, G. Gunther, I. Schulze-Neick, Y. Weng, M. Loebe, R. Hetzer OBJECTIVES: Patients with end-stage heart failure necessitating mechanical circulatory support often postoperatively present with overt right ventricular failure (RVF) after LVAD implantation. The effects of supplemental NO inhalation were studied in patients with RVF refractory to conventional drug therapy (catecholamines, nitrates, prostacyclin). DESIGN: Clinical course and outcome of patients with NO therapy were evaluated postoperatively and prospectively. SUBJECTS and METHODS: In 7 patients pulmonary and systemic hemodynamic parameters were measured invasively, right ventricular function was evaluated by repeated transesophageal echocardiography (RVEF, RVEDV). By intraindividual dose titration according to a standardized protocol, the most effective dose of NO (20-40 ppm) was determined for each patient. RESULTS AND STATISTICAL ANALYSES: A highly significant, dose-dependent and persistent decrease of pulmonary pressures and resistance (PVR) was noted shortly after initiation of NO inhalation, and subsequently right ventricular function also improved within several days (RVEF increased: p<0.01, RVEDV decreased: p<0.05). Simultanious to the decrease of PVR, the cardiac index rose significantly (p<0.01). After successful weaning from NO inhalation therapy within 2 to 14 days, right ventricular function remained stable in all 7 patients. CONCLUSION: NO inhalation is a promising new therapeutic option in the treatment of RVF after LVAD implantation. German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany

787

801

EFFECT OF INHALED NITRIC OXIDE ON RIGHT VENTRICULAR FUNCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE D. Joseph, F. Baigorri, A. Artigas, L. Blanch.

TRANSOESOPHAGEAL ECHOCARDIOGRAPHIC ASSESSMENT OF LEFT VENTRICULAR FILLING PRESSURES. F. Colreavy MD, M. Balea MS, and M. Cahalan MD.

OBJECTIVES: Recent studies have shown that NO inhalation is able to increase right ventricular ejection fraction (RVEF) in patients with adult respiratory distress syndrome. The aim of this study was to determine whether inhaled NO can improve right ventricular function in patients with chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation. DESIGN, SUBJECTS, AND METHODS: We prospectively studied 11 patients with acute respiratory failure on COPD requiring mechanical ventilatory support. We measured hemodynamics, RVEF by the thermodilution technique, and blood gases. Data were collected before NO administration (Basal 1), during NO inhalation (20 ppm, 20 min), and 20 min after discontinuation of NO (Basal 2). RESULTS AND STATISTICAL ANALYSES: Results were analyzed using ANOVA. Data are presented as mean ± SE. NO inhalation was followed by a significant reduction of PAP (Basal 1: 26 ± 2 mmHg; NO: 22 ± 2 mmHg; Basal 2: 25 ± 2 mmHg; p < 0.0001) without change either in cardiac output or in oxygenation. Right ventricular ejection fraction and volumes did not significantly change either (Table). Basalt NO Basal 2 37 ± 3 Stroke volume, ml/m 236 ± 3 35 ± 3 92 ± 7 92 ± 4 End-diastolic volume, ml/m 289 ± 5 55 ± 5 56 ± 4 End-systolic volume, ml/m 253 ± 4 RVEF,% 41±2 42±3 40±3 CONCLUSION: Pulmonary vasodilation induced by NO inhalation does not significantly modify right ventricular function in COPD patients requiring mechanical ventilation. Intensive Care Service. Hospital de Sabadell. Parc Tauli, s/n. 08208 Sabadell. Spain. Grant FIS 95/1390

Objectives: Directional movement of the interatrial septum in relation to the respiratory cycle has been shown to reliably predict left ventricular filling pressure. The systolic fraction of pulmonary venous flow into the left atrium can similarly estimate left ventricular filling pressure . The aims of this study were (1) to assess the ease and reliability of obtaining real-time cchocardiographic estimates of left ventricular filling and (2) to compare measurements of left ventricular filling pressures from pulmonary venous inflow with movement of the interatrial septum. Methods: 37 patients having transoesophageal echo (TOE) monitoring during cardiac surgery were prospectively studied. Echocardiographic measurements were made by two investigators who were blinded to each others results and haemodynamic data were simultaneously collected by a third investigator blinded to the echo data. A 2-D view of the interatrial septum (IAS) was obtained and curvature of the IAS after a Valsalva maneuver noted. Pulmonary venous flow (PVF) velocity was measured by pulse wave doppler and a systolic fraction of flow estimated from the spectral display. Immediately after echo measurements patients were assigned to one of three groups; normal LV filling (pcwp < 15mmHg.), elevated LV filling (pcwp > 15mmHg.) and indeterminate (unable to estimate LV filling). Echocardiographic measurements were analysed off-line by two independent experts and assigned to an off-line LV filling group. Results: 146 echo measurements were made on 37 patients. Table l: Echocardioeranhic estimates oft .V fillinn Echo variable measured indeterminate normal elevated IAS intraop 37 2 5 30 off-line 37 7 24 6 PVF intraop 7 36 2 27 6 off-line 9 20 35 Table 2: Off-line agreement between IA S and P V F measured disagreed indeterminate agreed 35 3 16 16 Conclusion: Echocardiographic estimates of LV filling are easy to obtain in real time. Measurements of PVF and movement of the IAS concordantly predict left sided filling.

S 291

842

856

FACTORS THAT INFLUENCE HOSPITAL DELAY FOR THROMBOLYTIC TREATb NT IN ACUTE MYOCARDIAL INFARCTION (AMI) AND A WAY TO IMPROVE JL Carpintero, MC de la Fuente, MA Estecha, .TM Molina, LR de! Fresno, D Dega, R Toro.

EXHALED NITRIC OXIDE AFTER OPEN HEART SURGERY A. Michalopoulos, K. Rellos, D. Skambas, O. Liakopoulos, S. Geroulanos.

OBJECTIVES: (1) To know the times spent in diagnosis and treatment of .AMI before starting the thrombolytic treatment; and to report their differents components. (2) To identify main mechanisms and lacks of the Health System that delay thromholysis administration. (3) To evaluate these several factors, with positive and negative influence of the process, in order to make a program and stablish a system for a better and quicker care. SUBJECTS Patients admitted to a coronary care unit at a University Hospital who underwent thrombolytic treatment from September to December 1994. Including criteria were. Typical coronary chest lasting more than 30 minutes. ECG abnormalities and increases in serum creatine kinase levels. METHODS: We report the total number of fibrinolysis in that period and time spent from the addmission of the patient to the begining of the procedure We analyzed the reasons for delay, the whole process and implement a Fast Track protocol to optimize that time RESULTS: We studied 301 patients admitted with isehemic chest pain, in 119 At it diagnosis was confirmed, 70 of them underwent fibrinolytic therapy. Median Hospital delay was 65 minutes (range'. 20-509). This time was divided into 8 minutes for admission, 7 minutes to make the first ECG, 10 minutes for taking clinical history. 29 minutes to move to the coronary unit and 11 minutes for preparing and delivering medications. Identified causes of delay were: Lack of guidelines and training of the emergency physicians that used to consult a specialist, duplicated physical explorations, lack of avalaible beds, waste of time in preparing medications. We promoted a protocol to quickly identify AVII patients, and carry out thrombolysis treatment in the emergency room instead of the coronary unit. The main intervention was to train and stimulate the personnel involved. After a follow up of 3 months we get a time reduction from a median of 65 minutes to 24 We will report in detail the protocol used. CONCLUSIONS: With this protocol, we significantly reduce the delay in thrombolysis administration What means optimizacion in vcntriculc rescue. Future lines are pointed to extrahespitalary thrmbolysts. Intensive Care Unit. H.U. Virgen de la Victoria, Malaga Spain.

OBJECTIVES of this study was to measure exhaled nitric oxide (NO), NO 2 , and NOX during the first postoperative hours in cardiac surgery patients. DESIGN: Prospective study. SUBJECTS: Exhaled NO, NO 2 and NOX were recorded every hour in 18 patients. The measurements started immediately following ICU admission and continued for 8 hours. METHODS: Exhaled NO, NO2 and NO were measured in the expired air of mechanically ventilated cardiac surgery patients using a sensitive chemiluminescent analyser (Pulmonox, MG, Austria) which can measure concentrations of one part per billion (ppb). STATISTICAL ANALYSES: Differences at any study interval were analysed by ANOVA. Data were considered to be significant when p values were less than 0.05. RESULTS: Mean values of NO, NO 2 and NO, in the exhaled air of cardiac surgery patients are presented in the table. Table: Mean values of exhaled NO, NO2 and NO ), (ppb) during the first 8 postop. hours in the ICU. hour NO NO2 NO

1 3.5 2.9 6.4

2 3.5 2.5 6.0

3 3.7 1.9 5.6

4 3.7 1.9 5.6

5 3.3 1.7 5.0

6 3.1 1.5 4.6

7 2.9 1.5 4.4

8 2.6 1.4 4.0

0.5 0.19 0.08

CONCLUSIONS: 1. Despite the aspect that cardiac surgery patients develop SIRS during the first postoperative hours, we found low levels of exhaled NO, NO2 and NO x during this early period. 2. Exhaled NO, NO2 and NOX remained approximately constant during this whole period (p=NS). Intensive Care Unit, Onassis Cardiac Surgery Center, 17674, Athens

843 FAST TRACK IN THE EMERGENCY ROOM IMPROVES TIMES IN THE . THROMBOLYSIS . OF ACUTE MYOCARDIAL, INFARCTION (AMI). JL Carpintero, MA Estecha, MC de la Fuentes R Toro, A Poullet, MV de la Torre, AJ Garcia. OBJECTIVES: To show the efficacy of a Fast Track for thrombolysis, and to compare it with the general thrombolytic treatment in AMI. DESIGN: Prospective study. SUBJECTS: Patients admitted to an University Hospital, diagnosed of AMI in base of standard criteria, who underwent thrombolytic therapy according to a Fast Track protocol during 1995. METHOD: We compare patients thrombolised by the Fast Track protocol (n=100) to those with the same features thrombolised before the establishment of it (n=. Both groups of patients (Fast Track and non Fast Track) were similar in age, lasting of the chest pain (less than 6 hours) and electrocardiographycal criteria for thrombolytic therapy. The statistical test used was Mann-Whitney U for independent and non-parametric samples. RESULTS: We compare the global delay in minutes beetwen the two groups above mentioned. The median time spent in thrombolysis in the control group (standard protocol) was 65 minutes, and in the Fast Track group 25 minutes (p<0.005). The impact of the Fast Track protocol over the general thrombolysis became remarked because a 56.8% of the patients could be included in this protocol; reducing the median time to thrombolysis from 65 to 35 minutes. This protocol has not carried out unappropiated thrombolysis in our patients. CONCLUSIONS: The time we save is due to a change of physicians mind and in the way this pathology is approached to. That carries out an easy and quick procedure that may be completed in the emergency room avoiding unnecessary transports of the patient and reevaluations. Intensive care Unit. H.U. Virgen de Ia Victoria. Malaga. Spain