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TRANSIENT OXYGEN DESATURATION FOLLOWING THE ADMINISTRATION OF INTRAVENOUS RADIOLOGICAL CONTRAST MEDIA. PS SIDHU, JF Cockburn,DA Jlicholson,A. Kennedy,P. Dawson.

THE EFFECTS OF HYPO. NORMO AND HYPERCAPNIA IN INTRAPULMONARY SHUNT AS REFLECTED BY OXYGENATION INDICES. JH Boix •, J Marin , A Arnau , F Alvarez , F Peydro F , E Servera

A prospective trial was undertaken using both ionic and non-ionic contrast media, measuring the oxygen desaturation using the Ohmeda Biox 3700 pulse oximeter, in patients undergoing a variety of radiological procedures requring the administration of intravenous contrast media. A total of 106 patients were investigated;69 male and 47 female. There were a total of 54 patients in the group recieving ionic contrast media and 52 patients in the nonionic group. A total of 78 patients underwent a CT scan, 26 had an IVU, one a IVDSA and one a venogram.The age range of the patients wes 20-85 years and each patient recieved between 40 and 200 mls of contrast media. Oxygen saturation was measured at one minute intervals, 3 minutes prior to the administration of contrast and at one minute intervals for ten minutes, then at 15 and 20 minutes. In the non-ionic group 11 patients(21.1%) and in the ionic group 21 patients(38.9%) dropped the oxygen saturation by more than 2%, significant on a paired t-test.The presumed mechanism for this phenomena is a right shift of the haemoglöbin-oxygen desaturation curve. Thus the Beverley ill patient undergoing any radiological investigation requiring contrast administration will need close mointoring of oxygen saturation during the procedure.

Respiratory alkalosis, produced by mechanical ventilation, has been identified as a cause of hypoxemia, which improves when PaCO2 is normalized or increased. Moreover, moderate hypercapnia has been suggested for the treatment of acute respiratory failure (ARF) by the results observed in experimental animals. To correct the situation of hyperventilation one option therapeutic is the addition of dead space (VD). Whereas pulmonary disease that impairs the lung s capability to oxygenate the arterial blood can be evaluated with the utilization of oxygen tension-based indices such as: F(A-a)02, PaO2/PA02, Pa02/FiO2, and Respiratory Index R.I.= P(A-a)O2/PaO2, or oxygen content-based indices such as: Estimated Shunt (Est Bunt). To determine the effects of hypo, normo and hypercapnia on the variations in arterial oxygenation and their indices in critical patients with acute respiratory failure (ARF) receiving mechanical ventilation. 15 ARF patients, prospective and randomized, intubated and mechanically ventilated, were studied within the first 48 hours of evolution. Three stages warp delimited: I) 30 min after the beginning of anaesthesia; II) 30 min after adding 30 cm of dead space (VD); III) 30 min after replacing the previous VD with VD of 60 cm. Ventilation parameters and FiO2 were kept stable. Stage I was characterized by respiratory alkalosis and stage II by normal acid-base balance with an increase in Pa02 (p<0.01) and a decrease in intrapulmonary shunt (Qsp/et) (p<0.001); the indices alveolar to arterial oxygen tension gradient EP(A-a)02], respiratory index (R.I.) and estimated shunt (Est Shunt) also decreased significantly, whereas arterial to alveolar oxygen tension ratio (Pa02/FA02) and arterial oxygen tension to inspired oxygen fraction ratio (Pa02/FiO2) increased significantly. In stage III there was pure hypercapnic acidosis, with decreases in PA02 (p<0.001), P14-a1O2 (p
Department of Diagnostic Radiology, Hammersmith Hospital, Ducane Road, London W 12 OHS, England.

ILitensive Care Unit. Hospital Gran Via, Castelldn. Spain_

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THROMBOLYTIC THERAPY WITH rt-PA IN PATIENTS WITH LIFETHREATENING PULMONARY EMBOLISM D. Siebenlist, W. Gattenlöhner

PHOSPHODIESTERASE INHIBITOR ENOXIMONE IN PATIENTS AFTER SEVERE THORAXTRAUMA W. Lingnau, Ch. Hörmann, Ch. Putensen, N. Mutz

Fibrinolytic therapy with recombinant tissue type plasminogen activator (rt-PA) seems suited for patients with massive pulmonary embolism. This drug opens the occluded pulmonary vessels without severe bleeding complications because of its clot-specific affinity and its highly thrombolytic efficiency. We report a series of five patients (average age: 62,8 years) with fulminant pulmonary embolism needing resuscitation by external chest compression (average duration of resuscitation: 26 min.).Dli'ägnosis was established in all cases by ECG, arterial blood gas analysis and echocardiography. All patients were treated with high-dosed catecholamines and mechanical ventilation. In order to reach a stable hemodynamic condition a short-time thrombolytic treatment with rt-PA (100 mg rt-PA/90 min.) was administered. After two hours all patients showed normal blood pressure so that vasopressor and inotropic support could gradually be reduced. One patient died 12 hours after a recurrent pulmonary embolism, another patient after 10 days because of a hypoxic cerebral damage during cardiac arrest. No patient had severe bleeding complications in particular no intracerebral bleeding. The short-time thrombolytic therapy with rt-PA is an efficient therapeutic alternative to the usual thrombolytic treatments in cases of live-threatening pulmonary embolism.

Introduction: Phosphodiesterase inhibitors have shown

Medizinische Klinik I, Leopoldina-Krankenhaus der Stadt Schweinfurt, Gustav-Adolf -Str. 8, 8720 Schweinfurt, FRG

favourable impact on cardiac performance in heart failure and following cardiac surgery. Aim of the study was to investigate patients after severe blunt chest trauma and low cardiac output despite of adequate volume resuscitation. Methods: After approval by our Institutional Review Board 14 traumatized patients (median age 32 years) who suffered from severe thorax trauma (Hospital Trauma Index HTI >_ 3) and showed a cardiac index of 53.0 I/min x m 2 were included and studied for 24 hours. All patients were controlled mechanically ventilated. Patients were then treated with an iv bolus of 0.5 mg/kg Enoximone followed by a continous infusion of 5 tg /kgxmin. Differences between time levels were assessed by ANOVA considering a p<0.05 as statistically significant. Results: Cardiac Index increased significantly 30 min after bolus application (2.5±0.08 I/minxm 2 vs 33±0.1) and further increased after 24 hours (4.1±0.07). Heart rate went up after 30 min (83.9±4.6 vs 101.1±4.0) and remained constant thereafter. Systemic and pulmonary vascular resistances decreased Significantly, DO2 improved and due to a lower rise of V02 oxygen extraction normalized (29.9%±1.1 vs 24.2%±0.9) after 24 hours. Conclusion: As shown in patients after major cardiac surgery and in heart failure we could demonstrate that the phosphodiesterase inhibitor enoximone rapidly increases cardiac index and tissue oxygenation in ventilated patients after severe chest trauma. Departement of Anesthesiology and General Intensive Care University Clinics, Anichstr. 35, A-6020 Innsbruck, Austria

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COMPARISON OF THREE PHOSPHOOIESTERASE INHIBITORS (P01) FOR THE TREATMENT OF SEVERE HEART FAILURE. L. Jacquet, J.C. Jouret, P. Herein, M. Goenen.

ENALAPRILAT INFUSION ATTENUATES HAEMODYNAMIC AND HORMONAL CONSEQUENCES OF INTRACTABLE HEART FAILURE AFTER ACUTE MYOCARDIAL INFARCTION H. Tohmo', M. Karanko', K. Korpilahti 1 , M. Scheininc, 0. Viinamäki`,

The efficacy of various PDI has been well described in the treatment of both acute and chronic heart failure but no comparison of the different molecules has been published so far. We studied 3 POI in 12 patients (pts) with severe

P. Neuvonen`

stable congestive heart failure, mainly candidates to heart transplantation. Amrinone (A)IRI) was given as a loading infusion of 0.5 mg/kg followed by a maintenance infusion of 5 ug/kg/min for 2 hours, then 10 ug/kg/min for 2 hours. The same dosage was used for endximone (ENOXI). The'dosage for miLri none (MILRI) was 50 ug/kg as loading dose, then 0.5 ug /kg/min and 0.75 ug/kg/min for 2 hours respectively. A washout period of 6 hours was allowed between drugs and the order of administration was changed from one patient to the Ether. Hemodynamic and respiratory changes expressed in percent and at the low dose regimen were as follows :

H.R. (beats/min) HP systolic .(mmHg)

AMRI ENOXI MILRI Anova 5ug/kg/min 5ug/kg/min 0.5ug/kg/min -1.2 + 1.9 -2+3.1 -1.6 + 2.3 P=0.9 +5.2 + 3.6 +2±3.2 +4.6 + 3.4 p=0.8

+1.9 + 3.8 -3.8 + 3.2 -7.6 + 3.3 -20.7±4.9 -6.8 + 4.7 -8.8 + 7 +2.4+3.3 -6,1!3.7 -8.3 + 3.7 PCWP (mmHg) -0.4 +5.5 -8.5 + 4.8 -17.8+4.7 Cardiac index(l/min/m2) +18.2+4.5 +20+4 +43.7+5.1 Stroke index(mL/bt/m2) +20.1±4.8 +23.5+4.5 +46.1 + 5.1 SVR) (dyne.5cm-5.m2) -6.2±4.1 -12.5 + 4 -29.5+4 PVRI (dyne.5.cm-5.m2) +1.6 + 5.6 -13.5 + 4.2 -12.1+6.8 Sat.02 a. (%) -0.9 + 1.4 +1,6 + 2.1 -0.8 + 1 + 4.5 + 3.8 +17.7+4.4 +20+4.3 Sat.02 V. (%) D02(ml/min/m2) +15.1+4.3 +18.9+4.4 +41,2 + 6 V02(ml/min/m2) +10±4.1+1+4.8 +25+7.7 BP diastolic (mmHg) CVP (mmHg) PAP mean (mmHg)

Os/Op (%)

p=0.2 p=0.59 p=0.1 p=0.2 p=0.019• p=0.03• p=0.006' p=0.5

+ 12.5+4.4 +13.9+8.1 +56.5+7.1

p=0.11 p=0.10 p=0.05* p=0.3 p=0.07

In conclusion , MIL has a more pronounced effect than the other PDI on cardiac

output and systemic vascular resistance. Shunt fraction is elevated with Ill but total oxygen transport remains higher than with AMRI or ENOXI. Results were not Significantly different at a higher dosage.

The acute effects of low dose intravenous enalaprilat (ENA) infusion, combined with inotropic, vasodilating and diuretic therapy and ventilatory support, were investigated in 8 patients suffering from intractable heart failure (HF) after acute myocardial infarction (AMI). The effects of ENA infusion on haemodynamics, oxygenation, and hormonal regulation [plasma renin activity (PRA), plasma noradrenaline, adrenaline, endothelin (ET), atrial natriuretic peptide, and vasopressin concentrations, serum angiotensin converting enzyme (ACE) activity, and serum levels of aldosterone] were assessed repeatedly during 2 h. ANOVA for tepeated measurements was used in statistical analysis. ENA infusion (median dose 0.3 mg) caused significant short-lasting (30 min) decreases in pulmonary capillary wedge pressure (27 to 19 mmHg, p = 0.007), mean arterial pressure (77 to 64 mmHg, p = 0.003), mean pulmonary arterial pressure, and rate pressure product. These findings coincided with inhibition of serum ACE-activity, an increase in PRA, and a decrease in plasma ET concentrations (p < 0.041). Cardiac output and left ventricle stroke work index remained unchanged. Concurrently, arterial oxygen (0 2) partial pressure increased (p < 0.001), while venous admixture, mixed venous and arterial 0 2 saturations and 0 2 extraction ratio remained unaltered. As an adjuvant to conventional intravenous drug therapy, ENA infusion attenuates the hemodynamic and hormonal consequences of intractable HF after AMI. Arterial oxygenation is preserved or may even improve. Cardiorespiratory Research Unit and Departments of Anaesthesiology', Internal Medicine', and Pharmacology', University of Turku, SF-20520 Turku, Finland.

Cardio-thoracic surgical Intensive Care Unit, University Hospital St. Luc 10 Avenue Hippocrate, 1200 Brussels, Belgium.

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PERIOPERATIVE MYOCARDIAL ISCHEMIA AND INFARTACTION IN NON CARDIAC SURGERY: INCIDENCE AND PREDICTIVE FACTORS,

PROLONGED LOW PRESSURE INFLATION OF G SUIT (GS) LEADS TO MUSCULAR ISCHEMIA IN CORONARY ARTERY BYPASS GRAFT (CABO) PATIENTS. P. Plaisance, E. Vicaut, S. Beloucif, D. Payen.

A.Sabate, R.Sopena, R.Ramön, E.BarceI6, C.Roqueta, A.Abad, L.Garcia, X.Garcia. Cardiac disturbaces are the first main cause of perioperative morbimortality. Non cardiac major surgery represents an high risk factor in relation to cardiovascular morbidity. The objective of this study was to determinate the incidence of ischemia, myocardial infarction (AMI) and cardiac death in non cardiac surgery. We propectively studied 327 patients, criteria for entry into study Included one of the following: Preoperative cardiopathy, Non cardiac surgery, Intraoperative hemodynamic disturbances. Data obtained in The

Postanesthetic Intensive Care Unit(PAICU) were: CK-MB isoenzyme and

ECG, every eight hours during the first 24h. and at the 2on and 3th da ys. We also did total CK at 24h. AMI was diagnosed if the patient had ECG

evidence of subendocardial or transmural infarction, confirmed by an

Independent cardiologist. In order to found predicters a stepwise logistic

regression analysis was made.

Mean age was 61 t 12 y., 72% were man, 75% were ASA Phy. Stat. III-IV. Major surgical procedures were done in the 55% of patients. Previous diagnosed coronary disease were found in the 17% of patients, while the 26% had a previous abnormal ECG. Mean stage in PAICU was 2±4 days.

We found hemodynamic and rytme disturbances in the 22% and 8% of patients repectively. AMI was detected in 10 patients (3.3 %), while ischemia was detected in the 14% of patients. Operative death was 7.6%, mostly from cardiac origin.

We have found good correlation between CK-MB value and AMI. Although major surgery did intra and postoperative hemodinamic changes, it could not be relationed with AMI and ischemia during postoperative time. The incidence of AMI and ischemia have been found to be related to previous diagnosed coronary disease. Departament d'Anestesia. Ciutat Sanitaria de Bellvitge. Barcelona 08907

C /Feixa Llarga s/n.

GS can be used for a long period to treat mild cardiopul. monary hypovolemia. Because muscular flow could be reduced with its prolonged application, we studied the effed of 24 hours GS inflation in 29 CABG and 29 valvular disc ase (VD) postoperative patients with low filling pressures and/or systemic hypotension in absence of cardiac heart failure. Each population was randomized in 2 group: with (GS+:,lower limb =35 mmHg; abdomen=I0 mmHg) and without (GS-) GS. Serum isoenzyme levels of MM creatine kinase (CK) were measured just before, 6112 and 24 hours after the beginning of the protocol. -We kept 2 principal values of CK: at control (CKo); and'the peak level (CKp) between T6, P12, T24• RESULTS: can + SE GS n CKo (U/l) CKp (U,'].) n =2 CABG n =2

+ + -

13 i6 16 13

217

34 29 233 t 2 5 247 + 41 I6

513

1 29 ° j 85° 1308 283° 779+ 227°] 410

" : p < .0) peale vs control; 9 : p< .05 GS+ vs GSDISCUSSION: All groups ellicited a peak value at 6th hour. In valvular patients, there was no difference between presence or absence of GS A eliminating a proper effect of its inflation. In CABG patients, a more pronounced increase in CK levels was found in the GS+ group, suggesting a higher sensibility of skeletal muscles to ischemia. These results aLlor - t, o..utiously use this device ir: coronary artery disease patients because of risks of rhabdomyolysis and renal failure.

Department of Anesthesiology and Critical Care, Lariboisiere Hospital, 2 Rue Ambroise Pare 75010 Paris, FRANCE:

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USE OF THERMODILUTIC11 RVEF CATHETER FOR EARLY DETECTION OF RIGHT VENTRICULAR FUNCTION IN POSTCARDIAC SURGERY INTENSIVE CARE UNIT. L. Pasint, G. Ortalli, C. Sorbara

ACUTE VOLUME LOADING WITH COLLOID VS. CRYSTALLOID AFTER CORONARY ARTERY BYPASS D. Laeonidis and S. Magder.

INTRODUCTION

There is an increasing interest in detecting right ventricular function (RVF) in crititatty ill patients, because right ventricle (RV)plays an

important rote in cardiac performance: It is now evident that RV is no

merely a passive conduit for blood at low pressure but it is strictly related to LV by an anatomic and functional interdependence.

The thermoditution right ventricular ejection fraction (RVEF) catheter represents nowadays the more recent and effective tool for bedside evaluation of RVF because it gives not only pressure data but also volumetric parameters and performance indexes. Because in postcardiac surgery many pathological conditions are complicated by the sppearance or worsening of pulmonary artery hypertension (PAN), the aim

of this study Peas to investigate if an early and more precise detection

of RV failure by RV volumes and RVEF could improve the management and outcome of these patients. MATERIALS AND METHODS

From January to december 1991, 22 patients were monitored by RVEF catheter;

9 were submitted to orthotopic cardiac transplantation, 8 to coronary artery bypass grafting, 4 to mitral valvular replacement, 1 to pulmonary embolectomy. We monitored the following parameters: CO, HR, REF, RVEDV, CVP, IPAP, PCWP in the operating room and I.L.U.

We compared the hemodynamic effects with albumin solution

of REF (24.3

0/-

excluded patients on inotropes, diuretics and those with valve surgery. In all patients cardiac index (CI) was measured by thermodilution. We also measured right atrial (Pra) pressure, pulmonary' capillarywedge (Pew)

pressure, -heart rate (HR), stroke volume index (SVI), left ventricular stroke work index (LVSWI), right ventricular stroke work index (RVSWI),

and systemic vascular resistance index

CONCLUSIONS

An earlier and more accurate diagnosis of RV disfunction was obtained by RVEF catheter monitoring: in this way it was possible to assure a more rational and quicker therapeutic management. Moreover it appears from our data that Frank-Starling mechanism (interpretated as an index of ventricular filling 3 plays a little role in augmentation of RV performance. Department of Anesthesia and Intensive Care, University of Padua Medical School, via C. Battisti 267, 35121 Padova, Italy

Following random

Pra

shows changes: A Pow II(9

A Pro

mmHg

Group A Group N

1.61±0.49' 3.38±0.55

2.05±0.83 3.27±0.6

A LV5iJ.t

index) and REF. On the contrary there is not any correlation between RVEDV

(a preload index) and CVP.

(SVRI).

assignment, in group A (n =9) patients received 100 ml of 25% albumin solution over 15 min, whereas in group N (n =9) normal saline was infused rose by g 2 mmHg (volume infused was 272 ± 31 ml). All until measurements were taken before and immediately after AVL. Table

3.3%; p00.001).

three principal groups (cardiac transplantation, CABS, valvular replacement), although the slope was different. There.is also a significant correlation (r=0.67) -inversely proportional- between mPAP (an afterload

of acute volume loading (AVL)

normal saline in patients after aorto-coronary

bypass grafting. Eighteen hemodynamically stable patients were studied on the first postop. day (4.8±1.6 hrs after operation, mean ± SE). We

RESULTS In 9 patients (40,9%) we found after the operation a significative reduction The correlation between REF and CO was statistically significant in all the

to

Group A Group N

g-M/at` 7.58±2.56 2.33x1.05

e RVSiJ

g.Mh` 2.88±1.01 1.59±0.52

A

A SVI

A CI L /min•.2

mt/min•m2

0.4±0.11' 0.0±0.11

4.82±1.61• 0.36±1.21

e SVRI

dynes/arrs•m? -204.8±101.1 -7.5± 97.6

NR

b/min

0.2211.07 ±1.43

0.0

e PVRI 5 2

de yns/rear -30.2!27.8 -7.3±14.6

* p < 0.05 in comparison with the N group. These results suggest that AVL with albumin was associated with improved cardiac function. Division of Critical Care, Royal Victoria Hospital and Meakins-Christie Labs., McGill University,

687 Pine

Ave., Montreal, CANADA H3A lAlz

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PROGNOSTIC VALUE OF EARLY ATRIAL PACING STRESS TEST IN

USEFULNESS OF ECHOCARDIOGRAPHY FOR EMERGENCY CARDIAC PACING.

POST-MYOCARDIAL INFARCTION PATIENTS J.J.Guardiola, X.Sarmiento, S.Alonso We tried to determine the value of early atrial pacing as a prognostic indicator in addition to easily obtained clinical variables in patients recovering from an acute myocardial infarction (AMI). Methods : 131 non-consecutive patients with 'AMI were enrolled. None of the patients had received thrombolytic therapy. Simple clinical variables were collected during the patients stay in the ICUICCU and consisted of age and gender, previous infarct, NYHA class prior to infarct, infarct location, Infarct type (0. non-Q), Killip class, new A-V block, new bundle branch block, post-infarction angina. Atrial pacing test was carried out an average of 5 days post-AMI. A subclavian vein was punctured and an electrode advanced to the right atrium. Every two - minutes the pacing rate was increased by ten beats/minute, until the -target heart rate of 160 beats/minute was achieved. Test was considered positive if 1) >1.0 mm of horizontal or downsloping ST segment depression developed, 2) patient experienced severe oppressive chest pain, or 3) systolic blood pressure dropped >15 mmHg Patients were followed prospectively during three years. End-points were sudden cardiac death and reinfarction. Multiple logistic regression analysis was used. Results: 131 patients underwent atrial pacing. After eliminating patients with an incomplete test, patients lost to follow-up and patients who had coronary bypass surgery (5), 103 patients were left, out of which 32 had a positive test. There were no significant side effects from the test. Of the 32 patients with a positive test, 19 had an adverse outcome (either reinfarction of cardiac sudden death) Of the 71 patients with a negative test, 3 had an adverse outcome Multivariate analysis showed that atrial stress test was the strongest predictor The mortality rate was highest among the patients with a non-Q wave infarction and a positive atrial stress test. , Conclusions: Early atrial stress test after AMI is safe end predictive of reinfarction and sudden cardiac death in the post -hos)ital phase. DEPARTMENT OF INTENSIVE CARE. HOSPITAL JOAN XXIII, TARRAGONA. SPAIN

NIGOND J', ARICH C, BERTINCHANT.

STORDEUR

JP,

BENGLER C,

JM.

Insertion of a temporary endocardial pacemaker is easy using fluoroscopy ; in critically ill patients receiving a mechanical ventilation, in emergency care room or in intensive care unit, with a low hemodynamic status due to a severe bradycardia, a cardiac pacing should be implanted very quickly at the bedside. Although external transthoracic pacing may be useful for a short period, ventricular demand transvenous pacing is usually needed. If a mobile fluoroscopy material is not available, echocardiography is very helpful. We report five patients, with complete atrioventricular block due to an acute myocardial infarction (4) or drug intoxication (1) in whom the pacing electrode was inserted percutaneously via the right femoral vein, at the bedside, using transthoracic echocardiographic control. The subcostal approach (longitudinal view) allows to visualize the tip of the bipolar lead in the inferior vena Cava at the insertion in the right atrium ; the advance of the lead in the right cavities, the way through the auriculoventricular orifice and the positioning at the apex of the right ventricule are facilitated by the echographic guidance (two operators are needed). Mean time from venous punction to location of the electrode in the ventricule was 8 minutes ± 2. In all the cases, threshold for pacing was low. We found that echocardiography is a simple and effective technique for a rapid positioning during emergency cardiac pacing in critically ill patients. Intensive Care Unit and Coronary Care Unite - University Hospital, 5 rue Hoche, 30006 NIMES FRANCE.

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DEPRESSION AND RECOVERY OF RIGHT VENTRICULAR (RV) "EJECTION EFFICIENCY" AFTER CARDIOPULMONARY BYPASS (CPB) FOR CORONARY ARTERY SURGERY IM Chandler, EL Stein, TA Gasior, EL Kormos, MR Pinsky

THE USE OF INTRA-AORTIC PUMP BEFORE OPERATION IN PATIENTS WITH SEVERE HEART FAILURE

Ejection efficiency of the RV can be defined by volume loading maneuvers as the ratio of one minus a change in both RV end-systolic volume and end-diastolic volume indices, 1-(4RVESVI/ARVEDVI), which reflects how completely the RV empties during ejection. Transient RV dysfunction after CPB has been described with maximal depression occurring 6 to 8 hours after CPB. Thus, we examined RV ejection efficiency before and following CPB.

M. Fortuna, M. Horvat

Introduction:

Fourteen patients (7 males, 7 females, age 66±9, mean±SD), undergoing elective coronary artery bypass surgery with normal preoperative ventricular function (LVEF>40%) were studied prospectively. None had pulmonary hypertension and all had normal RV wall motion with no or trivial tricuspid regurgitation pre-CPB. Utilizing a thermodilution RV ejection fraction (RVEF) catheter (REF-1. Baxter-Edwards), multiple measurements (23) of cardiac index (CI), stroke volume (SV), heart rate, and RVEF taken at end-expiration were averaged. Serial measures were made following five or more rapid bolus infusions of colloid (total volume infusion, I L) at four intervals: pre-CPB, 2-3 hours, 6-8 hours, 24 hours post-CPB. Vasoactive agents were infused as needed to maintain a CI between 2.4-3.0 L/min/m' but held constant for each interval. Statistical analysis was performed on pooled data by simple linear regression and two-way analysis of variance. Methods:

Results:

Volume loading at all time intervals increased RVEDVI significantly. ARVESVI/ARVEDVI r' RV ejection (slope±SEE) efficiency±SEE

Pre-CPB

.798±.029

.95

0.202±.029

Post-CPB 2-3 hours

.700±.032±

.92

0.300±.032?

Post-CPB 6-8 hours

.871±.032±#

.95

0.129±.032?#

Post-CPB 24 hours

.728±.0211

.97

0.272±.021±

t p <0.05 compared to pre-CPB t p<0.05 compared to all other intervals Conclusion: The ejection efficiency relation, AESVI/AEDVI, varies in a directionally similar fashion to other measures of RV function following CPB. There was initial improvement in ejection efficiency after CPB (slope moving towards zero, such that proportional increases in RVEDVI correspond to increased SV). This was followed by a deterioration in function 6-8 hours post-CPB (slope moving toward the line of identity where increases in RVEDVI do not result in enhanced SV but instead in RV dilation) with recovery of RV function at 24 hours post-CPB. Ejection efficiency is clearly defined by this analysis. Its use as a guide to diagnosis and therapy remains to be defined.

Intraaortic balloon pump (IABP) and other ventricular assist devices present an irreplaceable tool for mechanical supprot of the left ventricle in patients with severe heart failure. The most common use of IABP is during postoperative period of cardiac surgery, and in patients with acute myocardial infarction and cardiogenic shock. During the last 5 years, we treated 28 patients (18 men, 10 women, age 58 ± 7 years), who required mechanical circulatory assistance due to severe, acute heart failure. In the whole group the mortality was 59% (17 patients). All suffered from acute myocardial infarction and its complications. From five patients, who had interventricular septum defect, one died before operation, the other four were successfully operated. In three patients acute initial regurgitation due to rupture of a papillary muscle was indication for IABP and urgent operation; all three survived. Two of patients with acute initial regurgitation were also artificially ventilated due to severe pulmonary congestion. Conclusion: In selected patients, use of IABP may overcome the acute phase of severe heart failure until the patient can be submitted to urgent cardiac diagnostic procedures and surgery. Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 61000 Ljubljana, Slovenia

Department of Anesthesiology and Critical Care Medicine, and Surgery, University of Pittsburgh, Presbyterian University Hospital, Desoto at O'Hara Streets, Pittsburgh, PA 15213-2582 U.S.A.

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DECREASED LEFT VENTRICULAR PERFORMANCE DUE TO PULMONARY HYPERTENSION IN ACUTE RESPIRATORY FAILURE K. Szab6

PROGNOSIS FACTORS IN HIGH RISK CARDIAC SURGICAL PATIENTS

The present study is aimed at studying circulatory failure frequently occurring in burned patients despite the left ventricular hypercontractility, first of all in acute respiratory failure. 7 burned patients with acute respiratory failure were involved and 38 invasive (thermodilution) and noninvasive (STI) haemodynamic measurements performed. The results obtained after data processing by PC with SPSS program package are as follows: 1. Normal mean CI value with a wide variety, of individual measurements (CI -3.1:0.219 l/min/m 2).Increased PAP, SWRI, PVRI, I{R with low SW! and LVSWI cannot be considered as a consequence of the decreased contractility because shortened ICT and almost normal PCWP (14.3:0.96 mm Hg) are seen. 2. Inverse regression between PAPs or PAPm versus CI according to equation PAP-c +VCI. 3. PAPd is higher (18±0.88 mm Hg) than PCWP (p<0.001) and PAPd-PCWPgradient is over 4 min Hg in 13 measurements. This critically high PAPd-PCWP gradient has no effect on the left ventricular performance parameters (CI, SVI, LVSWI) but at the time of these measurements higher PVRI (p<0.002) and lower pO o/FiO2 (pcO.05) are present. PAPd/PCWP gradient and PVRI show a close correlation (r-0.6357 p<0.001 n -38). 4. Extremely high PAPs values (56±2.3 mm Hg) are seen in 22 measurements. Anacrotic notch on carotid curve suggests narrowed left ventricular outflow; as compared to the other measurements, CI, SVI, LVSWI, LVEDVI are lower and PCWP is higher with moderately increased PAPS (32.1±1.1 mm Hg). In response to vasodilators, PAPs showed an essential decrease of within some hours in 11 measurements. That time an improved performance was seen and anacrotic notch of carotid curve disappeared. Relying on these findings it can be concluded that in acute respiratory failure cardiac output and performance may be improved only by decreasing pulmonary hypertension. -

Central Military Hospital, Burn Centre, H-1553 Budapest, P.O.Box 1. Hungary

P.Burtin,M.Clavey,P.M.Mertes,B.Levy,N.Bi schoff,P.Mathieu, J.P.V illemot,J.P.Haberer. The purpose of this study was to assess the prognosis value of early post-operative hemodynamic data in high risk cardiac surgical patients.During a three month period,all patients with low ejection fraction (<4O%),left main coronary disease,pulmonary hypertension (>50mmHg),emergency cardiac surgery or coronary and valvular surgery were prospectively studied.For each patient,the following data were recorded within the first hour post-operatively:heart rate (Hr),cardiac index (Cl),mean arterial and pulmonary pressure (MAP and PAP),capillary wedge pressure (PCW),central venous pressure (CVP),arterial and venous blood oxygen saturation (SaO2 and SvO2),haemoglobin,pH,arterial blood lactate (L) and CO2 tension (PaCO2).Oxygen delivery and consumption (D02 and VO2),systemic and pulmonary vascular resistances (SVR and PVR) were calculated according to standard formulas.Patients were divided in two groups according to outcome:group 1 (survivors) and group 2 (nonsurvivors).The two groups were compared by analysis of variance. 87 patients were included;mean age was 61+/-11 and overall mortality was 16%.Type of surgery was:bypass 58%,valve replacement 26% and others 16%.Main risk factor was:impairement of left ventricular function 52%,pulmonary hypertension 18%,left main coronary disease 15%,emergencies and others 15%.lnotropic support was indicated in 65 patients (78%).Five factors were significantly different between group I and 2:SvO2,PCW,L,pH,PaCO2,(p<0,01).CI,DO2,VO2,Hr,showed no statistical differences between the two groups. Major 'prognosis factors can be assessed as early as in the first postoperative hour.PCW elevation reflects the prognostic significance of left ventricular function impairement in cardiac surgery patients, even when Cl is maintained by inotropic drugs.Sv02,pH and L underline the prognosis value of biologic signs of oxygen debt although DO2 and V02 did not differ between the two groups.

Departement of Anesthesiology and Cardiovascular surgery and Transplantation.CHRU,Hopital de Brabois,54500 Vandoeuvre -lesNancy,France.

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DSFROVIHO SURVIVAL RATE TN PATIENTS WITH CARDIOOBNIC SHOCK USING HECR11NICAL CIRCULATORY SUPPORT SYSTEMS

Tragsportation of Patients on Percutaneous Cardiopulmonary Support Systems A.El-Banayosy, H.Posival, K.Minami, H.KBrtke, M.M.KOrner, R.KOrfer

A. E1-Banayosy, H. Posival, K. Minami, M.M. Korner, D. Hartmann, R. KOrt er During the last three years 53 patients (pts), ag=_! between .33 and 82 years (mean 54 yr) with cardiogenic shock refractory to maximum pharmacological therapy, required mechanical circulatory support systems (MCS) . The indications for use of MCS were as following; A) Postcardiotosy heart failure (n=20): patients could not be weaned from the ECC . B) Post-resuscitation (n=21):' when conventional resuscitation procedures in the ICU (following open heart surgery, after.acute mc , ocardial infarction (AMI)) were not successful. C - tdging to cardiac transplantation (n=10): D) Acute Myocarditis (n=2) 2f patients were supported with the aid of an Abiomed pes. (BVS System 5000),•a centrifugal pump was implanted in 3.0 pts and in 3 pts both systems were used.. We used the following devices:. LVAD In 35 pts, RVAD in 2 pts, and BVAD in 11 pta. S pre were initially treated with femofemoralis bypass, 2 of them received later on LVAD. Duration of support was between one and 670'.hours (mean 94 )r).. Results: Group A (n =20): 10 pts could be weaned, 8 of them discharged, 2 died (due to MOF and to septic complications). 10 pts could not be weaned, 7 of them died (due to hemorrhagic complications (n=5) and to HOF (n=2)). The other 3 pts underwent cardiac transplantation,2 of them survived, the other one died postoperatively of MOF. Group B (n=21): There were 8 early deaths due to hemorrhagic complications '(n=7) and brain death ,(n=1) . 2 late deaths occurred due tu MOF. 4 pts underwent cardiac transplantation, one of them died early postoperatively of dissiminated intravascular coagulation, 3 pts survived more than 30 days and 1 of them could be discharged.The other 7 pts could be successfully weaned and all discharged. Group C-(n=10): 2 pts died 3 hours after the implantation of the LVAD due to hemorrhagic complications, another one died at the sixth day of thromboembolic complications. 7 pre successfully underwent orthotopic cardiac transplantation, one of them died and 6 of them werefinally discharged. Group D (n=2): 2 pts suffered from severe virus myocarditis. 1 patient could be weaned after 120 hours from LVAD support, but died five days later due to malignant arrythmias. The other patient had 216 hours of Evil) support, underwent .cardiac transplantation and was discharged. Conclusioni Considering the inhomogenious profile and the otherwise hopeless situation of these patients the obtained results (30 days survival 60% and long term survival = 47%) are encouraging. Better results may be achieved with more experience and advanced mechanical circulatory support systems.

To save the transportation of patients in severe cardiogenic shock (shock refractory to maximum pharmacological support) for further treatment we-used a percutaneous cardiopulmonary support system (PCPS). The system is consisted of centrifugal pump with membrane oxygenator. and an.intra aortic balloon pump (ZABP). Four patients were successfully supported and transported on the system. The table shows the diagnoses, duration of support, method of transportation: age Diagnoses duration of support Method of Transport Pat. 41y AMI, CPR 24 hours intensive mobile 1- K.B. AMI, CPR 8 hours helicopter -2- R.H. 43y 48 hours SOy AMI Intensive mobile 3- K.F. - 5G. 63y AMI,PTCA 118 hours intensive mobile 4CPR=cardiopulmonary resuscitation AMl=acute myocardial infarction PTCA=percutanous transluminal coronary angioplasty All of the patients required cardiopulmonary support initiated at thier referral institutions and were subsequently transported for diagnostic studies and operative treatment - in our hospital. Results: The first patient after 24 hours of PCPS support developed leg ischemia, because of this we supported him with a left ventricle assist device (ABIOMED) for 28 days. The left ventricular dysfunction was irreversible that is why we accepted him for heart transplantation, which could be done on the 28th day of support. The second-patient could be weaned from the PCPS, his coronary angiography showed 3 vessel disease. 6 Weeks later he underwent uneventfull a coronary artery-bypass grafting operation and discharged from the hospital in a very good condition. The third patient underwent an emergency PTCA to - the left anterior descending artery and could be weaned from PCPs 24 hours later. He is also discharged and in a good condition. The fourth .patient developed AMI and- cardiogenic shock after PICA, we supported his initially with the PCPS for 118 hours and because of leg ischemia we took him on Left Ventricle Assist Device (THORATEC), the patient is still on the device since 6 days. conclusion: PCPS can initially stabilize and save the transportation of critically ill patients which positivelyaffect the patients outcome. Heart Center NRW, Ruhr University Bochum, 4970 Bad Oeynhausen, Germany

Heart Center NRW, Ruhr University Bochum, 4970 Bad Oeynhausen, Germany

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TIERAPEUTIC USE OF L-CAIIITIIE II TIE CABDIOGEIIC SHOCK. G.G. Corbucci

NEUROHUMORAL ACTIVITY IN PATIENTS AFTER CARDIOGENIC PULMONARY EDEMA AND THE INFLUENCE OF TREATMENT

Our research experience on the use of L-Carnitine in conditions of acute hypoxia underline the protective role of this molecule on cellular enzymic complexes. To obtain reliable clinical data the survival rate and baemodynamic response to this molecule were evaluated in two .groups of patients affected with cardiogenic shock. In this randomized, double-blind study the conventional therapy was combined with L-Caroitiae (6g i.v. bolus and 2g i.e. daily for 14 days) in one group of patients (27), while other group (15) received Sodium Bicarbonate in standard doses. The results., shored a significant response to L-Carnitioe treatment, in terms of survival 'to shock according to the clinical and haemodynamic data collected `using Scan-Ganz catheter. In fact statistical evaluation of the results shored that 80% of L-Carnitine treated patients survived cardiogenic shock, compared to 40% in the Sodium Bicarbonate - treated group. The haemodyaamic data were in accordance with the trend shown by the survival rate. These data confirmed that in the reversible phase of cardiogenic shock LCarnitine plays an enzymatic- protective role against cellular oxidative damage affecting energy metabolism and then the cellular ability to counteract the hypolic injury. -

Institute of Anaesthesia - Intensive Care, Ospedale S.Giovanni di Dio V.Ospedale, 09100 Cagliari, Italy

B. Pohar, J. Osredkar, S. Kladnik, M. Horvat

The aim of our study was to assess the neurohumoral (NH) response after glyceryl trinitrate (GIN) and diuretics (D) in 15 patients with deterioration of congestive heart failure (CHF). GI'N was used for rapid (0.5 - 1 hour) and D for slow (2 - 3 days) induction of hemodynamic changes (HDC). The initial HD parameters. (HDP) were as follows: heart rate (HR) 103 t 16 beats/min (BPM), mean systemic arterial pressure (SAP) 107 ± 21, right atrial pressure (RAP) 11 ± 5, pulmonary arterial wedge pressure (PAWP) 29 f 4 mm Hg, and cardiac index 2.5 ± 0.7 1/min m 2 . Plasma adrenaline (A) was 1.10 t 0.81 gumol/l, noradrenaline (NA) 2.70 ± 1.42 Itmol/l, renin (R) 3.97 ± 4.42 nmol /h 1, and aldosterone (AL) 0.76 ± 0.62 nmol/l. After GTN, SAP decreased to 95 ± 19, RAP to 6 ± 4, and PAWP to 19 ± 4 mm Hg (p<0.005). Changes in other HDP and NH activity were not significant (ns). One hour after (if N the initial state was attained. After D HR decreased to 91 ± 12 BPM, SAP to 94 ± 15, RAP to 6 ± 3, and PAWP to 20 ± 5 mm Hg (p<0.01), other HDC were ns. A decreased to 0.56 ± 0.38 and NA to 2.13 ± 1.0614mol/l (p<0.01), other NH changes were ns. We conclude that rapidly induced HDC with GTN do not influence A, NA, R, and AL in patients with deterioration of CHF. After D treatment A and NA decrease, probably because of prolonged improvement of clinical state. Centre for Intensive Internal Medicine, University Medical Centre Ljubljana, Zaloska 7, 61000 Ljubljana, Slovenia

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HYPOVOLEMIA AND PROPOFOL ANESTHESIA. Bellinzona G.. Noli S., Giordano A., 2lzzi S., 'Maestri M., 'Spade M., Raimgndi M.,

PULMONARY ARTERY PRESSURE-FLOW PLOTS IN SEPTIC SHOCK DOGS : EFFECTS OF PROSTAGLANDIN El AND

Albarterio F.,Dionigi R.V. Cardiovascular effects of propofol have been evaluated following its use for both induction and maintenance of anaesthesia )Claaya M.A., 1983). Aim of our study is to emphasize whether propofol influences the cardiovascular responses to hemorrhage. 10 Large-White piglets (20-25 Kg) were anesthetized with isoflurane in oxygen and air and catheters pieced in the pulmonary and carotid arteries for monitoring. Then isoflurane was discontinued and eliminated by ventilation over 30 min. (basal, BIO)). Afterwards 5 awake, unmedicated piglets (group C) were compared with 5 anesthetized with propofol (2 mg/Kg plus 10 mg/Kg/h) (group P). Evaluations were performed 10 min after induction (B(10)) and after removal of 10-20-30-40-50 ml/kg of blood at a rate of I ml/Kg/min (H(10), H(20), H130), H(40), H(50)). Hemodynamic values are summarized in the following table of means (SE); significant differences between group C and P are shown )', p<0.05).

8IO)

8(10)

Hf1O)

H(20)

H1301

H(40)

H(50)

43 (31 109 (6) 76)13) 125 (3) 133 (5) C 130(7) 138 (5) PAM 47 (5) 53(5) P 120(4) 118 (5) 85 (16)' 61 (101' 52(61° (mmHg) 222 (6) 173 (3) 209 (8) 230 (7) C 139 (10) 138 (10) 149 (6) HR P 132 (12) 122 (14) 110(15) 117(23) 126111)' 173)14)' 225)19) Ibhnin) 56 (5) 82 (41 22 (6) 116 (7) C 176 (9) 1801101 154(41 CI 36)8) 53)5) 6118) (ml/min/Kg) P 186(15) 132)111° 93(13)' 68(9) 82(9) 53(111 50(6) 41(41 32(21 C 26.9 (2) 28.6 (2) SVR 35 (4)' 54.4(12)' P 25.5 (2) 31.5 (2) 30.6)2) 29.5 (2) 29 (3)' (U.A.I 2.2(1) 6.2)11 C 24.8(1) 26.3)2) 21.8)1) 15.5(1) 10.411) T021 4.3,11) 6.6(1) 7.6111 11.7(1)' 8.6(1)' Iml/min/Kgl P 23.7)21 17.9)21 C 4.4 (0.5) 4.8 (0.2) 5.9 (0.7) 5.3 (0.6) 5.9 (0.5) 4.7 (0.3) 1.9 (0.6) V021 (ml/min/Kg) P 5.4 (0.8) 5.5 (0.7) 5.5 (0.5) 5.2 (0.6) 5.3 (0.6) 6.3 (0.4) 3.8 (0.7)' 79)8) LACTATE C 14.4 (1) 14.5 (1) 14.9 (1) 15.5 (1) 15.5(2) 29.8 (4) 13.3 (2) 14.9 13) 19.4 (3) 27.7 (6) 51.3 (13)' (mg/lOOm)) P 16.2 (2) 18)5) 91121 34.6 (4) 56.3 (4) 7715) 27 13) O2EX C 17.6 (2) 17.7 (t) 90121 81(11 P 23.9(4) 31.4(4)' 48.2(31' 62.6(5)' 71.5)4)' (%) Propofol anaesthesia (9(10). in our swine model, induces a 25% decieeee of Cl and T021 while MAP is unaltered. During graded hemorrhage C), T021 and EXO2 deterioration is linearly related to the amount of hypovolemia in both groups, although significant differences are detected at points (-1(10) and H(20). V021 decreases (and lactate increases) only after a 50 ml/Kg removal of blood in both group but to a smeller extent in group P). In group C MAP is unaltered until H(30), whereas in group P MAP shows an inverse linear relation with hypovolemie and follows the decrease of Cl and T021. In group P no tachycardia land increase of SVR) occurs until H140). II Department of Anesthesia and Intensive Care and Department of Surgery, I.R.C.C.S. Policlinico S. Matteo, Piazza Golgi, 27100, Pavia, ITALY

NITROPRUSSIDE. V. D'Orio, C. Martinez, G. Saad, P. Mendes and R. Marcelle.

The effects of prostaglandine El (PGE1) and nitroprusside (NP) on pulmonary vascular pressure-flow relationships (P-Q) were investigated in two groups of 6 anesthetized dogs suffering from septic shock by using a low dose endotoxin infusion (0.25 ug/kg/min) over 2 hours. Vascular resistance to flow was computed as the slope of the P-Q relation and critical closing pressure was referred to as the

extrapolated pressure intercept. The gradient across the pulmonary arterial compartment (Pa = PAP-PC) and across the venous segment (Pv = PC - PWP) were defined by the computation of both capillary pressure (PC) and wedge pressure (PWP) obtained from the waveform

mathematical analysis of the pulmonary arterial pressure (PAP) transient during rapid arterial occlusion. Blood flow was changed by stepwise inflations of a balloon in the inferior vena cava. Endotoxin insult increased the slope of the Pa-O relation from 0.048 to 0.083 mmHg/mVmin/kg, while Pv versus flow showed a significant increase

in intercept pressure value from a baseline value of 1.1 to 7.2 mmHg.

PGE1 105 ng/kg/min intravenously did not change the slope of the PaQ relation but attenuated the level of critical closure to 2.3 mmHg. In contrast, NP 8 ug/kg/min did not influence the level of critical closing pressure but could reverse the slope of Pa-Q relation to baseline value. We conclude that endotoxin effects were exerted at two different loci such that these effects were additive. They consisted on

increased ohmic resistance of the arterial segment which was suppressed by nitroprusside infusion, and appearance of a venous Starling resistor which consequences were counterbalanced by PGE1 administration. Department of medical intensive care and emergency medicine, University hospital Liege, Belgium.

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First results of a new extracorporal Endotoxin (ET) detoxifi-

IMPACT OF GLUCOSE ON SYSTEMIC AND HEPATIC HEMODYNAMIC IN ENDOTOXIC RABBITS.

cation device in a porcine E T-shock model

K.H. Staubach

M.R. Losser, F. Lenfant, B. Teisseire and D. Payen.

Once endotoxemia occurs in sepsis a vicious cycle can be established and due to increased mucosal permeability the translocation of ET and even bacteria are promoted, which itself induces more "ET to enter the systemic circulation from the GI-tract. Augmenting the clearance capacity for ET would be the ultimate aim to break this vicious cycle. For this purpose we developed a new ET on-line adsorption system in whole blood by means of PB coupled covalently to a matrix consisting of acrylic particles via a 13 atom-chain

spacer. In watery solution the detoxification capacity, was

150 ug/ET/ml column material. The blood compatibility was good resulting in a more than 90% platelet recovery. The column contained 7 ml of adsorber material and was sterilized by high steam autoclave. Hemoperfusion was performed on 8 pigs at a rate of 50 ml/min by means of a roller-pump until the animals succumbed (H). 8 animals served as controls (C). Results are listed in the following table: Time after 0 2 4 6 8 ET/hour

MAP mmHg HR (min d )

in glucose (GIc) uptake during sepsis. Moreover GIc dyshomeostasis

which Implies liver metabolic function, was shown to influence the

outcome during sepsis. Aim of the study: to investigate the Impact of glucose diet on systemic (SH) and hepatic (HH) hemodynamic and metabolic response to endotoxin (EDTX) Rabbits (2.2±0.03kg, n=22) were anesthetized and ventilated with

pure 02. Mean arterial pressure (MAP, mmHg), ascending aorta (AoV), hepatic artery (HAV), portal vein (PVV) blood flow velocities

(20MHz pulsed Doppler, cm/s), blood gases, lactate (mM/I) and glucose (mM/I) plasmatic levels were registered during 180 min after endotoxin injection (EDTX-1,200 mcg Iv). Animals were divided Into 3 groups: nj (n=10) fed; ^ (n=6) fasted (24h food deprivation); ß (n=6) fasted, with a 2g/kg GIc load before'EDTX. Basal hemodynamic and metabolic status in fasted and fed animals ..

were not different excepted for lactate (1.7±0.2 and 4.6±0.8 respectiveIy-p<0-.01),. A similar hypotension appeared after'EDTXinrlhe 3 groups. ACV evolution in G1 and 3 (50% progressive decrease) was

different (p<0.01) from G2 (no change). HH was similar in G1 and 3 after EDTX (60% decreased PVV and 40% early transient increased

C H C H

HZV

C

(1/min)

H

96 91 60

72 77 83

78

48 60 105

92

119

3,0 3,3

2,7

2,7

1,6 2,0

HAV); in contrary EDTX did not change PVV but decreased HAV (20%) 80 101 1,9

90 96 2,0

PB, although highly toxic, seems to be an ideal material after being coupled to a matrix. In this preliminary report we demonstrate that the extracorporal ET removal may well

be clinically feasible in the future.

Department of Surgery, Medical University, Lübeck,

Germany

The macrophages-rich tissues as the liver have the highest increase

In G2. Lactate. at 3h were 10.1±1.5, 4.9±1.3 and 7.9±1.3 in G1, 2

and 3 (1 vs 2, p<0.05). After glucose loading, glycemia was higher in G3 than Gi and 2. After 3h, the other metabolic parameters were not different in the 3 groups.

EDTX after fasting induced a systemic vasodilation with a maintained portal flow and an hepatic arterial vasoconstriction associated with a lesser lactate' increase. Since fasted animals after portal glucose loading had a. similar hemodynamic and metabolic profile than fed animals, this suggests that hepatic glucose metabolism modulates septic hemodynamic profile.

Lab. Research Anesth.-Lariboisiere University Hosp.-2,rue A.Pare75011 PARIS- France.

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P443 EFFECTS OF PHYSIOLOGICAL DOSES OF GLUCOCORTICOIDS IN SEPYIC SHOCK WITH RELATIVE ADRENOCORTICAL DEFICIENCY. PE Bollaert, PF Laterre, G Audibert,M

Evenepoel, B Levy, Ph Lelarge, A Larcan.

Attention has-been recently focused on the high mortality of septic shock(SS) patients with a negative response to a short corticotropin test (Rothwell at al. Lancet, 1991)., In a preliminary study, the effects of low doses of hydrocortisone (100 mg IV twice daily) on hemodynamic parameters have been prospectively evaluated in patients fulfilling the following criteria: presence. of a SS needing dopamine (>10 µg/kg/min) and/or norepinephrine or epinephrine for at least 48 hours, a negative corticotropin test (<60 nmol/I, increase in cortisol, 30 and 60 min after a 0,25mg IV bolus of corticotropin) and no previous administration of corticosteroids. RESULTS : Seven patients_ (mean age: 67 years; mean Apache 11:.27) were enrolled.' Baseline hemodynamics were (mean±SD): mean

arterial pressure (MAP)70±11 mmHg, cardiac index 4.5±1 ,6

/min.m2, systolic vascular *resistance index (SVRI) 1250±541 dynes.sec.cm - S.m -2 . One hour after the first hydrocortisone bolus, there was a significant' increase in SVRI (p< 0,02;Wilcoxon) and a close to significant increase in MAP (86±11 mmHg; p= 0,06). Cl was not modified. Further SVRI and MAP improvement allowed weaning of catecholamines in 5 patients within 30 hours. Two patients remained unresponsive and died shortly after in intractable

shock.

CONCLUSION : Low doses. hydrocortisone replacement may be beneficial in SS with presumed relative adrenocortical insufficiency, mainly by resolution of peripheral circulatory failure. Whether the improvement on hemodynamic parameters results from pharmacological or physiological effects and is limited to corticotropin-non responders should be further assessed. Services de Reanimation Medicale et Chirurgicale, Centre Hospitalier Universitaire, NANCY, France and Unite de Soins Intensifs, Cliniques Universitaires St Luc, BRUXELLES, Belgique

P444 RAPID CORRECTION OF SEVERE HYPOPHQSPHATEMIA IN SEPTIC SHOCK. PE Bollaert, PF Laterre, Ph Bauer, Ph Lelarge, L Nace, MC Laprevote-Heully, 'A Larcan. Experimental and human studies have demonstrated that severe hypophosphatemia could decrease myocardial contractility, peripheral vascular response to catecholamines and tissue oxygen delivery (by lowering 2,3 DPG). Sepsis is a recognized cause of hypophosphatemia. Although not previously investigated,it would be of particular interest to achieve a rapid correction of hypophosphatemia in septic shock. Eight patients (age 30-83 years) were enrolled on the following criteria: presence of a septic shock (onset less than 48 hours), hypophosphatemia<0,5mmol/l, arterial lactate>2 mmol/l. All patients were mechanically ventilated, in stable hemodynamic condition and were receiving vasoconstrictive catecholamines (epinephrine (7), dopamine (1)). Hemodynamic and oxygenation parameters were measured just before (TO) and immediately after a 2g phosphorus IV load (glucoselphosphate) within 60 min (T60). RESULTS.( mean±SD; Wilcoxon; "p<0,01)

TO

T60

P (mmol/I) 0,35±0,13 1,3±0,3" MAP (mmHg) 72±21 67±10 3,2±1 3,6±1,2 Cl (I/min.m 2 ) Pwp (mmHg) 11±6 11±2 1637±576 SVRI(d.sec.cm -5 m -2 ) 1706±617 LVSWI (gm/m 2 ) 19,7±4,4 26,1±7,5*' 511±165 D02 (ml/min.m 2 ) 555±200 151±34 V02 (ml/min. m 2 ) 176±48 lactate (mmol/I) 5,8±5,3 5,7±5 P50 (mmHg) 23,9±0,9 24,2±1,3 CONCLUSION: Correction of hypophosphatemia can improve myocardial function. Short term effects on both peripheral vascular response to catecholamines and tissue oxygen delivery were not observed. Rapid loading of glucose1phosphate is safe and should be recommended in sepsis with severe hypophosphatemia. Service de Reanimation Medicale, Centre Hospitalier Universitaire, 54035 NANCY, France.

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IMPROVING SPLANCHNIC PERFUSION: THE EFFECTS OF DOPEX,MINE M.N. Smithies, Tai Hwei Yee, L. Jackson, R. Beale, D.J. Bihari

EPINEFHRINE ANI) NOREPINEPHRILE IN SEPTIC SHOCK

Splanchnic ischaemia may have an important role in the

development of multiple organ failure. We have shown that tonometric gastric intramucosal pH (pHi) predicts ICU outcome. (Maynard et al, Br.J.Surg. 1992, In Press.) MEi7-IOD. We studied dopexamine to assess its use in improving splanchnic perfusion measured by gastric tonometry and Indocyanine Green clearance (ICG half-life). Ten patients requiring mechanical ventilation and PA catheters were studied. Their mean age was 62.5 years (range 29 to 78), n ian admission APACHE II 24 (14 to 38), hospital mortality was 70%. The patients were resuscitated and haermdynamically stable. After a baseline set of measurements dopexamine was infused for an hour, the dose being increased to a maximum of 6 ug/kg/min. One hour after the infusion the measurements were again repeated. RESULTS Baseline Infusion Recovery S.V.R. I. 1516 1110 (*) 1420 (**) dyn.s.cm5857 - 3527 844 - 4154 771 - 3221 4.0 C.I. 4.8 (**) 4.0 (**) ml.min.m21.2 5.5 1.5 - 8.3 1.4 - 5.8 pHi 7.21 7.28 (*) 7.36 7.04 7.50 7.13 - 7.46 7.05 - 7.50 ICG tl/2 6.6 6.3 7.4 (*) mins. 3.8 13.2 3.7 - 12.8 4.4 - 14.8

[(*) = p < 0.05 and (**) = p < 0.01 by Wilcoxons signed rank test.) Changes in cardiac index correlated with changes in ICG half-life (Spearman rank correlation p 0.025) but not with changes in pHi. CONCLUSIONS. Dopexamine inproves splanchnic perfusion and its effect on pHi may be independent of its systemic effects. Department of Intensive Care, Guy's Hospital, St. Thomas' Street, London. SE1 9RT, United Kingdom.

C.Cisneros Alonso, J.Gutierrez.Rxlriguez, F.SAnchez Ramirez, J.Prados, V^rla, P.Arrijas Lbpez, A.fbrtinez de la Gändara INTRODUCTION: The unresponsive septic shock (RSS) to volu. men infusion and combination of Dopamine (IW) and Dobutamine (en) treatment has a high mortality.The aim of this paper is to comment on the effects with athird drug,Epinefhrine (EP) or Norepinefhrine (NEP). MATERIAL AND NHL'IK S: From January-december 1991 a pros-

pective study was carried out in 15 patients with RSS.We analyze 7 parameters before and after treatment with EP or NEP:Mean arterial pressure in mmHG (MAP) ‚systemic vascular resistence in Dynes.Sec /ans (SVR),cardiac index in 1/min.m2 (CI) ‚left ventricular stroke work index in gmM/m2. (V02,DO2),oxygen extraction in % (E02), RESULTS: MAP

DP+D8 64±8 NEP EP

85±11

-

SVR

870±257

CI

5±1

LVSWI j

1043±316 6±2 50_+8

68±14 895±517

V02

I

EI

T02—T--2

31 184±38 719±97 25±3

6±1152 +-11

182±99 873±23121+_9^ 186398 880±89,20±91 —

-i---

two patients were discharger, the remainder diedCONCLUSIONS: 1) The EP. and HER increase CL and D02 but dO not ame lierate V02 AND E02.2) HER and EP therapy had neither a positive nor negative effect on mortality in septic shock patients.3) the results may influenced for late tre atment.4) more studies evaluating larger series patients, are needed Hospital 12 de Octubre - UVI 20 plta., Crta. de Anddalucia Km 5.400. 28041 Madrid, Spain

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P447

P448

HAEMODYNAMIC (H) AND RESPIRATORY (R) EFFECTS OF TRAMADOL (T) AND PROPOCETAMOL (P) IN ACUTE EXACERBATION OF CHRONIC HEART FAILURE (HF). R. Boiteau*, A. Tenaillon*, T. Lherm*, F. Chamieh*, D. Perrin-Gachadoat*, M. Burdin*,; A.M. Masquelier**, M.H. Capron** T is a new analgesic, pure agonist of morphine, which seems to have only very. sligh H and R effets. The aim of this study is to verify if this assertion is valid in acute decompensation of left HF. This trial is a prospective, randomised, double-blind, cross-over, comparative

INFLUENCE OF M-ACETYLCYSTEINE IN SEPTIC SHOCK. A. Dougnac, P.F. Laterre, M. Andresen, 0. Deckers, M. Evenepoet, D. Henin, M.S. Reynaert.

study to P. P, without known H or R effect has

been chosen as the reference treatment (instead of placebo) for ethical reasons. Have been included in this trial twelve patients, 71 years (32,83) old, having a cardiogenic acute pulmonary oedema requiring a Swan-Ganz catheter and having a current analgesic prescription. Each patient was normally treated for the HF and also received, at a 24 hour interval, in a cross-over manner, a single 15 minutes I.V. injection of either T 100 mg or P 1 g. Were recorded before the injection, every 15 minutes during the first hour and then every hour till 6 hours after the injection right pressures, cardiac output, arterial blood pressure (radial artery catheter) heart rate,• respiratory rate, arterial and veinous blood gases. The H or R effects are not significantly different between the 2 drugs. However we can observe a slight tendancy to a' negative inotropic effect for T and positive for P, and also two opposit respiratory tendancies with a slight depression for T. The comparative global analysis is not statistically different between T and P.In conclusion, we did not observe any major pernicious effect with either T or P during acute exacerbation of congestive HF. *Hospital of Evry, France ;** (Searle, France).

N-acetylcysteine (NAC) administration in fulminant hepatic failure has been demonstrated to increase 002 and calculated V02 probably by replenishing tissue sulfhydryl groups that could restore nitric oxyde (NO) activity inducing an improvement in regional microcirculatory flow. Despite increased NO activity, the same effects might be expected in severe sepsis. In S patients with proven abdominal septic shock, after optimal treatment by volume loading and cathecolamines infusion, 150 u/kg of NAC Was administrated in 15 min. followed by a continuous infusion of 200 mg/kg/d. Before (TO) and 30 min.(T1) after initiation of NAC, CI, SVR, NI, 002, E02r, Lactate and measured V02 (indirect calorimetry - Del tatraatex) were obtained. TO and Ti values are reported on the table (mean values • SD). CI L min m 0

.1

LVSWI

95L52

SVR 002 e sec cm-5 ml mi

m2

E02r z

nVO2 ml/mm

Lact moot /I

5.4 +1.4

36.6

661

705

160

23

3.1

6.19

+305

+226

.42.2

+4.7

+2.1

6.1 ±2.4

33.5 11.9

524 +187

161

+226

+37.7

22.3 +5.2

3.6 +2.3

NS

NS

NS

NS

NS

747

Ni

NS

NAC infusion induced a non significant increase in CI and D02.mVO2 and Lactate were not modified. SVR decreased in a non significant way. LVSNI was not improved.

Conclusion : In this population, NAC did not inprove hemodynamic parameters +nnd did not increase mVO2. Cliniques Universitaires St. Luc. Intensive Care Unit 1200 Brussels - Belgium.

P449

P450

CARDIAL SIDE EFFECTS AFTER INJECTION OF PIRENZEPIN ARE SIGNS OF MISSING RECEPTOR SPECIF1TY C. Müller, S. Probst*, V. Lischke*

}i.ILä7YIIC 1ttJRA\CF.' 10 PDJix P1'I 1tKLFfLD E INF1 IO4 Itd SEP1IC PAIIUUS: PSELL`U1tAie RP f. V.Ivioovani, G.ihrr*dez, L.Bavestrello, L.Castillo

Under the aspect of life-threatening pneumonias in longterm

ventilated patients receiving antacidas or H2-antagonists the prophylaxis of stress ulcer with pirenzepine gains new

importance.

This study aimed to detect cardial side effects of pirenzepine due

to small receptor specifity. Pirenzepine (10 mg) were given via peripheral or central venous route at an injection velocity of 5 or

30 seconds as well as a control of 2 ml normal saline solution centralvenously during 5 seconds 20 times each. Heartrate and blood pressure were determined before and after the injection. Independent of injection site or velocity an increase of heartrate

was found after the injection of pirenzepine. The increase was more marked when using the central venous route. The percental rise in heartrate was up to the thirteenth minute highly significant comparing pirenzepine to normal saline solution. There were no changes in blood pressure. If M -cholinoceptors are blocked a reduction of heartrate is found, blocking M2- cholinoceptors causes a rise in heartrate. Injecting 10 mg of the Mi -antagonist pirenzepine results in a significant increase of heartrate, independent of site or velocity of injection which can be explained by blocking M2-cholinoceptors at the same time. To prevent this probable dose dependant effect, pirenzepine should begiven slowly over a couple of minutes. Departments of Surgery and Anesthesiology*, University Hospital Frankfurt, Theodor-Stern-Kai 7, 6000 Frankfurt 70, FRG

I^ntoId.fyllille (FIX) has siloco benefit.ial effects in ex perim ental

septic models based on nmrr different points of activity (1IF production, WBC adnesivity and others), which could affect microcirculatory response. Miese are few clinical reports evaluating hEmodyriaiic tolerance to FIX infusion in critically ill patients (P). In a prospective protocol 5

ain frdsterei PLY to 5 Septic P (iii AGE 70,5 Y). A cargiete bemodynanic recording T,es assessed before and after one hour of PIX infusion (0,6 nE/Ks'), aryl repeated one hour after an additional 125 cc 5% dextrose control infusion. All the P iere on llganire (9

up3Kg/min) and two on Ibbutanrirn (7,5 ug/ g/min) during this experiane. (VP, PAW, Nd, LlUd, arxi 02 ext. showed To sigLificant cteres neither did the other results shown n in tie folkMig table: RAI. FLY

(;1

3,2

WE

87

IJ02

SVR

540 794

RBI PIN 3,6

541

77

830

RBY

3,6

]ÄL

537 82

935

Ile only found in are P a drop in PVR (239 10 202) associated with a slit increase in stunt (5%). lle conclude that acute PIX infusion agxmars to hasfl tolerated in septic patients under CatecholaeriraT sur3xort. Future stain sluuld look al the stint r+espolse. ICU - ISP - Clfnica Ptiaca, San Ui el 210 Via del rar - Chile.

S231

P451

P452

PENTOXIFYLLINE INCREASES OXYGEN EXTRACTION DURING TAMPONADE IN AN ENDOTOXIN SHOCK MODEL H. Zhano. H. Sen. M. Benlabed. N. Nbuyen. JL. Vincent

FIBRINMONOMERCONCENTRATION IN SEPTIC AND TRAUMATIC SHOCK

Pentoxifylline (PTX), a xanthine derivative used in the treatment of circulatory insufficiency, has been found to have protective effects in different models of sepsis. We hypothesized that this drug might either increase oxygen delivery (DO2) and/or increase tissue oxygen extraction to meet oxygen demand in sepsis. We studied the effects of PTX on the oxygen uptake/oxygen delivery (VO2/DO2) relationship and tissue oxygen extraction when blood flow was reduced by Inducing cardiac tamponade in 14 anesthetized, ventilated and paralyzed dogs. Via a left thoractomy, a catheter waa inserted into the pericardial space for saline injection. Each dog was given a 2 mg/kg bolus of E. coli endotoxin and received 20 mlkg.h of normal saline•duririg the study. In 7 dogs, PTX was administered as a 20 mg/kg i.v. bolus, followed by a continuous infusion at 20 mglkg.h. V02 was derived from the expired gases. 002 was calculated by the product of the modüution cardiac index and arterial oxygen content. Oxygen extraction ratio (02ER) was defined as the ratio of V02/002. Dual-line regression was used to determine the critical 002 (DO2crit) in each animal. ANOVA was used for statistical analysis. PTX resulted in significant increases in V02 and DO2. Critical V02 was slightly higher in the PTX-treated than in the control group, but it did not reach statistical significance (6.3 ± 2.4 vs 5.4 ± 1.0 ml/kg.min, NS). D02crit which was 11.3± 4.9 ml/kg.min in the control group, was decreased to 9.6 ± 3.6 mlkg.min in the PTX-treated group (p = 0.05). Critical 02ER significantly increased from 50 ± 20% in the control to 68 ± 19% in the PTX-treated animals (p< 0.05). The V02/D02 dependency slope was steeper in the PTX-treated than in the control group (0.77 ± 0.31 vs 0.46 ± 0.18, p< 0.05). At D02c rit, PTX-treated group had lower venoarterial PCO2 difference (12.9 t. 4.3 vs 18.4 ± 7.4 mmHg, p < 0.05) and arteriovenous pH gradient (0.08 ± 0.02 vs 0.11 ± 0.06 U, p < 0.05) than in the control group. Thus, the addition of PTX and fluid therapy can increase 002 and global oxygen extraction capabilities when cardiac output is progressively reduced in the endotoxemic dog. The exact mechanisms remain to be defined. -

Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik. 808, B-1070 Brussels, Belgium

0.Kunitz, T.Hillermann, P.Glöckner, Chr.Agternkamp F.G.Muller, G.kalff During the last years a lot of experimental and clinical studies were made to show the important role of fibrinmonomers (fm) in identifying DIC. According to our animal study - after creating a septic shock in femal pigs by injection of a defined quantity of endotoxin - the fm-concentration raises up to more than 300 % - we started a . cinical study measuring the fmconcentration in different groups of patients. Fm-concentrations were measured in the following groups b using the spectrophotometric method (CoA Set Kabivit rum) group A: controlgroup, healthy patients n=30 group B: non septic / non traumatic patients n= 6 group C: patients with traumatic shock n= 6 group D: patients with septic shock (per definition) n=14 (Patients of group B to D were treated in an ICU) After a fixed schedule blood was taken from all patients for fm-analyse. Fm-concentration was measured in the first day every 4 hours, until the end of septic symptoms every 8 hours. In the controlgroup the fmconcentration was analysed once. In group A and B the fm-concentration was always below 20 nmol/l. In group C and 0 (septic and traumatic shock2 we found ncreases of the fm-concentration (more than increases 100 nmol./1) because of a changed coagulation system. An early increase before appearing oT clinical septic symptoms or a correlation to the clinical picture was not found. In difference to the animal study with 'suboptimal treatment' in our clinical study was shown that the fm-concentration interfeares extremely with the intensive therapy (volumetherapy, blood, heparin and AT III substitution) so that the measured fmconcentration does not relate to the coagulation status. -

Department of Anesthesiology Univ.Dir. Prof. G.Kalff Pauwelstr.30 D-5100 Aachen

Miscellaneous III P453 TRANSFUSION OF FRESH FROZEN PLASMA IN HEART SURGERY PATIENTS SR Leal,JM Flores,V Rivera,P Camacho,J Garnacho,F Murillc Most fresh frozen plasma (FFP) recipients are patients undergoing heart surgery.Although the reason most centers transfuse FFP is to replace clotting factors,it has not been demostrated that its routine use can reduce postoperative blood losses.The present study was designed to evaluate the effect FFP transfusions has on postoperative bleeding in heart surgery patients. undergoing and forty-nine patients A hundred cardiopulmonary bypass (CPB) during 1991 were studied.In the immediate postoperative period,78 patients (Group A) received four units of FFP,however,the remaining 71 (Group B) were not transfused.Average age was 53+12 years (Group A) and 56472 years (Group B) and average weight was 71±12 kg (Group A) and 71+11 kg (Group B).The following factors were evaluated:Surgical procedure (CABG and valve arterial replacement) ,history of heart surgery,NYHA hypertention,diabetes,previous functional classification,prior ingestion of aspirin,warfarin or heparin,graft type employed, numbers of CABGs performed,surgical complications,CPB time (mins),aortic cross clamp time (mins) and postoperative platelet count. First 24-hours and total postoperative blood losses were also recorded. Both groups were statistically homogeneous as far as the before mentioned factors were concerned.Total blood losses were 1022+698 cc and 8791699 cc (NS) and first 24-hours losses were 7451557 cc and 597+460cc (NS),for groups A and B, respectively. Pending confirmation,our results indicate that the routine use of FFP for patients undergoing heart surgery does not reduce postoperative bleeding. Unidad de Cuidados Intensivos.Hospital Universitario Virgen del Rocio.Avda Manuel Siurot s/n.41013.Sevilla.Espana.

P454 MA. ULIBARRENA, N. SAINZ PARDO, JJ. BALLESTERO, V. BOADO JC. VERGARA, JR. IRURETAGOYENA. STERNAL WOUND COMPLICATIONS: A REVIEW OF 647 CONSECUTIVE OPERATIVE PROCEDURES. Sternal dehiscence and mediastinal infection are the major sternal complications following open-heart operations. The rate in some series is 0.5 to 5.9%, and several factors have been suggested as predisposing to this complication. The present retrospective clinical study designed to assess the incidence of major sternal wound complications and its relationship with the factors that appear to increase the risk of these complications. Sis hundred forty seven- operative procedures involving median sternotomy from 1989 to 1991 compose the study group, 67 patients experienced sternal dehiscence (10.4%) and 13 mediastinal infection. Risk factors associated with the development of a sternal wound complication included age, diabetes, chronic pulmonary disease, harvesting of the internal mammary artery, prolonged aortic cross-clamp time, early reesploration for bleding and prolonged respiratory assistance. All cases of mediastinal infection were associated with. sternal dehiscence.

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