Kaposi''s sarcoma-associated herpesvirus and human herpesvirus 8 (KSHV/HHV8)-associated lymphoma of the bowel. Report of two cases in HIV-positive men with secondary effusion lymphomas

BACKGROUND: We evaluated the ability of the standards issued by the Danish Society of Anaesthesiologists to reflect a blood loss. METHODS: In 9 pigs bled (0-24 ml kg-1 and retransfused (to 28 ml kg-1) during halothane anaesthesia central cardiovascular, thoracic electrical impedance (TI), oxygen, acid-base and temperature variables were recorded. RESULTS: With the recommendation for minor surgery (mean arterial pressure (MAP) and heart rate (HR)), the correlation to the blood loss was 0.74 (P < 0.001) and with that for major surgery (MAP, HR, central venous pressure (CVP) and rectal temperature (Tempr)) it was 0.79 (P < 0.001). With the recommendation for extensive surgery (MAP, HR, CVP, pulmonary artery catheter variables and the central-peripheral temperature difference (delta Tempr-t)), the correlation was 0.84 (P < 0.001). Non-invasive monitoring (MAP, HR, delta Tempr-t, TI and near-infrared spectroscopy of the brain (SinvosO2)) was only slightly better than basal monitoring (r = 0.76, P < 0.001). However, adding arterial base excess (BE), TI, and peripheral temperature (Tempt) to the recommendation for major surgery resulted in a correlation of 0.87 (P < 0.001), while adding BE and TI to the recommendation for extensive surgery raised correlation to only 0.88 (P < 0.001). CONCLUSION: When the recommendations were followed the correlation to the blood loss ranged from 0.74-0.84. However, with the recording of MAP, HR, CVP, delta Tempr-t, BE and TI a correlation of 0.87 was achieved, indicating that a pulmonary artery catheter may not be in need for patients undergoing surgical procedures with expected haemorrhage.     

Utility of transesophageal echocardiography and pulmonary artery catheterization during laparoscopic assisted abdominal aortic aneurysm repair

BACKGROUND: Advanced laparoscopic procedures are more commonly performed in elderly patients with cardiac disease. There has been limited data on the use of pulmonary artery catheters (PAC) and transesophageal echocardiography (TEE) to monitor hemodynamic changes. METHODS: We prospectively studied eight patients undergoing laparoscopic assisted abdominal aortic aneurysm repair. All patients had a PAC and all but one had an intraoperative TEE. Data included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex) and was obtained prior to induction, during insufflation, after desufflation, during aortic cross-clamp, and at the end of the procedure. End diastolic area (EDA), a reflection of volume status, was measured on TEE. ANOVA was used for data analysis. RESULTS: No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. PAD and CVP were greater during insufflation compared with baseline and aortic cross-clamp without associated changes in EDA. MAP was higher at baseline compared with all other times during the procedure. CONCLUSIONS: Insufflation increased PAD and CVP. However, volume status as suggested by EDA and PCWP did not change. These data question the reliability of hemodynamic measurements obtained from the PAC during pneumoperitoneum and suggest that TEE may be sufficient for evaluation of volume status along with the added benefit of timely detection of ventricular wall motion abnormalities.     

Influence of urapidil on cerebrospinal fluid pressure in humans with uncompromised intracranial compliance

OBJECTIVE: Determine the influence of urapidil on mean lumbar cerebrospinal fluid pressure (CSFP), mean arterial pressure (MAP), mean central venous pressure (CVP) and heart rate (HR) in awake humans without any evidence of cerebral or cardiovascular disease. DESIGN: Open, single-dose volunteer study. INTERVENTIONS: CSFP was measured via a spinal needle after i.v. injection of a single dose of 0.2 mg kg-1 urapidil in six volunteers (2 female, 4 male). MEASUREMENTS AND RESULTS: After administration of urapidil, CSFP increased from 7 +/- 1 mmHg to 10 +/- 1 mmHg (p < 0.05), MAP decreased from 88 +/- 7 mmHg to 74 +/- 5 mmHg (p < 0.05), CPP decreased from 81 +/- 7 mmHg to 64 +/- 5 mmHg (p < 0.05) and CVP decreased from 0 +/- 1 mmHg to -3 +/- 1 mmHg (p < 0.05). CONCLUSION: Our data suggest that in humans with presumed normal intracranial compliance the administration of urapidil causes a small but statistically significant increase in CSFP due to a parallel decrease in MAP.     

Effect of isosorbide dinitrate on pulmonary venous compliance

Irreversible poor pulmonary venous compliance (PV comp) could worsened natural course of patients (pts) with high pulmonary capillary wedge pressure especially pts with mitral stenosis. Nitrates (isosorbide dinitrate-ISDN) possessing venous dilating action could increase PV comp in most of pts. The main aim of that study was to assess hemodynamic effects of ISDN, in pts with MS, with special emphasis on PV com changes. PV comp was estimated according to Hirakawa equation (dV/dp = 0.4*k2*SV/(v-d) in 35 pts with MS, during preoperative right heart catheterisation with VYGON 5155-180 thermodilution catheters during rest and effort in supine position (25W). The same protocol was performed after Iso-Mack sprawy 3.75 mg. According to the PV comp response to ISDN, pts were divided in two groups: good responders (I)-15% and higher increase in PV comp and poor responders (II). ISDN increased PV comp in the whole group according to the response to ISDN, there were significant differences in stroke volume index (SVI) and heart rate (HR). In the group of good responders mean right atrial pressure (RA), mean pulmonary artery pressure (PAP), mean pulmonary wedge pressure (PWP) decreased significantly with simultaneous slight not significant decrease in SVI and not significant increase of HR. In the group of poor responders SVI decreased significantly by about 20% with significant increase of HR. In conclusion significant decrease in pulmonary pressures (PAP, PWP) in pts with good response to ISDN are secondary to the increase of PV comp, while among poor responders the same effects are due to diminished flow secondary to the decrease of the systemic venous return.     

Short-term outcome and predictors of adverse events following pulmonary thromboendarterectomy

Pulmonary complications including hypoxemia, right heart failure, and prolonged ventilation may follow pulmonary thromboendarterectomy (PTE) performed via cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. Seventeen adult patients have undergone PTE at the University of Maryland Medical System during the preceding 3 years. From these patients, clinical and hemodynamic parameters were tabulated pre-CPB, post-CPB, at admission to the intensive care unit (ICU), and prior to discontinuation of invasive monitoring in the ICU. Data on anthropometric variables, survival, and times of extracorporeal circulation, mechanical ventilation, and hospital stay were also collected. The mean values for pulmonary arterial systolic and diastolic pressures and pulmonary vascular resistance (PVR) decreased significantly from pre-CPB values after PTE (all p < 0.05). Mild mixed acidosis present at ICU admission resolved prior to discharge (p = 0.002). The length of mechanical ventilation time was positively correlated with the absolute post-CPB PVR and negatively correlated with the relative change in central venous pressure (CVP) from pre-CPB to post-CPB values (r = 0.75, p = 0.037). Of the pre-CPB anthropometric variables, only body mass index was significantly higher in nonsurvivors (p = 0.037). Pulmonary artery pressures and vascular resistance fall significantly after PTE. A lower post-CPB PVR and a relatively decreased (i.e., from pre-CPB values) CVP predict reduced length of postoperative ventilation but not of the hospital stay. Mortality appears increased in patients with a large body habitus.     

Effects of lamotrigine and conventional antiepileptic drugs on amygdala- and hippocampal-kindled seizures in rats

A computer aided monitor-data processing system (CAMP-System) was developed in order to get a consistent and comprehensive database which can very precisely reflect intra-operative haemodynamic courses. The goal of the present study was to introduce a new method to scan and to gauge haemodynamic courses and to demonstrate its superiority over the traditional way of data processing based on a handwritten anaesthesia protocol. METHODS: The computerized system was applied to a study which was designed to investigate the influence of ketanserin (K) vs. urapidil (U) on haemodynamic stability during cardiac operations. Twenty male patients scheduled for myocardial revascularization received either 20 mg K or 30 mg U. Heart rate, central venous, arterial and pulmonary artery pressures were measured and on-line recorded every 20 seconds by the computer record system. In the handwritten protocol these variables were registered at eight pre-defined time points. Computerized data processing (including artifact depletion and data condensation) was compared to the results evaluated from the handwritten protocol. RESULTS: While the only significant differences in the handwritten protocol were slightly higher values of pulmonary artery pressures in group K, the computer analysis revealed a number of further differences. Higher maximum and a less stable time course of HR in group K in the pre-bypass phase and lower mean and standard deviation of MAP during cardiopulmonary bypass. CONCLUSION: Computerized data processing including automatic artifact suppression and data condensation was able to reveal differences in the course of haemodynamic variables that cannot be detected in a conventional handwritten protocol.     

Circulatory changes during anesthetic induction: impact of d-tubocurarine pretreatment, thiamylal, succinylcholine, laryngoscopy, and tracheal lidocaine

Circulatory changes after IV d-tubocurarine (3 mg), thiamylal (4 mg/kg) plus succinylcholine (2 mg/kg) and followed by direct laryngoscopy with or without intratracheal lidocaine spray (2 mg/kg) just before endotracheal intubation (EI), were measured in 40 adult patients. Pretreatment with d-tubocurarine did not alter mean arterial pressure (MAP), heart rate (HR), or central venous pressure (CVP). One minute after thiamylal-succinylcholine and just before laryngoscopy, MAP was 15 torr less than the awake value (p less than 0.05) and HR was 13 beats/min greater than the awake value (p less than 0.05). Laryngoscopy and EI elevated MAP above awake levels and further increased HR in all patients. The magnitude of these responses immediately following EI was not altered by tracheal lidocaine. However, the pressor and HR changes following EI were more transient when tracheal lidocaine was used (20 patients) and these patients were more likely to tolerate the tracheal tube without immediate additional anesthesia. The incidence of ventricular dysrhythmias was not altered by tracheal lidocaine. Compared with awake values, the cardiac index did not change significantly following intubation but stroke volume was decreased (p less than 0.05), with or without tracheal lidocaine.     

Molecular genetics of asymmetric cleavage in the early Caenorhabditis elegans embryo

BACKGROUND: Pharmacological control of blood pressure is usually indicated during aortic cross-clamping (AXC). The aim of this study was to analyze the modulation by isoflurane (ISO), sodium nitroprusside (SNP) and milrinone (MIL) of the systemic circulatory responses to a standardized infra-renal AXC. METHODS: Chloralose-anaesthetized pigs were exposed to AXC at control (no vasoactive drugs) and during the administration of each of the drugs. RESULTS: During control, AXC increased mean arterial pressure (MAP, 17 +/- 4%) and systemic vascular resistance (SVR, 27 +/- 7%), but induced no significant changes in cardiac output (CO), heart rate (HR), pulmonary arterial pressures, pulmonary vascular resistance or central venous pressure. Low-dose ISO (0.7%) and investigated doses of SNP and MIL did not significantly alter this response. High-dose ISO (1.4%, attenuated the AXC-induced increase in SVR, but not in MAP. All drugs decreased non-clamp MAP levels. Therefore, with low-dose ISO and with SNP or MIL, peak MAP during AXC was not significantly different from control non-clamp levels (i.e. prior to pharmacological or surgical interventions). High-dose ISO was associated with a MAP during AXC that was below control non-clamp levels. CONCLUSIONS: The objective that during AXC MAP should not exceed control non-clamp levels was achieveable by ISO, SNP or MIL. The modulating actions of the drugs on MAP during AXC were exerted mainly through reductions in non-clamp levels. This systemic hypotension was associated with decreased CO and SVR during ISO, and with decreased SVR and increased HR during SNP and MIL. Attenuation of the AXC-induced increase in SVR was produced only by 1.4% ISO.     

Growth-induced haemodynamic changes in healthy Friesian calves

This study investigated the pattern of growth-induced haemodynamic changes in normal calves during their first year of life. The central venous pressure (CVP), the right ventricular pressure (RVP), the pulmonary arterial pressure (PAP), the pulmonary capillary wedge pressure (PW), the systemic arterial pressure (SAP) and the cardiac output (CO) were measured in 41 healthy Friesian calves. The heart rate (HR), the stroke volume (SV), the cardiac and stroke indices (CI and SI, respectively), the pulmonary and systemic vascular resistance (PVR and SVR, respectively), the right ventricular and left ventricular work (RVW and LVW, respectively) and their corresponding indices (PVRI, SVRI, RVWI and LVWI, respectively) were also measured or calculated. The cardiac output, SV, SAP, PVRI, SVRI, RVW and LVW increased significantly while the HR, CI, PVR, SVR, RVWI and LVWI decreased significantly with somatic growth. The right-sided vascular pressures did not change significantly. The significant increase in systemic arterial pressure may be due to the simultaneous increase in CO. The high CI observed in the first few weeks of life was attributed to a high metabolic rate and might induce a reduced cardiac pumping reserve in young calves. In consequence, a therapeutic inotropic intervention may have little potential benefit at this age.     

Effects of loprinone hydrochloride on hemodynamics and respiratory oxygenation in patients after cardiac surgery

Loprinone hydrochloride (Lop), a phosphodiesterase fraction III inhibitor and positive inotrope, was recently released in Japan. We evaluated its dose-related effects on hemodynamics and oxygenation as as well as on plasma levels of Lop in ten patients after cardiac surgery. Immediately after admission to the intensive care unit, baseline hemodynamics and arterial blood gas data were obtained; patients with inotropic support, were given 0.1, 0.2, 0.3 microgram.kg-1.min-1.lop over 1 hour incrementally, and additional data were obtained. CI increased significantly from baseline (2.1 +/- 0.3 l.min-1.m-2) to 3.2 +/- 0.8 at 0.3 microgram.kg-1.min-1. Systemic vascular resistance decreased significantly from baseline (2853 +/- 439 dynes.sec.cm-5.m-2) to 1554 +/- 440 at 0.3 micrograms. kg-1.min-1, and mean arterial pressure also decreased significantly from baseline. There were no significant changes in heart rate (HR), central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), or PaO2.FIO2(-1) in patients over the period evaluated. Plasma levels of Lop rapidly increased to 27.8 ng.ml-1 (effective level; 20 ng.ml-1) at 0.3 microgram.kg-1.min-1. In this study, Lop was shown to effectively increase CI in patients after cardiac surgery with no significant changes in HR, CVP, PAOP or PaO2/FIO2. Thus, Lop has a beneficial effect in the treatment of patients with low cardiac output immediately after cardiac surgery.     

Effect of hemofiltration on hemodynamics and systemic concentrations of anaphylatoxins and cytokines in human sepsis

OBJECTIVE: To determine whether hemofiltration (HF) can eliminate cytokines and complement components and alter systemic hemodynamics in patients with severe sepsis. DESIGN: Prospective observation study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: 16 patients with severe sepsis. INTERVENTIONS: Continuous zero-balanced HF without dialysis (ultrafiltrate rate 2 l/h) was performed in addition to pulmonary artery catheterization, arterial cannulation, and standard intensive care treatment. MEASUREMENTS AND MAIN RESULTS: Plasma and ultrafiltrate concentrations of cytokines (the interleukins IL-1 beta, IL-6, IL-8, and tumor necrosis factor alpha) and of complement components (C3adesArg, C5adesArg) were measured after starting HF (t0) and 4 h (t4) and 12 h later (t12). Hemodynamic variables including mean arterial pressure (MAP), mean central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output were serially determined. During HF, cytokine plasma concentrations remained constant. However, C3adesArg and C5adesArg plasma concentrations showed a significant decline during 12-h HF (C3adesArg: t0 = 676.9 +/- 99.7 ng/ml vs t12 = 467.8 +/- 71, p < 0.01; C5adesArg: 26.6 +/- 4.7 ng/ml vs 17.6 +/- 6.2, p < 0.01). HF resulted in a significant increase over time in systemic vascular resistance (SVR) and MAP (SVR at t0: 669 +/- 85 dyne.s/cm5 vs SVR at t12: 864 +/- 75, p < 0.01; MAP at t0: 69.9 +/- 3.5 mmHg vs MAP at t12: 82.2 +/- 3.7, p < 0.01). CONCLUSIONS: HF effectively eliminated the anaphylatoxins C3adesArg and C5adesArg during sepsis. There was also a significant rise in SVR and MAP during high volume HF. Therefore, HF may represent a new modality for removal of anaphylatoxins and may, thereby, deserve clinical testing in patients with severe sepsis.     

Laparoscopy in high-risk cardiac patients

Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.     

Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease. Additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction

OBJECTIVES: The purpose of this study was to determine whether left atrial size and ejection fraction are related to left ventricular filling pressures in patients with coronary artery disease. BACKGROUND: In patients with coronary artery disease, left ventricular filling pressures can be estimated by using Doppler mitral and pulmonary venous flow velocity variables. However, because these flow velocities are age dependent, additional variables that indicate elevated left ventricular filling pressures are needed to increase diagnostic accuracy. METHODS: Echocardiographic left atrial and Doppler mitral and pulmonary venous flow velocity variables were correlated with left ventricular filling pressures in 70 patients undergoing cardiac catheterization. RESULTS: Left atrial size and volumes were larger and left atrial ejection fractions were lower in patients with elevated left ventricular filling pressures. Mean pulmonary wedge pressure was related to mitral E/A wave velocity ratio (r = 0.72), left atrial minimal volume (r = 0.70), left atrial ejection fraction (r = -0.66) and atrial filling fraction (r = -0.66). Left ventricular end-diastolic and A wave pressures were related to the difference in pulmonary venous and mitral A wave duration (both r = 0.77). By stepwise multilinear regression analysis, the ratio of mitral E to A wave velocity was the most important determinant of pulmonary wedge (r = 0.63) and left ventricular pre-A wave (r = 0.75) pressures, whereas the difference in pulmonary venous and mitral A wave duration was the most important variable for both left ventricular A wave (r = 0.75) and left ventricular end-diastolic (r = 0.80) pressures. The sensitivity of a left atrial minimal volume > 40 cm3 for identifying a mean pulmonary wedge pressure > 12 mm Hg was 82%, with a specificity of 98%. CONCLUSIONS: Left atrial size, left atrial ejection fraction and the difference between mitral and pulmonary venous flow duration at atrial contraction are independent determinants of left ventricular filling pressures in patients with coronary artery disease. The additive value of left atrial size and Doppler variables in estimating filling pressures and the possibility that left atrial size may be less age dependent than other mitral and pulmonary venous flow velocity variables merit further investigation.     

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit

BACKGROUND: Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL). METHODS: All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU. RESULTS: Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm3), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0. 001) than pre-DL pressures without any significant change in end-tidal CO2 or pCO2. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP). CONCLUSIONS: Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL.     

Hypotension during subarachnoid anaesthesia: haemodynamic effects of colloid and metaraminol

We have studied 45 patients, aged 60-95 yr, receiving subarachnoid block for neck of femur fractures. Patient received either colloid (polygeline, Haemaccel) 8 ml kg-1 (n = 15), metaraminol 5 micrograms kg-1 and 1.7 micrograms kg-1 min-1 (n = 15) or a combination of both treatments to maintain systolic arterial pressure (SAP) between 75 and 100% of baseline. If necessary, additional colloid 2 x 4 ml kg-1 or metaraminol 3 x 2.5 micrograms kg-1 was given. Arterial pressure was measured by automated oscillotonometry, central venous pressure (CVP) by a manometer and cardiac index (CI), stoke index (SI) and heart rate (HR) by transthoracic electrical bioimpedance. Systemic vascular resistance index (SVRI) was derived. Colloid was less effective than metaraminol (P < 0.05). In the colloid group, SAP and SVRI decreased and CVP, CI and SI increased (P < 0.001). In the metaraminol group, initial decreases in SAP, SVRI and CVP were restored after 10-15 min and HR decreased after 12 min (P < 0.001). In the combined group, initial decreases in SAP and SVRI were restored after 4 and 16 min, and CVP, CI, SI and HR increased (P < 0.001). Metaraminol was more effective than colloid because it increased SVRI, whereas colloid increased CVP without significantly increasing CI.     

Sequential cardiorespiratory patterns of anesthetic induction with ketamine in critically ill patients

Hemodynamic and O2 transport effects of ketamine anesthesia were evaluated in 22 critically ill patients. After placement of radial and pulmonary artery catheters, simultaneous measurement were made of cardiac output, intravascular pressures, arterial and mixed venous gases, saturations, pH, and Hct; cardiorespiratory values then were calculated for a preinduction control period and sequentially at frequent intervals over a 15-min observation period. In general, there was an early progressive increase in HR, cardiac index (CI), arterial and venous pressures, stroke work, and O2 delivery (DO2); O2 consumption (VO2) and O2 extraction (O2 Ext) decreased. In general, ketamine produced an inotropic cardiac response, but these responses were not uniform; a relatively small percentage had reduced pressures, flow, and reduced myocardial performance that were related to hypovolemia and associated medical conditions.     

Cardiovascular responses to gastric hypo-osmolar stimulation in anesthetized dogs

We compared the cardiovascular response to the gastric infusion of distilled water (DI) with that to the gastric infusion of 0.9% saline (SI) and gastric ballooning with 37 degrees C water (BA) through a gastric fistula in splenectomized mongrel dogs (n = 7). DI, and SI amounting to 5% of body wt and the same volume of water were infused in approximately 20 s through the tube and responses in mean arterial pressure (MAP), CVP, heart rate (HR), and intra-esophageal pressure (EP) were monitored continuously. After DI, SI, and BA, the measured variables showed significant increases and attained maximal increases at about 2 min after the treatments. After DI, the maximum elevation in MAP was 21.3 +/- 1.9 mmHg and 2 times higher than in SI and BA. The corresponding value in CVP was 5.0 +/- 0.3 mmHg and 2-3 times higher than with SI and BA, and HR increased by 26.1 +/- 3.0 beats/min showing 3 to 6 times larger increases compared with SI and BA. These gastro-cardiovascular reflexes were abolished after subdiaphragmatic truncal vagotomy. These findings suggest that both the mechanical and osmotic stimuli to the stomach induce cardiovascular reflexes and that the vagus is involved in the reflex.     

Polygraphic validation of distraction tasks in clinical differential tremor diagnosis

We studied the effect of inhaled nitric oxide (NO) on 80 patients who had undergone cardiac surgery in our center. The indications for receiving NO inhalation and the number of patients were as follows: Pp/Ps > 0.5 for pulmonary hypertension (PH) (n = 32; 21 children and 11 adults), severe PH crisis (n = 9), high pulmonary vascular tone (Glenn pressure more than 18 mm Hg after bidirectional Glenn operation) or arterial oxygen saturation (SaO2) less than 70% despite an FiO2 of 1.0 after Blalock-Taussig shunt (n = 6), mean pulmonary artery pressure (PAP) > 15 mm Hg and transpulmonary gradient (TPG) (mean PAP - left atrial pressure [LAP]) > 8 mm Hg after Fontan-type operation (n = 18), elevated pulmonary vascular tone (mean PAP > 30 mm Hg and left ventricular assist system [LVAS] flow rate < 2.5 L/min/m2) in patients with LVAS (n = 3), and impaired oxygenation (PaO2/FiO2 < 100 under positive end-expiratory pressure [PEEP] > 5 cm H2O) (n = 12). Low dose inhaled NO (10 ppm) had the following effects. In adult PH patients, it significantly reduced the mean PAP (from 37.3 to 27.0 mm Hg; average values are given) and increased the mean systemic arterial pressure (SAP) (64.7 to 75.3 mm Hg). In infant PH patients, it increased the mean SAP (51.8 to 56.1 mm Hg). In patients with a PH crisis, it significantly reduced the central venous pressure (CVP) (13.3 to 8.8 mm Hg) while increasing both the mean SAP (49.4 to 57.9 mm Hg) and PaO2/FiO2 (135 to 206). In patients after a Fontan-type operation, it significantly reduced the mean PAP (16.8 to 13.8 mm Hg) and TPG (9.5 to 5.8 mm Hg). In patients under LVAS, it reduced the CVP (11.7 to 8.0 mm Hg) and mean PAP (32.0 to 24.7 mm Hg). In impaired oxygenation patients, PaO2/FiO2 was increased (75 to 106). Sixty-five patients were all followed for 2.0-4.3 years (average, 3.1 years). All 65 patients remained free from oxygen requirement, and possible chronic adverse effects including the occurrence of malignant tumors or chronic inflammation in the respiratory tract were not observed.     

Scorpion venom leads to gastrointestinal ischemia despite increased oxygen delivery in pigs

OBJECTIVES: Scorpion envenomation may be accompanied by metabolic acidosis even in the absence of hypoxia and cardiovascular derangement. We tested the hypothesis that venom causes ischemia of the gastrointestinal tract rather than failure of delivery of oxygen to the periphery. DESIGN: Repeated measures, prospective study in experimental animals. SETTING: University-affiliated hospital research laboratory. INTERVENTIONS: In ten spontaneously breathing, intubated, sedated pigs, purified dried venom (Leiurus quinquestriatus), 0.05 mg/kg, was administered intravenously. Measurements were obtained before (baseline), and 5, 15, 30, 60, 120, 180, and 240 mins after injection. MEASUREMENTS AND MAIN RESULTS: Variables measured included: mean arterial pressure (MAP), heart rate (HR), mean pulmonary arterial pressure, pulmonary artery occlusion pressure, cardiac output, stroke volume, right ventricular ejection fraction (rapid thermistor), left ventricular dimensions (echocardiography), arterial gas tensions, lactate and catecholamine concentrations, gastric interstitial mucosal pH (tonometry), as well as systemic and pulmonary vascular resistances. Within 5 mins after venom injection, there was a hyperdynamic state accompanied by significantly increased MAP (97 +/- 18 to 136 +/- 47 mm Hg, p < .0003), HR (70 +/- 12 to 121 +/- 24 beats/min, p < .00006), and cardiac output (1.88 +/- 0.35 to 2.95 +/- 0.53 L/min, p < .0003), with no change in stroke volume, or pulmonary artery occlusion pressure. Right ventricular ejection fraction increased from 38.1 +/- 4.3 to 48.6 +/- 9.0% (p < .0009) by 15 mins. No change in left ventricular function was observed. There were significant decreases in systemic vascular resistance and pulmonary vascular resistance following envenomation. Arterial and gastric mucosal pH significantly decreased from 7.40 +/- 0.04 to 7.25 +/- 0.07 (p < .0001) for arterial pH, and 7.33 +/- 0.08 to 7.17 +/- 0.13 (p < .00001) for gastric mucosal pH by 30 mins after envenomation. The decrease in arterial pH was not sufficient to account for the change in gastric mucosal pH, indicating gastric mucosal ischemia. Arterial lactate increased from 2.6 +/- 1.4 to 7.4 +/- 1.9 (p < .05 x 10(-8)). There were significant increases in serum epinephrine and norepinephrine values by 5 mins. All hemodynamic variables and catecholamine concentrations returned to baseline by 4 hrs. However, there was persistent arterial and gastric mucosal acidosis and increased lactate concentrations even at 4 hrs. Oxygen delivery remained normal or supernormal for 4 hrs following envenomation. However, despite this finding, systemic and gastric mucosal pH changes indicate impaired gastrointestinal oxygen delivery. CONCLUSIONS: Despite increased peripheral oxygen delivery, scorpion envenomation was associated with evidence of ischemia of the gastrointestinal tract. This association could be due to shunting of blood from metabolically active areas, possibly associated with massive catecholamine release, or a direct toxic effect of the venom on regional oxygen transport at the cellular level.