Arterial blood gases in acute pulmonary edema

Arterial blood gas and pH measurements in 82 patients with acute pulmonary edema of cardiogenic origin entering the emergency department varied widely and were unpredictable using clinical examination. The mean arterial oxygen tension (PaO2) measured in 71 patients breathing room air was 59 mm Hg. Fourteen of the 82 patients were acidemic; 35, alkalemic and 33 had a pH in the normal range. The acidemic group had markedly lower PaO2, all under 60 mm Hg. Oxygen and furosemide were used in all cases and effectively corrected the hypoxia and reduced pulmonary congestion. Other drugs used included aminophylline (14 patients), morphine sulfate (9 patients) and digoxin (3 patients). Five of the nine patients who received morphine were hypercarbic initially but the CO2 retention did not worsen. No patient died during the initial 48 hours. This study reiterates the importance of directing therapy at ventilatory and cardiac abnormalities and points out the value of arterial blood gas monitoring to assess the initial status, monitor the patient's course, and to select drug therapy.     

Post-obstructive pulmonary edema after adenoid-amygdalectomy

A two-years-old boy with Down's Syndrome and a small interauricular communication was given priority scheduling for adenoidectomy and tonsillectomy to correct subacute obstruction of the upper airway. The only noteworthy event during surgery was an SpO2 of 92% during mechanical ventilation with FiO2 of 0.5 from no apparent cause. The patient suffered acute respiratory insufficiency due to the post-obstructive pulmonary edema in the hours immediately following surgery. The incidence of post-obstructive pulmonary edema is higher than might be expected, as symptoms can be interpreted as aspiration pneumonitis or left ventricular failure. Given the high prevalence of adenoiditis and tonsillitis with varying degrees of airway obstruction in children, we consider it useful to report this case. Such patients should be monitored carefully in the early postoperative period.     

Invasive angiology in acute arterial pathology in a critically ill newborn infant

Four patients who complained of symptoms and signs compatible with biliary tract disease and in whom the diagnosis of gallbladder (three cases) and common bile duct ascariasis (one case) was made sonographically are reported. In two patients with gallbladder ascariasis, cholecystectomy corroborated the presence of the round-worms, and was curative. The third patient was a pregnant woman (32nd gestational week) who took piperazine citrate, and a second sonogram performed 29 days later was completely normal. The fourth patient with common bile duct ascariasis underwent choledochotomy with extraction of one ascaris lumbricoides from the common duct, and a T tube was left in place for 15 days. All patients received antiparasitics and had a favorable outcome. Ultrasonography is an important noninvasive diagnostic procedure in the work-up of these patients, who usually describe a clinical picture suggesting gallstone disease: this is especially true in the presence of pregnancy.     

Postoperative acute pulmonary edema: a rare presentation of pheochromocytoma

The Duromedics bileaflet pyrolitic carbon mechanical prosthesis was introduced by Hemex in 1982 and subsequently acquired by Baxter. This communication documents a case of sudden leaflet fracture of a Duromedics mitral valve 48 months after implantation, which was managed successfully by replacement with a St. Jude Medical mechanical prosthesis. The patient presented in acute distress with paroxysmal atrial tachycardia and pulmonary edema. Transesophageal echocardiography was used to diagnose the leaflet fracture. The fracture had occurred transversely, with the fragments embolizing bilaterally to the iliofemoral arteries. These were removed at a subsequent operation. Cases of such fractures of the Duromedics prosthesis have been reported, with cavitation damage being the postulated mechanism.     

Communication breakdown: a preventable cause of acute renal failure in a newborn infant

A three-week-old boy had life-threatening renal failure which was successfully treated by salbutamol and sodium bicarbonate infusion, rectal resonium and a left percutaneous nephrostomy. Ultrasonography of this child at 19 weeks' gestation had shown a treatable renal tract abnormality (bilateral hydronephrosis). No arrangements had been made for follow-up.     

A case of acute pulmonary edema and bulbar paralysis after local epinephrine infiltration

A cataract developed in a 23-year-old man 4 months after a vitrectomy to repair a traumatic retinal detachment. An uneventful phacoemulsification was performed, using antibiotic-fortified infusion solution. Afterward, a large area of atrophic retina, consistent with gentamicin toxicity, was observed in the macula. The patient remains stable with 20/200 best-corrected acuity. The authors suggest that because the vitreous had been removed, gentamicin was able to settle over the macula during the entire cataract procedure. Therefore, gentamicin should be used intracamerally with caution, especially in eyes in which vitrectomy has been performed.     

Surgical correction of acute congenital cardiopathies in the newborn infant

The experience of the Cardiac Surgery Service at the Hospital del Ni?o IMAN with the deep hypothermia method and hemodynamic arrest is shown in 30 infants with severe congenital cardiac malformations. The procedures followed before and during the operation are carefully described in their three aspects; anesthesia, extracorporeal circulation and surgery, including postoperative care. Ventilatory assistance is stressed. Results are analyzed considering postoperative evolution; stress is made on the causes of morbidity and mortality. Considering the results of this and other similar reports, we believe that the deep hypothermia method and heart arrest in treating severe cardiac malformations in infants are of outstanding importance since they have significantly improved results in these problems.     

Effect of eicosanoid inhibition on the development of pulmonary edema after acute lung injury

In experimental models of acute lung injury, cyclooxygenase inhibition improves oxygenation, presumably by causing a redistribution of blood flow away from edematous lung regions. This effect on perfusion pattern could also reduce alveolar edema formation. On the other hand, pulmonary pressures usually increase after cyclooxygenase inhibition, an effect that could exacerbate edema accumulation. Therefore we tested the following hypothesis: the total accumulation of pulmonary edema in dogs during a 24- to 28-h period of observation after acute lung injury caused by oleic acid will be less in a group of animals treated with meclofenamate (n = 6) or with the thromboxane-receptor blocker ONO-3708 (n = 5) than in a group of animals treated with oleic acid alone (placebo, n = 6). Lung water concentrations (LWC), the regional pattern of pulmonary perfusion, and protein permeability were measured with the nuclear medicine imaging technique of positron emission tomography. After 24-28 h, LWC was significantly less (P < 0.05) in the ONO-3708 group than in the meclofenamate group (a similar trend was seen compared with the placebo group, P = 0.12). After 24-28 h, pulmonary arterial pressures were highest in the meclofenamate group. Regardless of group, the only significant correlation with the change in LWC was with the integral of pulmonary pressures over the 24- to 28-h period. The data suggest that thromboxane inhibition will reduce edema accumulation in acute lung injury but that this effect depends on reducing as much as possible the simultaneous development of pulmonary hypertension from other causes.     

Endothelial selectins in acute mountain sickness and high-altitude pulmonary edema

STUDY OBJECTIVES: Mechanical or inflammatory injury to pulmonary endothelial cells may cause impaired pulmonary gas exchange in acute mountain sickness (AMS) and noncardiogenic pulmonary edema in high-altitude pulmonary edema (HAPE). This study was designed to determine whether markers of endothelial cell activation or injury, plasma E- and P-selectin, were increased after ascent to high altitude, in AMS or in HAPE. DESIGN: We collected clinical data and plasma specimens in control subjects at sea level and after ascent to 4,200 m, and in climbers with AMS or HAPE at 4,200 m. Data analysis was performed using standard nonparametric statistical methods, and results reported as mean+/-SD. SETTING: National Park Service medical camp at 4,200 m on Mt. McKinley (Denali), Alaska. PATIENTS: Blood samples and clinical data were collected from 17 healthy climbers at sea level and again after ascent to 4,200 m, and from a different group of 13 climbers with AMS and 8 climbers with HAPE at 4,200 m. Climbers with AMS were divided into normoxic (n=7) and hypoxemic (n=6) groups. MEASUREMENTS AND RESULTS: Using an enzyme immunoassay technique, plasma E-selectin concentrations were found to be increased in the 17 control subjects after ascent to 4,200 m (17.2+/-8.2 ng/mL) as compared to sea level (12.9+/-8.2 ng/mL) (p=0.001). Plasma E-selectin concentrations were also increased in subjects with hypoxemic AMS (30.6+/-13.4 ng/mL) and HAPE (23.3+/-9.1 ng/mL) compared to control subjects at sea level (p=0.009). Increased plasma E-selectin concentration significantly correlated with hypoxemia (p=0.006). Plasma P-selectin concentrations were unchanged after ascent to 4,200 m and in subjects with AMS and HAPE. CONCLUSION: Because E-selectin is produced only by endothelial cells, increased plasma E-selectin after ascent to high altitude and in hypoxemic climbers with AMS and HAPE provides evidence that endothelial cell activation or injury is a component of hypoxic altitude illness.     

Afterload reduction with phentolamine in patients with acute pulmonary edema

Phentolamine in amounts of 10 to 40 microgram/kg/min was infused intravenously for the emergency treatment of acute pulmonary edema due to left ventricular failure. Fourteen patients with arteriosclerotic heart disease, ranging in age from 52 to 87 years, had clinical and roentgenographic signs of pulmonary edema. The pulmonary artery wedge pressure was increased to an average of 24 mm Hg and the cardiac index was decreased to 1.9 liters/min/m2 or less prior to the administration of phentolamine. A reduction in the pulmonary artery wedge pressure to 14 mm Hg and an increase in the cardiac index to 2.5 liters/min/m2 was observed in response to this alpha adrenergic blocking agent. Reduction in peripheral resistance with phentolamine was associated with reversal of pulmonary edema.     

Reexpansion pulmonary edema occurring after thoracoscopic drainage of a pleural effusion

Video assisted thoracoscopic drainage and tale pleurodesis was used to treat a recurrent pleural effusion in a 60 year-old woman undergoing major gynecologic surgery. She developed reexpansion pulmonary edema immediately following surgery. Several important risk factors that were present in this patient are discussed. In addition to almost, complete collapse of the underlying lung for several weeks, thoracoscopy resulted in manipulations and rapid re-inflation of the underlying lung, which further increased the risk to the patient.     

Hemodynamic pulmonary edema in dogs with acute and chronic lymphatic ligation

The effect of lymphatic ligation on relative lung water (g H2O/g dry lung) was studied in dogs. Raising left atrial pressure to 20 mmHg for 2 h in chronically lymphatic-ligated dogs (4 days) caused a significantly greater increase in relative lung water than the same hemodynamic challenge did in sham-operated and acutely lymphatic-ligated dogs. There was no significant difference in relative lung water between the acutely lymphatic-ligated and sham-operated dogs. At normal left atrial pressures, there was no significant difference in relative lung water between the sham-operated and chronically lymphatic-ligated dogs. Since the combined effects of chronic lymphatic ligation and left atrial hypertension is greater than the sum of the individual effects, it appears that chronic lymphatic ligation increases the susceptibility of the lung to hemodynamic edema, we suggest that chronic lymphatic ligation may have produced increases in the interstitial volume and protein mass that are undetectable by our technique. These increases, in turn, could lead to a reduction in tissue safety factors against hemodynamic pulmonary edema.     

Dysentery in the newborn infant

DNA replication in eukaryotic cells is closely associated with protein synthesis. When protein synthesis is specifically inhibited, DNA synthesis stops quickly too. No precise knowledge has been so far available concerning the reasons of this coupling. The data presented confirm an earlier established for Chlorella fact that the inhibition of DNA synthesis in L-cells, due to a several hours treatment with hidroxyurea, results in a consequent stability of DNA synthesis in these cells to a protein synthesis inhibitor--cyclohexamide.     

Accessory artificial circulation in complex treatment of experimental acute toxic pulmonary edema

In experiments on 50 dogs with toxic acute edema of the lung, induced with intravenous injection of 0.1% silver nitrate, the authors have studied the efficacy of accessory artificial circulation and "conservative" therapy. During the perfusion a discharge of the right portions, adequate extracorporeal gas metabolism, normalization of blood gas and acid-base balance were noted; an intensity of pulmonary edema is descreased. An intensive therapy for pulmonary edema was found to be more effective in association of "conservative" treatment with venoarterial perfusion and blood oxygenation.