Comparison of double-lung jet ventilation and one-lung ventilation for thoracotomy.

BACKGROUND AND OBJECTIVE: Thoracic surgery requires immobilization of the operating area. Usually, this is achieved with one-lung ventilation (OLV), however this may still lead to some movement. High-frequency jet ventilation (HFJV) may be an alternative way of ventilation in thoracic surgery. The purpose of this study was to determine the effectiveness of HFJV as an alternative option to OLV for thoracic procedures. METHODS: Sixty patients were randomized to receive either HFJV (n = 29) or OLV (n = 31) during the operation. During the course of the study 10 patients were excluded (4 patients in HFJV group and 6 patients in OLV group). The following haemodynamic and ventilatory parameters were recorded: heart rate, systolic and mean blood pressure, ventricular stroke volume, cardiac index, systemic vascular resistance, peak inspiratory pressure, oxygen saturation, PaO2 and PaCO2. Overall parameters were documented before the initiation of the chosen mode of ventilation every 15 min during the operation. RESULTS: Patients in both groups showed comparable cardiovascular function. Mean values of peak inspiratory pressure were significantly higher in the OLV group. Oxygen saturation values were statistically higher in the HFJV group. PaCO2 values were similar in both during surgery, but were higher in the OLV group after awakening. Mean values of shunt fraction were lower in the HFJV group. Lower values of peak inspiratory pressure were therefore associated with higher partial pressure of carbon dioxide levels in the HFJV group. In the OLV group, 44% of patients experienced a postoperative sore throat. Operating conditions were comparable. CONCLUSION: HFJV is safe option, comparable to OLV and offers some advantages for open-chest thoracic procedures.

Exhaled nitric oxide concentration in patients after heart transplantation.

Nitric oxide (NO) is present in exhaled air in humans and its level may decrease in heart diseases. In the present study we prospectively investigated how heart transplantation treated with oral immunosuppresive drugs based on ciclosporine A influences the exhaled NO concentration (exNO). The study was performed in 17 patients after heart transplantation in various time after procedure and 15 nonsmoking healthy volunteers as a control group. Patients after heart transplantation were free of clinical signs of rejection. End-tidal concentration of exNO was measured by the use of a chemiluminescence method. We found no statistically significant differences in the exNO level between patients after heart transplantation and healthy controls (6.81+/-2.70 part per billion (ppb) in the transplant group vs. 6.01+/-3.43 ppb in the control group). We conclude that heart transplantation and immunosuppresive therapy do not influence the exhaled NO concentration.

Potential confounding factors in measurement of exhaled nitric oxide.

Nitric oxide is present in the exhaled air. Factors affecting the level of exhaled nitric oxide (exNO), except for smoking, are not well defined. In this study we seek to determine whether age, gender, body mass index (BMI), part of the day, or time after a meal could modulate exNO levels. exNO was examined by the use of a chemiluminescence method in 100 subjects - 31 women (19 nonsmokers and 12 smokers) and 69 males (55 nonsmokers and 14 smokers). Forty four subjects took medications due to stable coronary disease, 22 were after heart transplantation, and 34 did not take any drugs. We found that exNO levels did not differ either between the whole groups of women and men or between smokers and nonsmokers of either respective group (4.91 +/-2.38 vs. 6.27 +/-4.23 ppb; 3.21 +/-1.16 vs. 3.71 +/-1.55 ppb; 5.98 +/-2.35 vs. 6.92 +/-4.45 ppb). The correlation of exNO with age in the whole population was weak (r=0.23; P=0.02) and insignificant in the smoking and nonsmoking subgroups. Likewise, correlations of exNO with BMI, part of the day, or time after a meal were insignificant in whole population as well as the subgroups. We conclude that the aforementioned factors are not able to confound the measurement of exNO in the population studied.

Moderate exercise decreases nitric oxide exhalation in patients with stable coronary artery disease.

Nitric oxide (NO) is present in exhaled air in humans and its level may decrease in heart diseases. Nitrates are metabolised to NO. In the present study we prospectively investigated how coronary disease treated with oral nitrates and physical exercise influence the exhaled NO concentration (exNO). The study was performed in 44 patients with stable coronary artery disease (CAD) treated with oral nitrates (31 nonsmokers and 13 smokers). End-tidal concentration of exhaled NO was measured by the use of a chemiluminescence method. The Bruce protocol of an exercise test was performed in 21 coronary patients and 11 volunteers. NO was measured before and 2-5 min after the test. We found no significant differences in the exNO level between healthy controls and CAD patients as analyzed either for the whole groups or non-smoker and smoker subgroups (6.01 parts per billion (ppb) vs. 4.91 ppb; 7.02 ppb vs. 5,89 ppb; 3.62 ppb vs. 3.33 ppb, respectively). However, the coronary patients group, as a whole, had lower exNO after exercise (4.22 ppb vs. 3,84 ppb, P<0.01). The difference persisted after division of this group into non-smokers and smokers; 5.19 ppb vs. 4,79 ppb, P<0.05 and 3.63 ppb vs. 3.27 ppb, P<0.05, respectively). The level of exNO changed inappreciably after exercise in control subjects. We conclude that coronary disease and oral nitrates, in themselves, do not influence the exhaled NO concentration. Physical exercise, on the other side, lowers the exhaled NO level in coronary patients.

Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine.

BACKGROUND AND OBJECTIVE: No clinical trials comparing the characteristics of sensory blockade caused by various local anaesthetics in thoracic paravertebral blockade have been published. The aim of this prospective study was a clinical assessment of sensory blockade after paravertebral injection of ropivacaine or bupivacaine in patients undergoing modified radical mastectomy. METHODS: Seventy ASA I-II patients were randomized to receive a single injection of ropivacaine 0.5% (n = 35) or bupivacaine 0.5% (n = 35) at the T4 level. General anaesthesia with propofol and fentanyl was provided during the procedure and patients were not intubated. The following parameters were analysed: duration and dynamics of the sensory blockade and the patient's and surgeon's assessment. RESULTS: Both ropivacaine and bupivacaine provided a similar level of analgesia. Ropivacaine was characterized by more rapid onset - after only 5 min 53% of patients in this group had the extent of sensory blockade wide enough to perform modified radical mastectomy in comparison to only 20% after bupivacaine (P 9 segments blocked) was noted more often in the ropivacaine group (88% vs. 65%, P < 0.05), lasted longer and appeared to be wider than sensory blockade produced by bupivacaine. Regression of sensory blockade was initially similar, but after 24 h sensory blockade in the ropivacaine group still had a potential to provide analgesia for modified radical mastectomy in 81% of patients in comparison to only 50% of such patients in the bupivacaine group (P < 0.05). Degree of postoperative pain, performance of the cardiovascular system, consumption of medications and complications were all similar between the study groups. CONCLUSIONS: Both agents provide satisfactory conditions for mastectomy, but ropivacaine seems to be superior to bupivacaine for thoracic paravertebral blockade during breast cancer surgery.

Haemodynamic disorders in the course of electrical burns. A preliminary report.

The results of Doppler haemodynamic investigations in electrically burned patients are described in this paper. A comparison with other burned patients is also provided. The following differences were found between the two groups: 1. diminished compliance of the myocardium in electrically burned patients; 2. markedly elevated ejection time measured by flow time. The results remain unclear and require further long-term investigations.

Major intrahepatic veno-venous fistula after modified Fontan operation treated by transcatheter implantation of amplatzer septal occluder.

Patients with complex congenital cardiac malformations who have been converted to the Fontan circulation with partial exclusion of the hepatic veins may develop progressive cyanosis because of formation of intrahepatic veno-venous malformations. We describe transcatheter closure of a major intrahepatic fistula in such a setting using an Amplatzer septal occluder delivered by the left jugular venous approach in a 5 year old boy.

Cellular adhesion molecules changes in myocardium during first year post heart transplant.

The increased presence of intercellular adhesion molecule-1 (ICAM-1) and vascular adhesion molecule-1 (VCAM-1) in the myocardium after orthotropic heart transplantation (OHT) has been implicated in early and late organ rejection. The aim of this study was to investigate the changes in ICAM-1 and VCAM-1 during the first years post-OHT. Accordingly, we studied multiple endomyocardial biopsy specimens collected from 11 randomly selected patients (all males, mean age 46 +/- 11 years). Qualification criteria for OHT included: ischemic cardiomyopathy in 6 pts (55%) and idiopathic dilated cardiomyopathy in 5 pts (45%). All patients were receiving triple immunosuppressive regimen. The therapy consisted of cyclosporine, azathioprine, and prednisolone. Multiple endomyocardial biopsy specimens were collected at 7, 30, 90 and 360 days post OHT from all patients (pts), and examined routinely for histologic signs of organ rejection. To assess levels of adhesion molecules we used monoclonal antibodies (murine anti-human ICAM-1 and VCAM-1) on frozen sections. Immunoreactivity (IR) was detected using a commercially available kit. Intensity of IR was assessed based on a semiquantitative scoring system. In this study, IR scores > or = 2 + were considered positive for ICAM-1, and scores > or = 1 + were considered positive for VCAM-1. IR scores in specimens obtained from consecutive biopsies were compared with the initial biopsy collected at the day 7. The results were analyzed using nonparametric statistics. The routine evaluation revealed histological signs of organ rejection (> or = 2) in 2 pts at 7 days, in 5 pts at 30 days, in 3 pts at 90 days, and in 1 patient at 360 days. On the other hand, ICAM-1 and VCAM-1 expression were absent in the majority of patients at 7, 30 and 90 days, but their presence was significantly increased at 360 days (p < 0.05). Absence of the early expression of ICAM-1 and VCAM-1 may be related to the protective effect of triple immunosuppressive therapy in these patients. The expression of ICAM-1 and VCAM-1 strongly emerging at 1 year post OHT may reflect chronic rejection in myocardium. In conclusion, the immunohistological monitoring of the adhesion molecules in biopsy specimens during routine biopsy schedule may be helpful for the discovery of chronic rejection.

[Construction and possible uses for the laryngeal mask]. / Budowa i mozliwosci zastosowania maski krtaniowej.

In the paper we present laryngeal mask, a device which can be used as an alternative to endotracheal intubation. This is of particular importance in case of short general anaesthesia without muscle relaxants, very popular in day case surgery. We also describe in detail the way of insertion of laryngeal mask. This device can protect the airways in case of lack of sufficient experience in laryngoscopy. This could be very important in first aid management.

Bilateral and unilateral use of internal thoracic artery for myocardial revascularization. Comparison of extubation outcome and duration of hospital stay.

The left internal thoracic artery is usually used as arterial conduit for myocardial revascularization; however, there is an increasing popularity of bilateral use of this artery for grafting. We examined 180 patients with both types of arterial conduits to answer whether bilateral use of the internal thoracic artery makes the difference in postoperative extubation outcome and duration of hospital stay in comparison to the unilateral use of this conduit. Ninety-three patients with bilateral conduit and 87 patients with unilateral conduit, with comparable age, cardiopulmonary bypass, and aortic cross-clamp time have been studied. On the basis of statistical and retrospective analysis, we conclude that bilateral use of internal thoracic artery for myocardial revascularization prolongs required postoperative respiratory support (12.0 h against 7.6 h) not affecting the duration of the mean hospital stay.

[Effect of slow infusion of magnesium sulphate on changes of arterial blood pressure values in patients with ischemic heart disease]. / Wplyw powolnego wlewu siarczanu magnezu na zachowanie sie wartosci cisnienia tetniczego krwi u chorych z choroba niedokrwienna serca.

In the paper the influence is presented of magnesium sulphate infusion on the changes of arterial blood pressure values in cases of initial hypertension and normotension in patients with coronary heart disease. Twenty-six patients were studied in this aspect, with precise measurement of arterial blood pressure by non-invasive method after careful preliminary qualification. The measurements were carried out during magnesium sulphate infusion by intravenous route. It was found that the magnesium sulphate infusion normalized arterial blood pressure in cases of initial hypertension while it failed to reduce the initial arterial blood pressure in cases of normotension.

[Controversies regarding the use of 0.75% bupivacaine]. / Kontrowersje wokól stosowania 0.75% bupiwakainy.

Controversies are described regarding wide introduction of bupivacaine with raised concentration (0.75%) of the active components, which has been introduced in other countries in the strongest local anaesthetic agent used as yet but in early 1980s it has been withdrawn from several western countries in view of possible serious cardiovascular side effects. Presently, after a number of studies it been demonstrated that these suppositions were unfounded and the observed complication were due errors in anaesthesiological techniques and not to an exceptional cardiotoxicity of the drug.

[Mathematical analysis of relations between dose, level or volume of bupivacaine and various hemodynamic parameters in epidural anesthesia]. / Matematyczna ocena zaleznosci miedzy dawka, stezeniem lub objetoscia bupiwakainy a niektórymi parametrami hemodynamicznymi w znieczuleniu zewnatrzoponowym.

Changes in the basic, hemodynamic parameters during the first 30 minutes of epidural anesthesia in relation of the dose, concentration, and volume of bupivacaine used are discussed. It was found, that in a proper epidural anesthesia a significant effect on the value of basic hemodynamic parameters was exerted only by a volume of administered bupivacaine solution, whereas its concentration or dose do not play any significant role. However, further prospective studies are necessary to extend this observation on the wider population.

[Use of cardiopulmonary bypass decreases leukocyte count and activation of the complement system]. / Zastapienie utleniania pozaustrojowego plucami chorego w krazeniu pozaustrojowym--zmniejsza aktywacje leukocytów i ukladu dopelniacza.

Platelet damage, complement activation and neutropenia during extracorporeal circulation are the result of blood contact with artificial surfaces, mainly in the oxygenator. To evaluate the biocompatibility of the ++auto-oxygenation technique of cardiopulmonary bypass (CPB) 2 techniques of extracorporeal circulation were compared in 40 patients undergoing elective coronary bypass surgery. Patients were studied in 2 groups, 20 patients in each: I (++auto-oxygenation --patients lungs used in CPB) and II (conventional technique of CPB with bubble oxygenator). Several blood samples were taken before, during and after perfusion to estimate pulmonary leukocytes sequestration in all patients and additionally complement C3a and C5a anaphylatoxins + were measured (radioimmunoassays) in 6 patients of each group. During cardiopulmonary bypass the decline in leukocyte number was observed in both groups, but leukocyte count was higher in group I then II, due to the transpulmonary leukocyte sequestration which was higher in group II. The difference between leukocytes count in group II was 1.46 +/- 0.5 x 10(3)/mm3 vs only 0.34 +/- 0.2 x 10(3)/mm3 in group I, p less than 0.001. In postoperative period an increase in circulating white blood cells was observed in both groups when compared to pre-bypass time, but the difference between groups was non significant. The level of C3a increased in group I from 244 +/- 46 ng/ml to 418 +/- 34 ng/ml, in group II from 268 +/- 46 ng/ml to 521 +/- 65 ng/ml, p less than 0.001, but in group I the levels were significantly lower, p less than 0.001. The current study confirms that cardiopulmonary bypass results in significant leukocyte and complement activation and supports the theoreticaly better biocompatibility of CPB with lung over oxygenator.