Diagnosis and long-term management of hydrolyzed wheat protein wheat-dependent exercise-induced anaphylaxis.

Case: A 37-year-old woman was admitted to the emergency room with bilateral periorbital edema, hypotension, and expiratory stridor that developed 30 min after starting to hang out washing following consumption of a jam bun. Despite no food allergies or similar episodes, she had recently developed facial wheals after bathing. Outcome: She was immediately and repeatedly administered adrenalin and succinic acid hydrocortisone sodium for wheat-dependent exercise-induced anaphylaxis. On the third hospital day, radioallergosorbent testing reactions to wheat, gluten, and omega-5 gliadin were mildly positive; skin-prick tests for hydrolyzed wheat protein and a face-wash challenge were positive. Therefore, we diagnosed hydrolyzed wheat protein wheat-dependent exercise-induced anaphylaxis. Despite advising her about hyposensitization, the episode recurred and an adrenalin auto-injector was prescribed. Conclusion: Differentiating hydrolyzed wheat protein wheat-dependent exercise-induced anaphylaxis from conventional wheat-dependent exercise-induced anaphylaxis is important owing to their severity and similarities. Each requires long-term management of patients' etiological conditions by advising them about hyposensitization and prescribing adrenalin auto-injectors.

[Recruitment maneuver and high PEEP in a patient with severe reperfusion pulmonary edema after pulmonary thromboendarterectomy].

Recently open lung approach such as recruitment maneuver and high PEEP has been applied in patients with acute respiratory distress syndrome. We report here a 29-year-old man with chronic pulmonary thromboembolism (CPTE). In this case, recruitment maneuver and high PEEP relieved postoperative respiratory failure. The major complications after pulmonary thromboendarterectomy (PTE) for CPTE are: reperfusion pulmonary edema (RPE), pulmonary hypertension (PH), hypoxia and bronchial bleeding, all of which the patient has demonstrated. Preoperative examination showed high pulmonary artery pressure (85/41, mean 50 mmHg), and high pulmonary vascular resistance predicted poor postoperative course. After PTE, he developed severe RPE, PH, hypoxia and bronchial bleeding, resulting in failed weaning from cardiopulmonary bypass. Therefore he required mechanical support of percutaneous cardiopulmonary support (PCPS). In ICU we repeated recruitment maneuver (PEEP: 30 cmH2O, peak inspiratory pressure: 42 cmH2O, respiratory rate; 15 breaths.min-1, for 1 min) and kept high PEEP (15 cmH2O). After initiating this ventilatory strategy, RPE was gradually relieved, followed by improvement of oxygenation and PH. We successfully weaned him from PCPS 38 hr after surgery and he was discharged alive on the 90 post-operative day. We conclude that recruitment maneuver and high PEEP may be useful for RPE developed after PTE.

[Venoarterial bypass in children with congenital heart disease--a retrospective study].

To investigate prognostic factors for patients supported by venoarterial (VA) bypass, we analyzed retrospectively 31 patients with congenital heart diseases supported by VA bypass between 1997 and 2000. Median age was 3.6 months and median body weight was 4.0 kg. Causes of VA bypass were difficult weaning from cardiopulmonary bypass in 8 patients, postoperative cardiac dysfunction in 5 and cardiopulmonary resuscitation in 18. Six (19.4%) of 31 patients were weaned successfully from VA bypass, and 2 (6.5%) survived to hospital discharge. In patients who were weaned from VA bypass successfully, VA bypass was instituted more quickly (41.6 +/- 5.0 vs 62.5 +/- 35.9 min), and good tissue perfusion was established in association with lower lactate levels at 12 hr (7.0 +/- 5.9 vs. 16.4 +/- 15.4 mmol.l-1) and larger urine output during first 24 h (81 +/- 68 vs. 22 +/- 43 ml.kg-1.day-1), compared to those who failed to be weaned. Major complications were intracranial hemorrhage in the newborn (50%), and hypoxic brain damage in patients with palliative operation (35%). It is necessary to establish guidelines of entry, weaning, and withholding of this support.

Effect of ventilatory settings on accuracy of cardiac output measurement using partial CO(2) rebreathing.

BACKGROUND: Recently, a new device has been developed to measure cardiac output noninvasively using partial carbon dioxide (CO(2)) rebreathing. Because this technique uses CO(2) rebreathing, the authors suspected that ventilatory settings, such as tidal volume and ventilatory mode, would affect its accuracy: they conducted this study to investigate which parameters affect the accuracy of the measurement. METHODS: The authors enrolled 25 pharmacologically paralyzed adult post-cardiac surgery patients. They applied six ventilatory settings in random order: (1) volume-controlled ventilation with inspired tidal volume (V(T)) of 12 ml/kg; (2) volume-controlled ventilation with V(T) of 6 ml/kg; (3) pressure-controlled ventilation with V(T) of 12 ml/kg; (4) pressure-controlled ventilation with V(T) of 6 ml/kg; (5) inspired oxygen fraction of 1.0; and (6) high positive end-expiratory pressure. Then, they changed the maximum or minimum length of rebreathing loop with V(T) set at 12 ml/kg. After establishing steady-state conditions (15 min), they measured cardiac output using CO(2) rebreathing and thermodilution via a pulmonary artery catheter. Finally, they repeated the measurements during pressure support ventilation, when the patients had restored spontaneous breathing. The correlation between two methods was evaluated with linear regression and Bland-Altman analysis. RESULTS: When VT was set at 12 ml/kg, cardiac output with the CO(2) rebreathing technique correlated moderately with that measured by thermodilution (y = 1.02x, R = 0.63; bias, 0.28 l/min; limits of agreement, -1.78 to +2.34 l/min), regardless of ventilatory mode, oxygen concentration, or positive end-expiratory pressure. However, at a lower VT of 6 ml/kg, the CO(2) rebreathing technique underestimated cardiac out-put compared with thermodilution (y = 0.70x; R = 0.70; bias, -1.66 l/min; limits of agreement, -3.90 to +0.58 l/min). When the loop was fully retracted, the CO(2) rebreathing technique overestimated cardiac output. CONCLUSIONS: Although cardiac output was underreported at small VT values, cardiac output measured by the CO(2) rebreathing technique correlates fairly with that measured by the thermodilution method.

Nitric oxide inhalation increases oxygen delivery after cardiovascular surgery in adult patients whether or not they have pulmonary hypertension.

PURPOSE: The purpose of this study was to quantify the increase in oxygen delivery (DO2) produced by nitric oxide (NO) inhalation, and to clarify whether NO inhalation might be effective in adult patients after cardiovascular surgery whether or not they have pulmonary hypertension (PH). METHODS: The study was done on 26 adult patients after cardiovascular surgery. The indications for NO inhalation were postoperative hypoxic respiratory failure (POHRF) with or without PH. NO was administered via a premixing system or via a side-stream system. The dose was adjusted to between 1 and 10 (5.7±2.0) (mean±SD) ppm. Data were obtained just before and within 120 min after the initiation of NO inhalation. We initially analyzed the data from all the patients together and then compared data from two groups made up from just 22 of the 26 patients: 14 patients without PH whose PaO2/FiO2 before NO inhalation was less than 200 mmHg (simple POHRF group), and 8 patients who had both POHRF and PH (systolic pulmonary arterial pressure higher than 40 mmHg) (POHRF with PH group). RESULTS: In the original group of 26 patients, significant improvements were observed in PaO2, PaO2/FiO2, CI, SPAP, CaO2, DO2I, and SvO2 during NO inhalation. The increase in DO2I was 68 ml·min-1·m-2 (+19.5%). PaO2, PaO2/FiO2, CaO2, DO2I, and SvO2 increased significantly in both groups. The increase in DO2I was 60 ml·min-1·m-2 (+18.9%) in the simple POPHRF group and 79ml·min-1·m-2 (+18.0%) in the POHRF with PH group. CONCLUSION: NO inhalation increases DO2 by approximately 20% in adult patients after cardiovascular surgery, irrespective of whether or not they have pulmonary hypertension.