Video assisted thoracoscopic surgery (VATS) for pneumothorax: a reason for unscheduled surgery?

Timing of urgent surgery, with full schedules and the businesslike attitude of operating room management, can lead to animated discussions, affecting quality of care and job satisfaction. No publication appears to address the timing of definitive care for a stable, spontaneous, pneumothorax (SP) by unscheduled, or urgent, video assisted thoracoscopic surgery (VATS). We reviewed the literature and describe our series of 38 patients with SP and VATS. Of 185 patients with SP, 38 were presented for VATS. Of these 29% were unscheduled. Average time between diagnosis of SP and VATS was 11 days, with four days between decision for VATS and its execution. Post-operative antibiotics were prescribed to 37% of patients. There was a correlation between chest drain time in situ and infective signs (p = 0.001, rho = 0.654) as well as proven infections (p = 0.05, rho = 0.386), but not between for scheduled and unscheduled procedures. In conclusion, our case series and review did not identify reasons why VATS for SP should be performed as an urgent procedure, though we support more rapid planning.

The Donders model of the circulation in normo- and pathophysiology.

The solution of some recent as well as of long standing problems, unanswerable due to experimental inaccessibility or moral objections are addressed. In this report, a model of the closed human cardiovascular loop is developed. This model, using one set of 88 equations, allows variations from normal resting conditions to exercise, as well as to the ultimate condition of a circulation following cardiac arrest. The principal purpose of the model is to evaluate the continuum of physiological conditions to cardiopulmonary resuscitation (CPR) effects within the circulation.Within the model, Harvey's view of the circulation has been broadened to include impedance-defined flow as a unifying concept, and as a mechanism in CPR. The model shows that depth of respiration, sympathetic stimulation of cardiac contractile properties and baroreceptor activity can exert powerful influences on the increase in cardiac output, while heart and respiratory rate increases tend to exert an inhibiting influence, with the pressure and flow curves compatible with accepted references. Impedance-defined flow encompasses both positive and negative effects.The model also demonstrates the limitations to cardiopulmonary resuscitation caused by external force applied to intrathoracic structures, with effective cardiac output being limited by collapse and sloshing. Stroke volumes from 6 to 51 ml are demonstrated. It shows that the clinical inclination to apply high pressures to intrathoracic structures may not be rewarded with improved net flow.

Airway management by first responders when using a bag-valve device and two oxygen-driven resuscitators in 104 patients.

BACKGROUND AND OBJECTIVE: To evaluate the capability of first responders to ensure an airway and ventilate the lungs of a patient employing a bag-valve device and two oxygen-driven resuscitators. METHODS: Prospective, controlled, blinded, single-centre clinical trial using a bag-valve device and one of two FR-300 devices, with 20 cmH2O working pressure, flows of 24 and 30 L min(-1). One-hundred-and-four patients were analysed. Induction of anaesthesia was followed by ventilation of the lungs with a bag-valve device and an Oxylator (CPR Medical Devices Corp., Markham, Ontario, Canada) in manual and automatic modes. Each series was repeated twice by a fireman first responder using a hand-held mask to seal the airway, once under anaesthesia and then again under anaesthesia with muscle relaxation. RESULTS: Patients' mean age 49 +/- 17 yr; 47% male, 48-132 kg. Only 29% had optimal facial and airway physiognomy. Airway management was significantly poorer when the bag-valve device was used than with either Oxylator mode (P < 0.0001); 23% of cases were not manageable with the bag-valve device. Gastric insufflation was markedly less with the Oxylator (P < 0.02). CONCLUSIONS: The use of an oxygen-driven device improves the ability of first responders to secure an airway and reduce gastric insufflation, even when distracted. Oxylators perform significantly better (P < 0.0001) than the bag-valve device.

Can first responders achieve and maintain normocapnia when sequentially ventilating with a bag-valve device and two oxygen-driven resuscitators? A controlled clinical trial in 104 patients.

BACKGROUND AND OBJECTIVE: To evaluate the capability of first responders to achieve and maintain normal ventilation of the lungs of victims employing a bag-valve device and two oxygen-driven resuscitators. METHODS: Prospective, controlled, blinded, single-centre clinical trial using a bag-valve device and one of two FR-300 devices, with 20 cmH2O working pressure, and flows of either 24 or 30 L min(-1). One hundred and four patients were analysed. Induction of anaesthesia followed by ventilation of the lungs with a bag-valve device and an Oxylator in manual and automatic modes performed by a fireman first responder. Each series was repeated for three conditions (anaesthesia; anaesthesia plus muscle relaxation, both with facemask; anaesthesia plus relaxation using an endotracheal tube). RESULTS: Patients age 49 +/- 17 yr; 47% males, 48-132 kg. Normocapnia was achieved and maintained in 66% (bag-valve device), 82% (Oxylator). CONCLUSIONS: The use of an oxygen-driven device improves the ability of first responders to achieve and maintain normocapnia even when distracted. Use of the Oxylators improves performance (P < 0.001) vs. the bag-valve device significantly.

Shape of the left ventricle and its computer modelling.

A simple computer program was made to draw different left ventricle shapes in order to support the theory of elongation and to get a visual presentation of the shape of the left ventricle. Experimental data, obtained from echocardiography and Simpson's rule, were used for this program. The results yielded different shapes under different physiological circumstances, indicating the sensitivity of the method. It was concluded that these figures (shapes) support the use of elongation as a shape index.

Elongation as a new shape index for the left ventricle.

OBJECTIVES: This study was done to quantify the shape of the left ventricle (LV). It was proposed that the shape of the LV is intimately related to its performance and that its elongation (ELO) is a sensitive measure of this performance. The performance was tested against classical cardiovascular parameters. METHODS: Using echocardiography and Simpson's rule, the endocardial surface area of the LV was calculated noninvasively with a simple experimental-mathematical model at enddiastole and endsystole. ELO as shape index was derived from the endocardial surface area of the LV with a simple formula. The endocardial surface area of the LV and ELO were determined in volunteers, in patients with mild heart failure and in patients with severe heart failure. RESULTS: The normal value of endocardial surface area of LV at enddiastole is 138.3 cm2 while the normal value at endsystole is 99 cm2. The endocardial surface area of the LV is significantly bigger in patients with mild heart failure than in volunteers (p < 0.01) while the parameters ELO, ejection fraction and Doppler measurements are similar. The normal values of ELO at diastole and systole are 12 and 25 respectively. The value of ELO at endsystole is lower only in patients with severe heart failure. This means a more spherical shape and poor systolic function of the LV. CONCLUSION: ELO is usefull as quantitative and qualitative index of left ventricular shape. ELO could be integrated and applied with new diagnostic tools such three-dimensional and contrast echocardiography.

Infinite number of solutions to the hemodynamic inverse problem.

Investigators have had much success solving the "hemodynamic forward problem," i.e., predicting pressure and flow at the entrance of an arterial system given knowledge of specific arterial properties and arterial system topology. Recently, the focus has turned to solving the "hemodynamic inverse problem," i.e., inferring mechanical properties of an arterial system from measured input pressure and flow. Conventional methods to solve the inverse problem rely on fitting to data simple models with parameters that represent specific mechanical properties. Controversies have arisen, because different models ascribe pressure and flow to different properties. However, an inherent assumption common to all model-based methods is the existence of a unique set of mechanical properties that yield a particular pressure and flow. The present work illustrates that there are, in fact, an infinite number of solutions to the hemodynamic inverse problem. Thus a measured pressure-flow pair can result from an infinite number of different arterial systems. Except for a few critical properties, conventional approaches to solve the inverse problem for specific arterial properties are futile.

Constructive and destructive addition of forward and reflected arterial pulse waves.

Although the physics of arterial pulse wave propagation and reflection is well understood, there is considerable debate as to the effect of reflection on vascular input impedance (Z(in)), pulsatile pressure, and stroke work (SW). This may be related to how reflection is studied. Conventionally, reflection is experimentally abolished (thus radically changing unrelated parameters), or a specific model is assumed from which reflection can be removed (yielding model-dependent results). The present work proposes a simple, model-independent method to evaluate the effect of reflection directly from measured pulsatile pressure (P) and flow (Q). Because characteristic impedance (Z(0)) is Z(in) in the absence of reflection, the P with reflection theoretically removed can be calculated from Q x Z(0). Applying this insight to an illustrative case indicates that reflection has the least effect on P and SW at normal pressure but a greater effect with vasodilation and vasoconstriction. Z(in), P, and SW are increased or decreased depending on the relative amount of constructive and destructive addition of forward and reflected arterial pulse waves.

The left ventricular ejection effect.

A recently developed model of the left ventricle, based on experimental data, has been shown to exhibit the main features of the heart's ability to pump. Two special cases during blood ejection, termed pressure deactivation and hyperactivation, were identified. This study proposes an 'ejection effect' correction to the model that addresses deactivation, hyperactivation and adjusts the shape of the computed ventricular ejection curve in late systole. Also, a new approach based on new animal experiments is proposed to identify the ejection effect mechanism(s).

Human circulatory system model based on Frank's mechanism.

A new analytical model of the left ventricle as a pump, developed from isolated canine experiments, was adapted to describe each of the four heart chambers in a complete human circulatory system model. Each chamber is embodied as a volume and time dependent isovolumic pressure source, after Otto Frank's classic experiments. Analytical results show that a small set of equations is sufficient to describe the main features of the heart as a pump, including isovolumic and ejecting beats for a wide range of ventricular and circulation conditions. This model allows interactive teaching of cardiovascular system dynamics. Computed results demonstrate that, with additional experiments, a quantitative description of the human circulation for research purposes may emerge from this approach.

The changing view of the heart through the centuries.

In human perception, the heart was not always part of the blood circulating system. It was later included as a suction pump until Harvey argued that the heart is actually a compression pump, the central organ of the circulation, and the only organ responsible for the motion of blood. Considered initially as an autonomous pump, the heart gradually became viewed as subservient to the needs of the peripheral organs it perfuses. Constant properties assigned to the heart had to be replaced, one after another, by adjustable parameters. Even the adequacy of the heart as the sole pump has been doubted, an issue that resurfaces today.

True arterial system compliance estimated from apparent arterial compliance.

A new method has been developed to estimate total arterial compliance from measured input pressure and flow. In contrast to other methods, this method does not rely on fitting the elements of a lumped model to measured data. Instead, it relies on measured input impedance and peripheral resistance to calculate the relationship of arterial blood volume to input pressure. Generally, this transfer function is a complex function of frequency and is called the apparent arterial compliance. At very low frequencies, the confounding effect of pulse wave reflection disappears, and apparent compliance becomes total arterial compliance. This study reveals that frequency components of pressure and flow below heart rate are generally necessary to obtain a valid estimate of compliance. Thus, the ubiquitous practice of estimating total arterial compliance from a single cardiac cycle is suspect under most circumstances, since a single cardiac cycle does not contain these frequencies.

Training needs and qualifications of anaesthesiologists not exposed to ALS.

OBJECTIVES: To establish which needs exist for specific training in Advanced Cardiac Life Support (ALS) in anaesthesiology residents and interns not exposed to structured ALS courses. METHODS: 48 residents, and seven interns accepted for training in anaesthesiology, were tested in a spontaneous, blind, cross-sectional, prospective assessment using a recording manikin with validated scoring system, a questionnaire, and 35 multiple-choice questions. RESULTS: 65% admitted not having had any CPR training within the last 2 years. The answers were correct in 55 +/- 14% of the cases, increasing significantly with the length of training (P = 0.001). One-rescuer CPR skills were inadequate: only 13% (n = 7) of participants scored within acceptable limits when using the Berden Scoring system (Berden et al., Resuscitation 1992;13:31-41), which assigned weighted error points to BLS skills. No correlation with skill was noted with increased length of residency, confidence, ER or ICU experience, or participation in CPR-incidents. CONCLUSIONS: Anaesthesiology residents and interns were not able to demonstrate BLS skills properly even while in training and did not recognize this themselves. CPR-related knowledge is poor and increases only incidentally over the years of residency even though participants were frequently confronted with seminars and resuscitation situations, and see protocols daily. The use of multiple-choice questions and the Berden scoring system avoids difficulties in evaluating case-scenario type of tests. We suggest that trainees are motivated to take part in standardized, intensive, recognised ALS courses which emphasize BLS skills and require (re)certification.

Apparent arterial compliance.

Recently, there has been renewed interest in estimating total arterial compliance. Because it cannot be measured directly, a lumped model is usually applied to derive compliance from aortic pressure and flow. The archetypical model, the classical two-element windkessel, assumes 1) system linearity and 2) infinite pulse wave velocity. To generalize this model, investigators have added more elements and have incorporated nonlinearities. A different approach is taken here. It is assumed that the arterial system 1) is linear and 2) has finite pulse wave velocity. In doing so, the windkessel is generalized by describing compliance as a complex function of frequency that relates input pressure to volume stored. By applying transmission theory, this relationship is shown to be a function of heart rate, peripheral resistance, and pulse wave reflection. Because this pressure-volume relationship is generally not equal to total arterial compliance, it is termed "apparent compliance." This new concept forms the natural counterpart to the established concept of apparent pulse wave velocity.

Effects of an eight-day space flight on microvibration and physiological tremor.

Microgravity was used to study accelerometrically recorded microvibration (MV) and postural tremor (PT) at reduced muscle tone on one cosmonaut before, during, and after an 8-day space flight on the Russian Mir station. MV of the relaxed forearm in the 1 g environment showed the typical 7- to 13-Hz resonance oscillations triggered by the heart beat. In 0 g, these pulsations shifted to below 5 Hz and the waveform became similar to an ultralow frequency acceleration ballistocardiogram. PT of the arm stretched forward showed an irregular waveform in 1 g. In 0 g, the higher-frequency components were reduced and again an ultralow frequency ballistocardiogram emerged. As a control, hand force tremor was recorded as well; it was not affected by the gravity condition. A second-order analog with muscle stiffness (C) as parameter was used to evaluate the measurements. For MV it could be shown that cardiac impacts produce damped resonance oscillations when C is high enough (1 g). At low C (0 g), this resonance phenomenon is essentially filtered out. For PT both neuromuscular and cardiovascular forces produce an irregular output; when C is lowered (0 g) the higher-frequency content is strongly reduced. It is concluded that both MV and PT waveforms are sensitive to musculoskeletal stiffness, such that at the lowest stiffness achieved the cardiac impact dominates. In 1 g, the cosmonaut's data were not significantly different from the results in a control group (n = 6).

A perspective on myocardial contractility.

Myocardial contractile properties form the cornerstone of the heart's ability to pump blood. Efforts have been made to characterize these properties via classic elasticity theory concepts, which can lead to spurious results, as demonstrated by experiments measuring intramyocardial pressure. Two ways out of these difficulties are identified. One is to start at the cellular level, the other at the chamber level. The latter allows separation of ventricle (source) and arterial (load) effects on measured pressure and flow, distinct from previous definitions of ventricular contractility which tended to lump the two.

Differentiation of intramyocardial fluid pressure from fiber stress.

To characterize the complex force field generated in the ventricular myocardium, intramyocardial pressure (IMP) measurement is used as an indirect means of assessing the distribution of regional wall stress. To resolve the long term confusion associated with this measurement, IMP is divided into its two dominant components: intramyocardial fluid pressure (IFP) and intramyocardial fiber stress (IFS). The intramyocardial response to regional and global contractile function is examined in terms of changes in the magnitude and transmural gradient of IMP recording. The experimental results support the theoretical concept proposed where the hydraulic properties of the myocardium proved to have an influence on cardiac function. To gain a deeper understanding of myocardial function, cellular and subcellular components must be considered.

Unstable radii in muscular blood vessels.

A model of a muscular blood vessel in equilibrium that predicts stable and unstable control of radius is presented. The equilibrium wall tension is modeled as the sum of a passive exponential function of radius and an active parabolic function of radius. The magnitude of the active tension is varied to simulate the variable level of smooth muscle activation. This tension-radius relationship is then converted to an equilibrium pressure-radius relationship via Laplace's law. This model predicts the traditional ability to control the radius below a critical level of activation. However, when the active tension is raised above this critical level, the pressure-radius relationship (with pressure plotted on the ordinate and radius on the abscissa) becomes N shaped with a relative maximal pressure (Pmax) and a relative minimal pressure (Pmin). For this N-shaped curve, there are three equilibrium radii for any pressure between Pmin and Pmax. Analysis shows that the middle radius is unstable and thus cannot be maintained at equilibrium. Previously unexplained experimental data reveal evidence of this instability.

Two-port analysis of microcirculation: an extension of windkessel.

We examined the suitability of the three-element windkessel as a reduced model of pulsatile pressure-flow relations at arteriolar and venular ends of a microcirculatory bed. Frequency domain (two-port) analysis of a distributed model of an idealized (single input, single output) microvascular network in skeletal muscle, consisting of 391 discrete vessel segments from a 20-microns-diameter arteriole to a 28-microns-diameter venule, demonstrated that the three-element windkessel is a good representation of arterial input impedance when pressure pulsations are absent at the venous end. The same model with different parameter values accounts well for venous pressure-flow relations if no pulsations occur at the arterial end. We showed that a five-element model (2 compliances, 3 resistors) provided a superior representation of pulsatile pressure-flow relations at both arterial and venous ends. Relating parameter values to known properties of the network revealed the physiological significance of the five elements. This model may prove a useful component in circulatory models incorporating both arteries and veins. While parameter values obtained herein were strictly valid for the particular microvascular network described, guidelines are provided based on physiological properties so that values may be estimated for different microvascular beds.

Arterial wave propagation phenomena, ventricular work, and power dissipation.

The effects of wave propagation phenomena, namely global reflection coefficient (gamma G[omega]) and pulse wave velocity (Cph), are studied in a model of the coupled left ventricle/arterial system. The left ventricle consists of a time-varying elastance, while the arterial system is modeled as a single, uniform, elastic tube terminating in a complex load. Manipulation of model parameters allowed for the precise control of gamma G(omega) and Cph independent of each other, peripheral resistance, and characteristic impedance. Reduction of gamma G(omega) and Cph were achieved through increases in load compliance and tube compliance, respectively. The equations describing the system were solved for left ventricular and aortic pressures and aortic flow. From these, stroke volume (SV), left ventricular stroke work (SW), and steady (Ws), oscillatory (Wo), and total power dissipation (Wt) in the arterial system were calculated. An index of arterial system efficiency was the ratio Wo/Wt (%Wo), with lower values indicating higher efficiency. Reduction of gamma G(omega) yielded initial increases in Ws, while Wo increased for the entire range of gamma G(omega), resulting in increased %Wo. This reduced efficiency is imposed on the ventricle, resulting in increased SW without increased SV. On the other hand, decreased Cph yielded in a steady increase in Ws and a biphasic response in Wo, resulting in reduced %Wo for most of the range of reduced Cph. These results suggest that differential effects on arterial system efficiency can result from reductions of gamma G(omega) and Cph. In terms of compliance, changes in arterial compliance can have different effects on efficiency, depending on where the compliance change takes place. Reasons for these results are suggested, and the role of distributed compliances is raised as a new problem.