Correlation of blood volume values and pulmonary artery catheter measurements.

OBJECTIVE: To correlate the values generated by direct total blood volume measurement with pulmonary artery catheter parameters and commonly used laboratory values in the management of critically ill patients. METHODS: This study was carried out at the Lutheran Medical Center, Brooklyn, New York, United States of America, during the period 1998-1999. We prospectively correlated the total blood volume (TBV) values generated by the blood volume analyzer (BVA)-100 using I131-tagged albumin, with the values obtained from pulmonary artery catheter (PAC) of central venous pressure, pulmonary capillary wedge pressure, cardiac output, and with laboratory values of hematocrit, lactate, arterial blood gas and mixed venous blood, in critically ill patients. Twenty-four intensive care unit (ICU) patients were studied. INCLUSION CRITERIA: Admission to the intensive care, pulmonary artery catheter insertion and (APACHE) II Acute Physiology and Chronic Health Evaluation score of 8-30 (mean=17.875). EXCLUSION CRITERIA: Pediatric patients, hemodynamically normal or stable patients, pregnancy, and critically ill patients that were managed in an ICU setting without PAC catheter. Height and weight were recorded. After the collection of an initial blood sample (5 cc), one cc of I131-tagged albumin (15-25 microcuries) was injected using a patented syringe. Five venous samples were collected after the isotope injection. RESULTS: The collection times were entered into the BVA-100. Hematocrit measurements were performed in duplicate. Blood samples were centrifuged and one ml from the plasma of each sample was pipetted (in duplicate) into the sample tube then placed into the BVA-100. The results showed that the TBV did not correlate with either pulmonary capillary wedge pressure or central venous pressure, and except for the cardiac output, there is no correlation between pulmonary capillary wedge pressure readings or TBV results and the other parameters considered in this study. CONCLUSION: This method can be released from the research fields and can be safely incorporated into the clinical arena. It provides an accurate assessment of the volume status in intensive care unit patients.

Primary thoracoscopic evaluation of pleural effusion with local anesthesia: an alternative approach.

OBJECTIVE: The development of a thoracoscopically assisted technique to be performed with the patient under local anesthesia for both diagnostic and therapeutic purposes when treating pleural effusions and empyemas in high-risk surgical patients. METHODS: Twenty patients with pleural effusion or empyema who were also determined to be at high risk for complications following a thoracotomy, pleural biopsy, general anesthesia, or all of these, underwent placement of a thoracoscope while under local anesthesia followed by thoracic fluid drainage, pleural biopsy, and pleurodesis as required. Patients were retrospectively evaluated for a variety of factors including personal history, pre-existing medical conditions, and pre- and postoperative course. RESULTS: The average age of the patients was 59 years (18 to 89) with a 55% male/45% female sex distribution. Patients had this procedure as a consequence of malignancy (50%), empyema (30%), spontaneous pneumothorax (10%), bronchiectasis (50%), or heart failure (5%). The average duration of the procedure was 62 minutes (20 to 190), with an average of 861 mL of fluid drainage, and 114 mL of estimated blood loss. The tube thoracostomy was usually removed on the sixth (0 to 13) postprocedure day. This procedure was well tolerated by the patients with the majority of pain management being achieved with patient controlled analgesia (58%). The direct complication rate was 10%, with 2 patients requiring endotracheal intubation. CONCLUSION: This novel thoracoscopic procedure represents an acceptable alternative to the traditional treatment of pleural effusions and empyema with comparable outcome parameters and morbidity. This technique may eventually become the standard of care for the treatment of pleural effusions.

Nitric oxide expression by interleukin-10 in the endoscopic and open methods of vein harvesting in coronary artery bypass surgery.

OBJECTIVE: Interleukin-10 (IL-10) is an anti-inflammatory cytokine that suppresses lymphocyte functions, regulates production of proinflammatory cytokines, and suppresses nitric oxide production by activated macrophages. We examined IL-10 expression and its value as a surrogate index for nitric oxide (NO) production in endothelial cultures obtained from saphenous vein samples. METHODS: Using 2 different techniques (the open and endoscopic), we harvested samples of human saphenous veins from 90 randomly selected patients undergoing coronary artery bypass surgery (CABG). Endothelial cells collected from the vein samples retrieved through both techniques were cultured for 72 hours. Using a solid phase enzyme linked-immuno-sorbent assay (ELISA), we analyzed pre- and postoperative sera, in addition to the supernatants from the cultures, for IL-10. RESULTS: Mean preoperative levels of IL-10 (0.09 +/- 0.04 pg/mL) did not differ significantly from that for postoperative sera (0.14 +/- 0.17 pg/mL) (P = 0.54). Mean IL-10 levels for endothelial cell culture supernatants did not differ significantly between the endoscopic (0.32 +/- 0.39 pg/mL) and the open method (0.46 +/- 0.80 pg/mL) (P= 0.30). CONCLUSION: Our findings indicate that endoscopic and open saphenectomies are technically comparable with respect to their effects on IL-10 release during saphenous vein harvesting for CABG. We recommend the endoscopic method for its low morbidity and earlier hospital discharge.

Cardiac surgical procedures and glove reinforcements.

The purpose of this prospective study is to determine the frequency and site of glove perforation during cardiac surgical procedures. Over a period of six months, gloves from 206 surgical team members were collected at the conclusion of surgery. All cases of known perforations were eliminated from the study. The percentage of glove perforation was 14%. The distribution of perforation across locations of the hand was significantly unequal (P = 0.001). We found that 73% of the punctures occurred in one of four contiguous locations on the glove: the radial side of the index finger (28%), the radial side of the thumb (21%), the palmar side of the index (14%), and the palmar side of the thumb (10%). Therefore, we recommend glove reinforcement on these locations that would provide better protection against transmission of infectious agents. Discomfort from restricted dexterity and impaired sense of touch with double gloving renders glove reinforcement a suitable alternative for universal precautions, especially in cardiac surgery while high level of perfection and dexterity were needed in lengthy, critical operations.