Successful early intervention in air embolism during hysteroscopy.

Hysteroscopy is used as a diagnostic tool for intrauterine pathology. Gas embolism with air or carbon dioxide is a rare but sometimes fatal complication of laparoscopy or hysteroscopy. We present a patient who developed pulmonary air embolism during hysteroscopy that caused a noncardiogenic pulmonary edema in the recovery room. This case report emphasizes that early intervention can prevent life-threatening events associated with pulmonary embolism during hysteroscopy. Pathophysiology of pulmonary gas embolism, as well as that of noncardiogenic pulmonary edema, is discussed. A protocol for the prevention, early detection, and management of this emergency is provided.

Pressure-heart rate relationship in intact and after stepwise elimination of three major baroreflex loops in dogs.

Systemic arterial blood pressure (BP)-heart rate (HR) relationship (the pressor test) is often used as an index of baroreflex. We evaluated this index by simultaneously comparing BP-HR, right carotid sinus pressure (CSP)-nerve action potentials (NAP), and NAP-HR relationship in dogs anesthetized with pentobarbital. BP was increased or decreased stepwise by intravenous (IV) infusions of phenylephrine or sodium nitroprusside, respectively. In nine dogs BP-HR and CSP-NAP relationships were measured and NAP-HR relationship was constructed before and after sequential and stepwise sectioning of the left aortic depressor nerve (LADN), the right aortic depressor nerve (RADN), and blockade of the left carotid sinus nerve (BLK) with 1% lidocaine. We found that HR was a negative sigmoidal function of BP in intact dogs. Linear slope of this relationship was significantly reduced after sectioning of LADN and RADN, but returned toward baseline after BLK. NAP was a positive sigmoidal function of CSP in intact dogs. Linear slope of this relationship was significantly depressed after sectioning of LADN and RADN. However, after BLK, the slope surpassed control, suggesting the existence of a central communication between the two carotid sinuses. HR was a negative function of NAP in intact dogs. However, as the other baroreflex feedback loops were eliminated, the slope of the NAP-HR relationship approached zero indicating that a closed integrated parallel feedback system is required for reflex regulation of HR. Our findings suggest that under normal conditions the pressor test is a valid index for baroreceptor function, but its use may not be warranted in chronic pathological states, such as atherosclerosis and hypertension. However, in contrast to the present acute experimental model, chronic pathological processes may not develop in sequence, and baroreceptor function on the affected site may not be completely eliminated from the baroreceptor loop such as performed in this study.

Early markers of ventilator-induced lung injury in rats.

Positive pressure ventilation with hyperdistention of the lungs (PPVHDL) causes microscopic lung injury in rats and in mice. This study compared lung lavage and serum levels of lactate dehydrogenase (LDH), aspartate aminotransferase (AST), creatinine phosphokinase (CPK), lung lavage and plasma endothelin-1 (ET-1) concentration, lung tissue ET-1 mRNA expression, angiotensin converting enzyme (ACE) activity of lung homogenates, and histology of the lung structure in control and PPVHDL rats. Rats were anesthetized with pentobarbital. While control rats were breathing spontaneously, the PPVHDL rats were ventilated with a rodent ventilator delivering 30 percent oxygen, a tidal volume of 18.6 +/- 4.5 ml/kg, and a respiratory rate of 55 to 60 per minute. End-tidal CO2 was maintained at 38-40 mm Hg. After seven hours, rats were killed and the lungs were lavaged. Red blood cells were present in the sediment of lavage fluid in PPVHDL rats and their lung structure showed severe congestion, alveolar septa filled with red cells, and extravasation of red blood cells and inflammatory cells into the alveolar space. Lung lavage fluid AST and LDH were significantly higher in the PPVHDL compared with the control group (P < 0.03 and P < 0.001, respectively). Electrophoresis of the lung lavage LDH showed increased peak-5 in the PPVHDL group. Serum LDH, CPK, AST, and potassium concentrations [K]+ were significantly higher in the PPVHDL rats whereas their serum total protein level was significantly lower than the control group (P < 0.001). Electrophoretic patterns of serum and lung lavage protein were similar in both groups indicating a transmural passage of serum protein from the intravascular to the intra-alveolar space. No significant difference was found in lung tissue ET-1 mRNA expression and lung protein concentration between the two groups. Lung ACE activity, in contrast, was significantly lower in PPVHDL rats. This study demonstrated that moderate alveolar hyperdistention caused significant structural lung damage accompanied by decreased ACE activity after seven hours of mechanical ventilation and that elevated lung lavage and serum LDH and AST levels in lung lavage and in serum might be early markers of ventilator-induced lung injury in this rat model.

Effects of hyperosmotic mannitol infusion on hemodynamics of dog kidney.

This study evaluated the effect of systemic infusion of hypertonic mannitol on renal hemodynamics (aortic pressure [P]-renal blood flow [RBF] relationship, glomerular filtration rate [GFR], and effective renal plasma flow [ERPF]) during 50% reduction of left kidney blood flow. Conditioned mongrel dogs anesthetized with halothane were hydrated by continuous infusion of lactated Ringer's solution containing creatinine to measure GFR and p-aminohippurate (PAH), to measure ERPF. The left kidney was exposed and two hydraulic occluders were placed, one around the aorta just above the renal arteries and the other around the left renal artery. Experimental design consisted of measuring P near the left renal artery, RBF by electromagnetic flowmeter, and ERPF and GFR by clearance methods in both kidneys in response to stepwise reduction in the aortic pressure by aortic occlusion before and after 50% reduction in the left kidney blood flow. The P-RBF relationship, GFR, and ERPF thus obtained were compared with those obtained during systemic intravenous infusion of 20% mannitol for a period of 1 h. We found that 1) a transient increase occurred in RBF with step reduction of P from 80 to 60 mm Hg under control conditions; 2) reducing the RBF by 50% changed the shape of the P-RBF relationship from a convex to the P axis to a linear form with a marked shift toward the P axis; 3) infusion of mannitol, during reduced RBF, caused a significant shift of the P-RBF curve toward the RBF axis and returned the linear P-RBF relationship toward normal, but had no effect on altered yield pressure; and 4) infusion of hypertonic mannitol had slightly increased GFR and ERPF in the right (unconstricted) kidney. However, hypertonic mannitol significantly increased GFR and ERPF values in the left (constricted) kidney suggesting a beneficial effect of mannitol on ischemic kidney. The results are consistent with the hypothesis that infusion of hypertonic mannitol to ischemic kidney increases RBF, presumably by decreasing the intrarenal vascular resistance. We speculate that this compensatory response may be mediated either 1) by stimulating the release of a vasodilator substance (e.g., prostaglandins), or 2) by washing out interstitial sodium, thereby reducing the sensitivity of the renal vasculature to ischemia-induced stimulation of renin-angiotensin system.

Radiation pneumonitis in rats and its modification by the angiotensin-converting enzyme inhibitor captopril evaluated by high-resolution computed tomography.

Adult male Sprague-Dawley rats were irradiated to the right hemithorax with a range of total doses delivered in 10 equal daily fractions of 4 MeV X rays. Half of each dose group consumed control feed, and half consumed feed containing the angiotensin-converting enzyme inhibitor captopril (50 mg/kg/day) continuously after the last irradiation. High-resolution computed tomography (CT) of the entire thorax was performed at 4 and 8 weeks after the last irradiation, and the findings with CT were correlated with hemodynamic data, heart weight, and pulmonary histopathology. Rats exposed to 20 or 40 Gy in 10 fractions exhibited no acute changes in right lung density. After 60 Gy in 10 fractions, however, right lung density in rats on the control diet increased significantly at 4 weeks, and then returned to normal at 8 weeks. Captopril-treated rats exposed to 60 Gy/10 fractions did not exhibit this transient increase in right lung density. After 80 Gy/10 fractions, right lung density increased to 0.60-0.65 g/cm3 at 4 weeks regardless of diet. At 8 weeks after 80 Gy/10 fractions, right lung density increased further in rats given the control diet, but decreased to near normal levels in captopril-treated animals. The density of the shielded left lung based on the CT was independent of both contralateral radiation dose and diet. Histological examination of the irradiated lungs indicated that these acute changes detected by CT were associated with the exudative and edematous phases of radiation pneumonitis, and that captopril reduced the severity of these changes. Irradiated (40-80 Gy/10 fractions) animals fed the control diet exhibited a significant increase in central venous and pulmonary artery pressure, and cardiac right ventricular hypertrophy. Captopril prevented or attenuated these hypertensive reactions. These data demonstrate that high-resolution CT can detect radiation reactions in rat lung within 4 weeks after 60 Gy/10 fractions, and that captopril spares these acute changes detected by CT. The mechanism of captopril action is not clear, but may be due in part to a reduction in pulmonary arterial pressure, resulting in less severe edema in the irradiated lung.

A comparison of general versus local anesthesia during inguinal herniorrhaphy.

The current study was done to compare the hemodynamic changes, recovery events and economic impact of elective inguinal herniorrhaphy performed with general anesthesia (GA) or regional field block (RB) in 20 patients (American Society of Anesthesiology class I). In the GA group, anesthesia was induced with thiopental and the trachea was intubated after intravenous administration of 0.08 milligrams per kilogram of vecuronium. GA was maintained with 1.2 +/- 0.25 per cent enflurane in 50 per cent nitrous oxide and oxygen, and ventilation was controlled to keep PECO2 at 36 +/- 2 millimeters of mercury. Anesthesia in the RB group was accomplished by local injection of 3.5 +/- 0.5 milligrams per kilogram of 0.5 per cent bupivacaine. In each patient, a suprasternal ultrasonic Doppler probe was used to measure cardiac output before induction of anesthesia, during and after operation. Total peripheral resistance was calculated from mean arterial pressure and cardiac output. There were no statistically significant differences between cardiac output, mean arterial pressure, total peripheral resistance and heart rate in the two groups at any time period during the study. Patients in the RB group did not require parenteral medication for relief of postoperative pain, whereas all those in the GA group did. Significant cost benefits were realized by the RB group because of elimination of general anesthetic and reduction of recovery room fees.

Hemodynamic and catecholamine responses associated with extracorporeal shock wave lithotripsy.

Patients undergoing extracorporeal shock wave lithotripsy (ESWL) for nephrolithiasis are anesthetized and immersed in water in a semisitting position. Hypertension and tachycardia have been reported to accompany ESWL, and it was hypothesized that those problems were a result of adrenal medullary release of epinephrine or norepinephrine. Therefore, the effects of ESWL on cardiovascular variables and circulating epinephrine and norepinephrine levels in nine patients anesthetized with 1.1% isoflurane in 50% nitrous oxide and oxygen were studied. End-tidal carbon dioxide (CO2) was maintained at 34 +/- 2 mmHg. Cardiac output (CO) and mean arterial pressure (MAP) were measured, and total peripheral resistance (TPR) was calculated at the following time points: (1) after immersion prior to shock wave therapy (control); (2) after 300 shocks; (3) after 800 shocks; and (4) 5 minutes after the completion of ESWL with the patient still immersed. Circulating epinephrine and norepinephrine concentrations were determined at the above times as well as before and after induction of anesthesia but prior to immersion. There was a statistically significant (p less than 0.05) decrease in CO and an increase (p less than 0.05) in MAP and TPR with ESWL treatment. These values returned to baseline levels when treatment was stopped. Plasma epinephrine and norepinephrine values did not change significantly throughout the study period. It was concluded that these ESWL-associated hemodynamic changes were probably not mediated via epinephrine or norepinephrine.

Partition of carotid baroreceptor response in two-kidney renal hypertensive dogs.

This study evaluated the mechanism of carotid sinus baroreceptor resetting in two-kidney one-clip Goldblatt hypertension in dogs by partitioning the resetting between carotid sinus wall compliance and receptor neural elements. With dogs under halothane anesthesia, the left renal artery was constricted 70-80% with a Goldblatt clamp without disturbing the contralateral kidney. Ten weeks later, when mean blood pressure had risen to 151 +/- 6 mmHg (means +/- SE) compared with 105 +/- 5 mmHg in controls, we measured simultaneously whole nerve action potentials (N) and carotid sinus volume (V) during step changes in intrasinus pressure (P). Hypertensive N vs. P relationship was sigmoid shaped and shifted toward the P-axis compared with controls. Hypertensive V vs. P relationship was not significantly different from controls. The hypertensive N vs. V relationship derived from the composite plots of N vs. P and V vs. P was sigmoid shaped and shifted toward the V-axis compared with controls. These results suggest that the resetting of baroreceptors is due to changes in receptor properties rather than carotid sinus wall compliance.

Blockade of contralateral carotid sinus nerve enhances ipsilateral nerve action potentials under halothane anaesthesia.

In 10 dogs, one carotid sinus was isolated from the systemic circulation without disturbing its sympathetic innervation. The isolated sinus was connected to a servo-controlled pressure generator which kept mean intrasinus pressure, pulse pressure, and frequency of pulsation constant. The carotid sinus baroreceptor nerve action potentials (NAP) were measured, together with the intransinus and systemic pressures. Following control measurements, the end-tidal concentrations of halothane in oxygen were varied between 0.0 and 2%, in random increments of 0.5%, each with 30 min of stabilization. The carotid sinus NAP response to halothane was biphasic in a dose-dependent manner. The series was repeated after neural blockade of the contralateral sinus with 1% lignocaine 2-3 ml. This blockade enhanced all NAP responses (P less than 0.001), suggesting that a central inhibitory effect, initiated by the contralateral sinus, had been removed.

Renal tissue oxygenation following induced hypotension in dogs.

Renal oxygenation was studied during induced hypotension in mongrel dogs, anaesthetized with 1-1.5% halothane in oxygen. Hypotension was induced with an infusion i.v. of sodium nitroprusside (SNP) 70 +/- 17 micrograms kg-1 min-1 (mean +/- SEM) or trimetaphan (TMP) 36 +/- 16 micrograms kg-1 min-1, or by controlled arterial haemorrhage (45 +/- 6 ml/kg of body weight). Mean arterial pressure (MAP), cortical (Pcto2) and medullary (Pmto2) tissue oxygen tensions, arterial (Pao2), renal venous (Prvo2), and urine (Puo2) oxygen tensions were measured during the 40-min control, hypotension, and recovery periods. MAP was decreased to approximately 60% of the control value. Pcto2 decreased significantly (P less than 0.05) in all three groups while Pmto2 decreased significantly only in the haemorrhage group. Upon restoration of MAP to normal values, renal tissue oxygen tensions recovered in all groups, somewhat more rapidly in the SNP group. There were no significant differences in Pao2, Prvo2, and Puo2 during control, hypotension and recovery periods in the three groups. Tissue oxygen tension values followed the changes in MAP, but were not hypoxic, leading us to believe that both SNP and TMP are hypotensive agents safe for the kidney.

Local versus central effect of halothane on carotid sinus baroreceptor function.

Depressive effect of halothane on carotid sinus baroreceptor function may be due to direct local action, in the CNS, or both. Paris of dogs were anesthetized with pentobarbital and ventilated with oxygen. The carotid sinus of the recipient dog was isolated and perfused with blood from the common carotid artery of the donor dog. Blood from the recipient sinus was returned through its external carotid to the donor common carotid. Thus, both carotid sinuses of the donor and the contralateral carotid sinus of the recipient dog received uninterrupted circulation. Carotid sinus nerve action potentials and lingual artery pressure of the isolated recipient sinus were recorded before and during steady state end-tidal halothane concentrations of 0, 0.5, 1.0, 1.5, 2.0, and 2.5% in oxygen, given randomly first to the donor dog (to evaluate direct local effect) and then to the recipient dog (to determine central effect). The dog not given halothane received pentobarbital. Plots of normalized nerve activity versus halothane concentrations showed approximately zero slope when the donor was given halothane but showed significant decrease in nerve activity when the recipient was given halothane. Halothane appears to have no direct local effect but causes depression of baroreceptor nerve activity, possibly via CNS inhibition of sympathetic efferents to the carotid sinus.

Trimethaphan-induced hypotension: effect on renal function.

This study was designed to evaluate the effects of trimethaphan-induced hypotension on renal function in healthy young patients undergoing maxillofacial surgery. Anaesthesia was induced with thiopentone and was maintained with halothane 1.5-2.0 per cent in oxygen. Each patient served as his own control, and data were analyzed using the paired t-test. Trimethaphan was infused at a rate of 45-52 microgram.kg-1.min-1 for an average hypotensive period of 53 +/- 4 (mean +/- SEM) minutes to reduce the mean arterial pressure (MAP) to 49 +/- 2 torr. Endogenous creatinine clearance, urinary Po2, sodium reabsorption rate (Tna), and serum and urine osmolalities were determined before, during and after arterial hypotension with trimethaphan. Urine flow averaged 2.9 +/- 1 ml/min during the period of hypotension. Endogenous creatinine clearance and Tna were significantly decreased (p less than 0.05) in the hypotensive period. These values returned to normal levels within one hour upon discontinuation of trimethaphan and restoration of blood pressure. We found no statistical difference in urine Po2, and serum and urine osmolalities during control, hypotensive and recovery periods. These results suggest that medullary renal tissue oxygenation, an index of tissue viability, may have remained adequate despite a significant reduction in endogenous creatinine clearance during the hypotensive period. Furthermore, it appears that the effect of trimethaphan-induced hypotension on renal function is similar to the sodium nitroprusside-induced hypotension in man which we have reported previously.

Metabolism of sodium nitroprusside in dogs awake and anesthetized with halothane.

Sodium nitroprusside (SNP) is rapidly metabolized to cyanide (CN) and thiocyanate (SCN). The authors determined the rates of CN and SCN production during SNP infusion sufficient to maintain blood pressure at 80 per cent of baseline in the dog awake and during halothane anesthesia. Each dog served as its own control. The endogenous whole-blood CN concentration was significantly lower in anesthetized dogs (0.6 nmol/ml) than awake dogs (1.8 nmol/ml). CN concentration increased similarly during SNP infusion in awake (4.5 nmol/ml) and anesthetized dogs (2.3 nmol/ml). In another group of dogs, whole-blood CN concentration decreased significantly due to halothane anesthesia. The regression coefficient was -0.21 nmol CN/ml/hr. There was no significant difference in plasma SCN concentration following infusion of SNP in both awake (33 nmol/ml) and anesthetized dogs (26 nmol/ml). The cause of this decreased blood CN concentration with or without SNP infusion during halothane anesthesia is not known.

Lidocaine treatment of experimental cutaneous lesions from potassium chloride injection.

Potassium chloride (KCl) given subcutaneously in high concentrations causes necrosis of skin, possibly from vasoconstriction around the injection site. The authors studied guinea pigs given subcutaneous injections of various volumes and concentrations of KCl and observed the severity of the cutaneous lesions. In further experiments, therapeutic agents were injected subcutaneously 10 minutes after KCl infiltration. The severity of cutaneous lesions was not affected by various volumes of KCl of the same concentration, but was correlated positively with increasing concentrations of the salt when concentration was varied. Dextrose, 5%, and sodium bicarbonate, 1 M, had no effect on the cutaneous lesions caused by KCl, while hyaluronidase, 150 U/ml, lessened them. Lidocaine, 1%, a vasodilator, eliminated cutaneous lesions caused by KCl. Kcl-induced lesions may be due to vasocontriction, which can be relieved by lidocaine.

Prolonged, profound hypotension produced safely with sodium nitroprusside.

Nine and one-fourth hours of profound hypotension were necessary to accomplish the successful removal of a large arteriovenous malformation from the medial portion of the dominant parietal lobe. The hypotensive agent used was sodium nitroprusside. The removal was associated with a minimal neurological deficit. This is the longest known use of sodium nitroprusside for deliberate hypotension during surgery which emphasizes the safety of this hypotensive technique, provided the total dosage of sodium nitroprusside is reasonable.