The anesthetic management of a patient with chromosome 10qter deletion syndrome.

Terminal deletions of chromosome 10q are uncommon. The resulting syndrome includes cardiac and facial anomalies, urogenital abnormalities, limb defects, and mental retardation. Most affected infants require surgical correction of these anomalies. Presented are features inherent in the syndrome that will aid the anesthesiologist in the perioperative management of such patients.

Arterial-venous carbon dioxide tension difference during severe hemorrhage and resuscitation.

PURPOSE: To define clinically useful markers for determining the adequacy of resuscitation after hemorrhage. DESIGN: Prospective study of 20 Yorkshire swine, using an established model for hemorrhagic shock in swine. BACKGROUND AND METHODS: Clinically useful markers for assessing the adequacy of resuscitation after hemorrhage do not exist. We assess variables, such as BP and arterial blood pH. However, these variables do not correlate well with restoration of organ perfusion. In this study, 14 anesthetized swine were hemorrhaged to a mean arterial pressure of less than 25 mm Hg. After 30 mins without interventions, each animal was resuscitated with whole blood, hydroxyethyl starch, or normal saline. At baseline and during shock and resuscitation, hemodynamic variables, arterial and mixed venous blood gases, and arterial lactate concentrations were measured to determine which variables correlated most closely with the restoration of blood flow. RESULTS: The correlation between cardiac index and arterial or mixed venous pH and the correlations with arterial lactate values were poor. The correlation between cardiac index and mixed venous hemoglobin saturation also was weak (r2 = .28). Cardiac index correlated best with the arterial-venous PCO2 difference (r2 = .67) and the arterial-venous pH difference (r2 = .38). Using multiple regression, a linear correlation was established between the cardiac index and the arterial-venous pH and PCO2 differences throughout shock and resuscitation (r2 = .91). CONCLUSION: These findings suggest that the adequacy of resuscitation after hemorrhage can be assessed using paired arterial and mixed venous pH and PCO2 values.

Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care closed-suction system versus an open-suction system: prospective, randomized study.

Eighty-four intubated, mechanically ventilated patients were prospectively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received endotracheal suctioning by an "open" suction method vs. "closed" suction (Trach Care Closed Suction System) method. Results show that closed suctioning is associated with a significant (67% vs. 39% p less than .02) increase in colonization compared with open suctioning. However, difference in the incidence of nosocomial pneumonia was not significantly (26% vs. 29%) different between closed and open suctioning. Differences in severity of illness (Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention Scoring System), age, sex, presence of NG tubes, use of H2 antagonists or antacids, use of antibiotics, and history of smoking were all nonsignificant. Survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed-suctioning patients vs. open-suctioned patients (p less than .03). This study shows that suctioning performed via the Trach Care closed-suction system increases the incidence of colonization but not the incidence of nosocomial pneumonia, and may actually decrease mortality when compared with open-suction systems.

Cerebral electrophysiologic effects of resuscitation with hypertonic saline-dextran after hemorrhage.

When brain injury accompanies hemorrhage, resuscitation with hypertonic saline (HS) improves intracranial pressure (ICP) and elastance; however, its effect on brain function after a traumatic or ischemic insult has not been assessed. This study compares the electrophysiologic response to hemorrhage and resuscitation with 7.5% NaCl + 6% dextran (HSD), 6% hetastarch (HE), or 0.9% NaCl (NS) using somatosensory evoked potentials (SSEP). Resuscitation with HE resulted in a better return of electrocortical function than with either HSD or NS (SSEP grade 2.0 +/- 0.2 for HE vs. 3.2 +/- 0.3 for HSD and 2.9 +/- 0.3 for NS; p less than .01). SSEP response correlated closet with mean arterial pressure (MAP) (r = -.53). There was no correlation between the SSEP response and cardiac index (r = .06) or ICP (r = -.04). HSD blunted the usual early increase in ICP after fluid infusion, and resulted in a lower ICP throughout resuscitation. However, the restoration of MAP and cerebral perfusion pressure (CPP) after HSD infusion was poor. The vasodilatory properties of hypertonic saline have been well described, both in the systemic and in the pulmonary vascular bed. While these characteristic usually are cited as advantages of this solution, in the case of ischemic cerebral dysfunction, this diminished vascular tone prevents early restoration of the MAP and CPP. The result is suboptimal electrocortical recovery after hemorrhage.

A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage.

Hemorrhagic shock and closed head injury often accompany severe trauma. Hypertonic saline may be beneficial in these patients, but few have examined its properties when sufficient volume is infused to achieve sustained resuscitation. Solutions of 6% NaCl (HS), 0.9% NaCl (NS), 6% hetastarch (HE), and whole blood (WB) were used to resuscitate swine in hemorrhagic shock (MAP less than 30 mm Hg). The endpoint of resuscitation was normal oxygen delivery (DO2). Measurements of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and intracranial elastance (ICE) were made in the absence and presence of an epidural mass, created by inflating an epidural balloon. HS resuscitation resulted in a lower ICP [5 +/- 1 versus 9 +/- 2 (HE), 17 +/- 3 (NS), and 10 +/- 3 (WB) mm Hg; p = 0.016], and normalization of CPP throughout resuscitation. Animals resuscitated with NS had a lower CPP by the end of resuscitation [CPP = 45 +/- 4 for NS group, versus 63 +/- 4 (HE), 66 +/- 4 (HS), and 63 +/- 5 (WB) mm Hg; p = 0.009]. ICE fell markedly in the HS group, [a decrease of 12 +/- 2 vs. a rise of 5 +/- 3 (HE), 2 +/- 3 (NS), and 6 +/- 3 (WB) mm Hg/ml; p = 0.0005]. This improvement was even more dramatic in the presence of an epidural mass [a fall of 21 +/- 3 vs. no change (HE, WB) and a rise of 4 +/- 3 (NS) mm Hg/ml; p = 0.0005]. For hemorrhage accompanied by severe head injury, resuscitation with HS may benefit victims by decreasing ICP and diminishing the effects of an intracranial mass.

A comparison of the effects of suxamethonium, atracurium and vecuronium on intracranial haemodynamics in swine.

Sixteen Yorkshire swine weighing 15-20 kg were studied to compare the effects of suxamethonium, atracurium and vecuronium on intracranial pressure (ICP), heart rate (HR), arterial blood pressure (BP), and cerebral perfusion pressure (CPP) in swine with normal or elevated ICP. In each animal an intracranial pressure-volume curve was produced by the inflation of an epidural balloon. The baseline ICP (Po), the ICP at the inflection point (Pi) and on the steep portion (Pmax) of the pressure-volume curve were identified and the balloon volumes recorded. The animals were assigned to receive either suxamethonium 1.0 mg/kg, atracurium 0.6 mg/kg, vecuronium 0.2 mg/kg, or saline placebo intravenously at three conditions: First, with the epidural balloon deflated Po, next at Pi, then at Pmax. Neither atracurium, vecuronium, nor placebo produced any statistically significant effect on HR, BP, ICP, or CPP at any baseline level of ICP. Suxamethonium produced an early fall in ICP (0.8 +/- 0.3, 2.6 +/- 1.0 and 3.5 +/- 1.3 mmHg at Po, Pi and Pmax respectively: P = .0005) followed by a rapid rise above the pre-infusion level (1.8 +/- 0.6, 2.8 +/- 0.6 mmHg, and 2.2 +/- 0.5 mmHg at Po, Pi and Pmax respectively: P = .0005). A fall in BP coupled with the rise in ICP resulted in a fall in CPP (5.8 +/- 2.3, 6.1 +/- 1.2, and 6.3 +/- 1.8 mmHg at Po, Pi and Pmax respectively: P = .0005). Although the fall in CPP was not large, in the presence of elevated ICP, where CPP already is marginal, such a decrease may compromise cerebral blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

The hemodynamic effects of severe mitral stenosis and pulmonary hypertension during labor and delivery.

Pregnancy represents a hyperdynamic state characterized by increased cardiac output, blood volume, and oxygen consumption. Valvular heart disease may blunt this response and, especially when associated with pulmonary hypertension, carries a high mortality. We report the hemodynamic variables as measured through the completion of labor, delivery and postpartum period in a woman with severe mitral stenosis and pulmonary hypertension.

Continuous thoracic epidural analgesia for the control of pain associated with pleural sclerosis.

Successful use of nonnarcotic, thoracic epidural analgesia for the control of pain associated with pleural sclerosis was accomplished in three gynecologic oncology patients with severe respiratory compromise due to malignant pleural effusions. Excellent analgesia was obtained with no observed anesthetic complications.