Two cases of postpartum cardiomyopathy initially misdiagnosed for pulmonary embolism.

PURPOSE: To underline the crucial role of urgent echocardiography in the differential diagnosis of acute respiratory and/or circulatory failure in the postpartum period. CLINICAL FEATURES: A 24-yr-old woman was admitted to the intensive care unit (ICU) with a preliminary diagnosis of pulmonary embolism (PE) one week after Cesarean section. Neither computerized tomography nor Doppler sonography showed any signs of deep venous thrombosis or PE. In the ICU she required intubation and ventilatory support for acute respiratory and circulatory failure. Bedside echocardiography revealed features of left ventricular failure. A diagnosis of postpartum cardiomyopathy (PPCM) was made, appropriate treatment instituted and the patient soon improved. A 29-yr-old, previously healthy primipara presented at the Maternity Clinic on the fourth postpartum day complaining of increasing dyspnea and fatigue. Within eight hours she required intubation, ventilatory support and subsequent defibrillation due to cardiac arrest. She was transferred to the ICU with a preliminary diagnosis of PE. She developed pulmonary edema followed by cardiac arrest with successful resuscitation. Bedside echocardiography revealed a left ventricular ejection fraction below 30% with an increased systolic diameter of the left ventricle, restrictive diastolic abnormalities and no signs of pulmonary hypertension. Peripartum cardiomyopathy was diagnosed and supportive treatment for heart failure was instituted. CONCLUSION: It is possible to misdiagnose postpartum cardiomyopathy for PE. An error in diagnosis is life-threatening for the patient. Echocardiography is a valuable tool in the differential diagnosis. As a noninvasive procedure, it should be performed at the bedside as soon as possible to institute proper treatment and to avoid potentially fatal errors.

Influence of L-carnitine and its derivatives on myocardial metabolism and function in ischemic heart disease and during cardiopulmonary bypass.

Carnitine and its derivatives have recently been shown to protect cardiac metabolism and function in ischemic heart disease and other clinical conditions of myocardial ischemia. Potential mechanisms of this effect include an increase in glucose metabolism, a reduction of toxic effects of long-chain acyl-CoA and acyl-carnitine in myocytes, an increase in coronary blood flow and anti-arrhythmic effect. It has also been shown that propionyl-L-carnitine which penetrates faster than carnitine into myocytes is effective in inhibiting production of free radicals. Beneficial effects of carnitine supplementation have been demonstrated under a variety of clinical conditions such as acute cardiac ischemia, during extracorporeal circulation, in carnitine-dependent cardiomyopathy as well as in patients with chronic circulatory failure and in cardiogenic shock. However, further studies are required before carnitine administration could be recommended as a routine procedure in ischemic heart disease or before cardiopulmonary bypass.

Effect of sevoflurane on intracranial pressure and cardiovascular function in rabbits with experimental intracerebral haematoma.

BACKGROUND: Sevoflurane is one of the newest volatile anaesthetic agents. The effect of sevoflurane on ICP in conditions of intracranial pathology is essential from the clinical point of view but still not sufficiently clear. The aim of the study was to examine the effects of 1 MAC, 2 MAC, 3 MAC sevoflurane on intracranial pressure (ICP), mean arterial blood pressure (MABP) and heart rate (HR) in rabbits with experimental intracerebral haematoma (ICH). MATERIAL AND METHODS: The experiments were performed in 13 adult rabbits, 3.5-4.0 kg weight. The rabbits were randomly allocated to two different groups. In group I, (n = 7), sevoflurane was administered in stepwise increasing concentrations of 2.2 vol%, 4.4 vol% and 6.6 vol%, each for a period of 15 minutes. In group II (n = 6), intracerebral haematoma was produced and subsequently sevoflurane was administered in the same manner as in group I. Ventilation parameters, inspiratory and end-tidal sevoflurane concentration, end-tidal CO2 concentration (ETCO2), HR, MABP, ICP and body temperature, measured in the nasopharynx, were monitored throughout the experiment. RESULTS: Mean values of ETCO2 and temperature in the nasopharynx were not significantly different in both groups and remained stable in the whole observation period. In group II in all cases the evidence of intraventricular haematoma was observed. In this group mean values of ICP, MABP and HR after haematoma production were significantly higher than those in group I. Statistically significant increase of ICP was observed in 30th minute in group I, while in 35th minute in group II. In both groups a statistically significant decrease in MABP was observed from 20th minute of observation. A significant decrease in HR in both groups from 25th minute of experiment was also observed. CONCLUSION: In conclusion it should be stressed that sevoflurane, in doses not exceeding 1 MAC, shows no significant effect on ICP and cardiovascular function in the course of intracranial haematoma.

The influence of the intraventricular hemorrhage on the intracranial pressure and hemodynamic changes in the experimental intracerebral hemorrhage in the rabbits.

The experimental model of the intracerebral hematoma in the rabbit was used for the investigation of the changes of the intracranial pressure and selected hemodynamic parameters. The study was performed on 13 adult rabbits, divided into two groups receiving 1 ml (group I--6 animals) and 2 ml (group II--7 animals) of fresh arterial blood, respectively. The monitoring of the intracranial pressure (ICP), the mean arterial blood pressure (MABP), the heart rate (HR), the end-tidal CO2 concentration (ETCO2) and the body temperature was measured every minute in the hematoma production phase and every 5 minutes for the consecutive three hours. The volume of the hematoma was calculated according to Cavalieri formula, with the use of the system for the automatic picture analysis. The mean volume of the intraparenchymal part of the hematoma in group I was higher than in the group II. However, in all the representatives of the second group the evidence of the intraventricular hemorrhage was present. The dynamics of the ICP, MABP and HR changes differed significantly in both groups during the period of the observation. On the basis of the physiological and morphological observations we conclude that the changes of ICP remain the most sensitive and valuable parameter during the early course of the intracerebral hemorrhage. Coexistence of the rapid ICP, MABP and HR changes must be always regarded as the possible sign of the intraventricular hemorrhage.

Administration of clemastine--H1 histamine receptor blocker in the prevention of haemodynamic disorders after protamine sulfate administration in patients subjected to coronary artery bypass grafting in extracorporeal circulation.

INTRODUCTION: Adverse effects of protamine administration after CPB: fall in arterial blood pressure and pulmonary hypertension are still a source of problems. CPB and protamine administration are both accompanied by increased histamine levels in blood. The aim of this study was to examine if clemastine can accelerate the normalisation of arterial blood pressure during the protamine administration after CPB during CABG operations. MATERIAL AND METHODS: Fifty three patients subjected to CABG operations were studied. Control group (n = 27) did not receive clemastine, Clemastine group (n = 26) received 2 mg i.v. clemastine, before CPB. After CPB were completed, patients were given protamine (heparin to protamine ratio--1:1.5) within 7 minutes, through peripheral vein. Changes in arterial blood pressure from the beginning of protamine administration to 2.5, 5, 7.5, 10, 15, and 30 minutes thereafter, as well as heart rate, CVP, doses of inotropic drugs and vasodilators were compared between the groups. RESULTS: No difference in heart rate, CVP, doses of inotropic drugs and vasodilators between the group was noted. An increase in arterial blood pressure 5, 7.5, 10, and 15 minutes after the beginning of the protamine administration were greater in clemastine group than in control group. Groups were comparable with regard to surgical procedures and doses of anaesthetic drugs. It is now known that protamine exerts a negative effect on cardiac contractility either through a decrease in coronary perfusion pressure (vasodilatation), or through a direct toxic effect on cardiac muscle. The administration of clemastine before CPB can reduce peripheral vasodilatation and capillary leak related to histamine release during CPB. In the clemastine group, faster increase in arterial blood pressure toward a physiologic range was observed. We conclude that administration of clemastine is connected with the normalization of ABP during and after protamine reversal of heparin coagulation during CABG operations.

[Multiple venous air embolism during cerebellar tumor surgery. Case report]. / Wielokrotny zylny zator powietrzny podczas operacji guza mózdzku.

A case of successfully treated multiple venous air embolism occurred in a man aged 41 operated on for cerebellar tumour. Postoperatively exceptionally serious complication developed in the form of neurogenic pulmonary oedema. Attention is called to a number of aetiological factors in this case. The anaesthesiological management in such cases should include careful monitoring of end-tidal CO2 concentration and insertion of catheter into right atrium.

Serum enzyme levels in anaesthetic personnel.

The reported studies were carried out on 22 persons, 15 anaesthetists and 7 anaesthetic nurses with a history of long-term exposure to halothane in low concentrations. The activity of gamma-glutamyl-transpeptidase (GGTP) and aminotransferases, the level of bilirubin and thymol turbidity test were determined. No significant abnormalities were found in the mean values of these determinations. In some cases a rise in alkaline phosphatase activity and in two cases a rise of GGTP were found. The results are not suggesting the presence of hepatocellular damage in this group.