Which is the abnormal lung?

A case of acute respiratory failure with congestive heart failure is described. Unilateral pulmonary edema with left ventricular failure was demonstrated by hemodynamic data, excluding the initial diagnosis of right-sided pneumonia. Controlateral pulmonary hyperlucency was due to a pulmonary embolism confirmed by a cut off on the angiographic X-ray. At autopsy total lung infarction was the confirmatory finding.     

Interhepatic duct: A new biliary anomaly

True accessory bile ducts occur in only 1% of patients. An accessory bile duct connecting the right and left hepatic ducts at the porta hepatis is described. This anomaly has never been reported previously, and was clinically significant in the presence of partial obstruction of an anomalous right hepatic duct by stones. The embryologic origin of this duct, which we term an interhepatic duct, is uncertain.     

Is unified monitoring improving patient care?

We compared our standard method of data presentation in the operating room (i.e., using front end equipment) with a newly developed, computerized monitoring system called the data acquisition and display system. These two systems differed in that data presentation using the standard front-end equipment was scattered and poorly structured, whereas data obtained from the newly developed system were unified and integrated. To effect the comparison, we examined the controllability (i.e., the precision of control) by the anesthesiologist of hemodynamic variables: arterial systolic, mean, and diastolic pressures, mean pulmonary artery pressure, mean central venous pressure, and heart rate. Controllability was assumed to be an indictor of the quality of anesthesia. All perioperative data were stored every 15 seconds on a floppy disk, and these data were available for analysis. The controllability was quantified by calculating the surface area of the signal of a variable outside a defined control zone; the smaller this surface area, the greater the controllability. A Mann-Whitney-Wilcoxon statistical test was done to test whether the two different data presentation systems would result in different levels of controllability (the first zero hypothesis). A Kruskal-Wallis test was done to examine the inter-anesthesiologist variability between the two systems (the second zero hypothesis). Our data showed great variability. Looking for factors that might explain this, we found that if preoperative systolic blood pressure was greater than 160 mm Hg and diastolic pressure was greater than 95 mm Hg, hemodynamic variables fluctuated more widely. We could show no differences in controllability when the two systems were compard overall. However, we did see a trend toward a difference in controllability among different anesthesiologists using the data acquisition and display system.This study was partially funded by Stichting voor Technische Wetenschappen, and by Honeywell Medical Systems, Best, The Netherlands.The authors acknowledge the contribution of Dr Allen K. Ream in the development of the DADS display, and thank Dr H. M. van Kessel for his technical assistance.     

The effects of PEEP on arterial oxygenation

The effect of positive end expiratory pressure (PEEP) on arterial oxygenation depends on many factors. Two of the most important are the quality and the quantity of the physiological shunt. The quality depends on the mixed venous oxygen tension, and the quantity on the shunt fraction. Each of these factors may rise or fall with PEEP, depending on the pulmonary and circulatory state of the patient. Their ultimate balance influences the change in arterial oxygen tension.     

Elastase and granzymes during meningococcal disease in children: correlation to disease severity

Objective To investigate the levels of human neutrophil elastase and lymphocyte-derived granzymes A and B in relation to disease severity in children with meningococcal disease.Design Clinical observational cohort study.Setting Paediatric intensive care unit.Patients All patients with meningococcal disease during the study period were included.Measurements and results Blood sampling was done on the day of admission and on days 3 and 7. Assays for elastase and granzymes were done with ELISA. Sixty-one patients were included: 19 having distinct meningitis; 17 meningitis and shock; and 25 fulminant septicaemia. On admission levels of elastase were increased in all patients, being highest in those with fulminant septicaemia and lowest in those with distinct meningitis. Granzyme A (although marginally) and granzyme B levels were only increased in patients with shock. In 20 of the 28 patients admitted for 3 days elastase decreased from admission (rapid-decrease group). In the remaining 8 patients, elastase started to decrease after 2 days (slow-decrease group). Patients of the slow-decrease group had a higher temperature up to day 4, needed more respiratory support (mean airway pressure in cm H₂O on days 3 and 4: p=0.02 and p<0.01, respectively), and more circulatory support (>2 inotropic agents on day 3; p=0.04) compared with the rapid-decrease group.Conclusions Human neutrophil elastase and granzyme B are related with disease severity during the initial phase of meningococcal disease and prolonged neutrophil activation is associated with the extent of organ dysfunction during the period thereafter.     

Mixed venous blood gas sampling is not influenced by the speed of withdrawal in cardiac surgery patients

Objective To determine whether mixed venous blood gas sampling obtained by pulmonary artery catheter (PAC) is influenced by the speed of withdrawal.Design Prospective, observational study.Setting Surgical intensive care unit at a university hospital.Subjects Twenty-five patients in the early postoperative period of cardiac surgery.Measurements and main results After verification of the adequate position of the PAC, measurements of mixed venous blood gas oxygen saturation, oxygen partial pressure (PO₂), carbon dioxide partial pressure (PCO₂), pH and bicarbonates were obtained at two different rates of withdrawal. A slow sampling was taken at a mean speed of 3 ml/min and a fast sampling at 18 ml/min for each patient. The mean difference in venous oxygen saturation between slow and fast samplings was -0.18±1.3%, venous PO₂: –0.2±1.3 mmHg, venous PCO₂: 0.1±0.9 mmHg, venous pH: 0±0.03, venous bicarbonates: 0.03±0.5 mmol/l.Conclusion Using the Bland & Altman method, we showed a satisfactory agreement between slow and fast mixed venous blood gas sampling techniques when measuring PO₂, oxygen saturation, PCO₂, pH and bicarbonates though a PAC.Electronic Supplementary Material Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134.004.2392-4This study was supported by the Plan de pratique des anesthésiologistes de lInstitut de Cardiologie de Montréal.     

The haemodynamic effects of sublingual nitroglycerin spray in severe left ventricular failure

The use of sublingual nitroglycerin spray has been studied in twenty patients referred to our Intensive Care Unit for further treatment of severe left ventricular failure. Within five minutes of spray administration significant falls in pulmonary artery occlusion pressure, mean arterial pressure, heart rate, right atrial pressure and systemic vascular resistance occurred. Similarly significant increases in cardiac index, stroke volume index and left ventricular stroke work index were found. These results show a considerable improvement in the haemodynamic parameters of invasively monitored patients and we believe that its administration undoubtedly buys time for the critically ill patient. However, we would caution against its routine use at present in view of the potential problem of hypotension, until further information is available.     

Two Bankrobbers With “Antisocial” and “Schizoid/Avoidant” Personality Disorders, Comorbid With Partial Seizures: Temporal Lobe Epilepsy and Limbic Psychotic Trigger Reaction, Respectively

Diagnostic overshadowing is illustrated by two cases of unplanned, motiveless bank robbery, initially merely attributed to antisocoial or schizoid/avoidant (loner) personality disorder, respectively. Both disorders, however, were comorbid with their potentially unobservable counterparts, with brief partial seizures, supported by both men's abnormal scalp-EEG's, their symptomatology with psychosis, and their histories of closed head injury in childhood. Such injuries are known to render particularly the temporo-limbic brain system susceptible to later partial seizure: Mr. A. had temporal lobe epilepsy (TLE) with stereotypic auditory command hallucinations and clouding of consciousness. (His past antisocial aggressive behavior might also have reflected TLE-related inter-ictal events.) Mr. B. had the symptomatology proposed as limbic psychotic trigger reaction (LPTR). Mr. B., a social loner, typically ruminated on past intermittent moderate stresses, a specific precondition of seizure kindling, ultimately elicited by a specific stimulus, resembling his past hurts. As is typical for LPTR, Mr. B. had no clouding of consciousness and no amnesia for his atavistically regressive acts, committed with flat affect, nausea, and fleeting delusions of grandeur (being gifted, like Rembrandt).     

Small bowel edema: Mosaic pattern

We report an unusual radiographic appearance of small bowel submucosal edema produced by obstruction from metastatic colorectal carcinoma. The distinctive muscosal pattern of raised polygonal plaques is the same mosaic pattern described in the colon and referred to as urticaria. This mosaic pattern in the small bowel has not previously been reported.     

Tranexamic acid attenuates oleic-acid-induced pulmonary extravasation

Objective Activation of fibrinolysis is implicated in the development of vascular injury in certain lung injuries. It has yet to be reported that activation of plasmin is involved in extravasation caused by oleic acid (OA). We examined whether or not plasmin is involved in pulmonary extravasation by OA.Design Prospective trial.Setting University laboratory.Subjects A total of 78 guinea pigs (498.9±10.6 g).Interventions Evans blue (EB) was administered to anesthetized guinea pigs. Subsequently four protocols were followed: (1) After 1 min, 60 l/kg of OA was injected. Perfusion was performed 30, 60 or 90 min after OA injection to wash out intravascular EB. (2) After 1 min, 15, 30 or 60 l/kg of OA was injected. (3) Tranexamic acid (TA) (2 g/kg) or saline was administered 30 min before OA (15 l/kg) injection. (4) Diphenhydramine hydrochloride (2.9 mg/kg) or saline was administered 7 min before OA (15 l/kg) injection.Measurement and results Except in protocol 1, the chest cavity was opened 90 min after OA injection. Perfusion was then performed. Airway was separated into four parts from trachea to distal bronchus. EB was extracted from the tissues and measured. OA caused an extravasation throughout airways in a time-and dose-dependent manner. Extravasation was more conspicuous in peripheral tissues. TA significantly attenuated extravasation, while diphenhydramine hydrochloride did not.Conclusions It is suggested that plasmin, but not histamine, is involved in extravasation by OA. Inhibition of plasmin can be an effective strategy for treatment of this kind of lung injury.