Pulse dye densitometry using indigo carmine is useful for cardiac output measurement, but not for circulating blood volume measurement

BACKGROUND AND OBJECTIVE: We evaluated the validity of a newly developed pulse dye densitometer for indigo carmine for measuring cardiac output and circulating blood volume. METHODS: Measurements of cardiac output and circulating blood volume were performed with the indigo carmine densitometer during normovolaemia, hypovolaemia and hypervolaemia in nine mongrel dogs under general anaesthesia. The validity was evaluated by comparison of the values of cardiac output and circulating blood volume obtained by the thermodilution technique and the 51Cr-labelled red blood cell method, respectively. We also examined indigo carmine removal by continuous veno-venous haemofiltration after indigo carmine injection. RESULTS: There was good agreement between dye densitometer- and thermodilution-derived cardiac output (r = 0.885, P < 0.001). The bias and limits of agreement of these values were 0.09 and+/-1.07 L min(-1) (2 SD, n 22), respectively. The dye-densitometer-derived circulating blood volume was greater than that of the 51Cr-labelled red blood cell method, and both values showed weak agreement (r = 0.587, P < 0.027). The sieving coefficient of indigo carmine through continuous veno-venous haemofiltration was 0.34+/-0.06. CONCLUSIONS: These data indicate that indigo carmine densitometry is a reliable method for cardiac output determination, but it overestimates circulating blood volume, probably due to the transition of indigo carmine into the extravascular space in the systemic circulation.     

The adverse effects of indigo carmine

A case of diencephalic dysregulation is reported during urological endoscopy following the intravenous administration of indigo carmine. It should be kept in mind that according to the literature, indigo carmine has severe side-effects on the cardiovascular system caused by vasoconstriction. Ergotamine-like effects of indigo carmine due to direct vasoconstriction with spasm of the cerebral arteries are discussed.     

Severe hypertensive reaction to indigo carmine

An episode of severe hypertension induced by indigo carmine is herein reported. Treatment with intravenous hydralazine was required to restore systemic blood pressure to a safe level. The reported association of indigo carmine with hypertension is reviewed.     

Sentinel lymph node biopsy using indigo carmine blue dye and the validity of '10% rule' and '4 nodes rule'

This is the study which assessed sentinel lymph node biopsy (SNB) using indigo carmine blue dye and the validity of the '10% rule' and '4 nodes rule'. Patients (302) were performed SNB using the combined radioisotope (RI)/indigo carmine dye method. Excised SLNs were confirmed whether they were stained and numbered in order of RI count and the percentage of radioactivity as compared to the hottest node was calculated. The relationship between histological diagnosis, dyeing and RI count was assessed. All the patients were detected SLN. Positive nodes were identified in 84 (27.8%) patients and were identified up to the third degree of hottest. All the hottest positive nodes were stained by indigo carmine. From the results, removing the three most radioactive SLNs identified all cases of nodal metastasis without complications. These stopping rules were valid and useful under indigo carmine use too.     

基层医院开展内镜下黏膜切除术的临床体会

目的探讨基层医院开展内镜下黏膜切除术的特点与注意事项。方法回顾性分析2009年1月至2011年12月我们对结直肠黏膜可疑病灶行内镜下黏膜切除术的17例患者的临床资料。结果结直肠黏膜可疑病灶的17例患者均行的内镜下黏膜切除术,取材完整;病理检查均为早期结直肠癌,切缘无癌浸润;创面出血少。结论在基层医院对结直肠黏膜可疑病灶行内镜下黏膜切除术是能够一次性完成诊断与治疗的,具有费用低、操作简单的应用价值。     

Acute hemodynamic effects of indigo carmine in the presence of compromised cardiac function

This report describes the acute hemodynamic effects of indigo carmine in a surgical patient with compromised cardiac function. A 68-year-old woman with stable but severe cardiac dysfunction and renal artery stenosis was scheduled for an elective aortorenal bypass procedure. No hemodynamic instability occurred during the operation until the patient was administered intravenous (IV) indigo carmine 5 ml. At that time, the patient experienced an acute increase in afterload, which resulted in acute left ventricular failure documented by a decrease in cardiac output (CO) and an increase in pulmonary artery pressure (PAP). Until further studies defining the mechanism for its hypertensive side effect are performed, indigo carmine should be used with caution in patients with severe cardiac dysfunction.     

Life-threatening reaction to indigo carmine – A sulfa allergy?

Indigo carmine is commonly used during cystoscopy when evaluating for lower urinary tract safety after gynecologic surgery. We report a case of severe hypotension and bradycardia following intravenous indigo carmine injection in a patient with known sulfa allergy.     

Parathyroid surgery: the role of chief cell intracellular fat staining with osmium carmine in the intraoperative management of patients with primary hyperparathyroidism

The surgeon's gross evaluation, the hematoxylin and eosin stain, which assesses extracellular fat, and a new intracellular fat stain, osmium carmine, were comparatively evaluated in 30 consecutive patients who underwent surgery for primary hyperparathyroidism. The surgeon's gross judgment of enlarged and normal parathyroid tissue resulted in the correct functional assessment in 98% and 97% of the glands, respectively. The surgeon's functional assessment was correct in seven of 10 parathyroid glands that were considered by gross examination to be slightly enlarged (50 to 80 mg). The osmium carmine intracellular fat stain provided a correct functional assessment in all 10 of these glands. The osmium carmine stain also appears to have a role in providing scientific quantitative data to limit operations in patients who have a parathyroid adenoma to removal of the adenoma and biopsy of a grossly normal gland that demonstrates normal intracellular fat. Only one side of the neck was explored in 11 patients who fulfilled these criteria. There has been no persistent or recurrent hypercalcemia in these patients.     

Nonvisualization of intravenous methylene blue in patients with clinically normal renal function

Urologists use intravenous dyes in diagnosing genitourinary fistulas and in investigating ureteral patency. Methylene blue and indigo carmine are the most common dyes used today. Generally, patients with clinically normal renal function demonstrate dye in their urine after several minutes. We report on 2 patients in whom methylene blue was not visualized after intravenous injection. A review of urologic and pharmacologic published reports led to a possible explanation for this phenomenon. Methylene blue can metabolize into leukomethylene blue, which is colorless in urine. Indigo carmine, however, is not readily metabolized but is rather freely filterable by the kidneys. Therefore, it is important to appreciate that nonvisualization of methylene blue may be a metabolism effect and not an anatomic one.     

Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy.

OBJECTIVES: To determine the incidence of and risk factors for injury to the lower urinary tract during total laparoscopic hysterectomy. METHODS: All patients who underwent total laparoscopic hysterectomy for benign disease from January 1, 2002 to December 31, 2005, at an academic medical center are included. Subjects undergoing laparoscopic-assisted vaginal hysterectomy, supracervical hysterectomy, or hysterectomy for malignancy were excluded. Intraoperative cystoscopy with intravenous indigo carmine was routinely performed. Relevant data were abstracted to determine the incidence of lower urinary tract injury, predictors of injury, and postoperative complications. RESULTS: Total laparoscopic hysterectomy was performed in 126 consecutive subjects. Two (1.6%) cystotomies were noted and repaired before cystoscopy was performed. Two (1.6%) additional cystotomies were detected during cystoscopy. Absent ureteral spill of indigo carmine was detected in 2 subjects: 1 (0.8%) with previously unknown renal disease and 1 (0.8%) with ureteral obstruction that was relieved with subsequent suture removal. Only 40% (2/5) of injuries were recognized without the use of cystoscopy with indigo carmine. The overall incidence of injury to the lower urinary tract was 4.0%. No subjects required postoperative intervention to the lower urinary tract within the 6-week perioperative period. Performing a ureterolysis was associated with an increased rate (odds ratio 8.7, 95%CI, 1.2-170, P=0.024) of lower urinary tract injury. CONCLUSION: Surgeons should consider performing cystoscopy with intravenous indigo carmine dye at the time of total laparoscopic hysterectomy.     

Intraoperative detection of sentinel lymph nodes in breast cancer patients using ultrasonography-guided direct indocyanine green dye-marking by real-time virtual sonography constructed with three-dimensional computed tomography-lymphography

PurposeThis study aims to determine the utility of ultrasonography (US)-guided direct dye-marking of sentinel lymph nodes (SLNs) by real-time virtual sonography (RVS) constructed with three-dimensional (3D) computed tomography (CT)-lymphography (LG).Patients and methodsWe identified SLNs in 258 clinically node-negative breast cancer patients using an RVS system to display in real time a virtual multiplanar reconstruction CT image obtained from CT volume data corresponding to the same cross-sectional image from US. CT volume data were obtained using our original 3D CT-LG, which accurately detects SLNs in breast cancer. We then perform US-guided dye-marking close to SLNs using indocyanine green (ICG). Subsequently, indigo carmine blue dye was injected into the subareolar and peritumoral areas around each primary tumor. All patients underwent SLN biopsy and SLN metastases were examined pathologically.ResultsIn all 258 patients, we were able to detect the same SLNs visualized on 3D CT-LG, using the RVS system. We detected ICG close to SLNs in 257 of 258 patients (99.6%) during SLN biopsy. In 25 patients (9%), we failed to follow the blue lymphatic route stained by indigo carmine and SLNs were not stained by indigo carmine, but easily detected SLNs by ICG marking.ConclusionUS-guided direct ICG dye-marking of SLNs using this RVS system seems useful for the detection of SLNs, allowing easy detection of SLNs even when the stained lymphatic route is not followed.     

Laparoscopic resection of a non-communicating uterine rudimentary horn using intra-operative indigocarmine injection: A case report

Introduction and importanceAn unicornuate uterus with a non-communicating rudimentary horn (UUNCRH) is a very rare uterine malformation which is difficult to diagnose and to decide the surgical plan. We aim to describe the case of pediatric UUNCRH patient and our operative technique of laparoscopic intra-uterus indigo carmine injection (LIUICI) to confirm that the rudimentary horn (RH) is non-communicating before the resection and review the relevant literature to ascertain the most appropriate treatment option in these patients.Case presentationA 11-year-old girl who developed progressive severe abdominal pain and dysmenorrhea was referred to our hospital. Uterine malformation and right hematosalpinx was confirmed with magnetic resonance imaging (MRI). Pre-operative treatment with a gonadotropin-releasing hormone agonist enabled improvement in the symptoms. Laparoscopic exploration was scheduled. The right fallopian tube was resected laparoscopically and a 3Fr tube was inserted into its cut end. Indigo carmine injected in the RH through the tube. No leakage of indigo carmine was found from the vagina, indicating the diagnosis of the uterine malformation is an UUNCRH and we performed the resection of the RH safely.Clinical discussionIn pediatric patients transvaginal detailed examination is not easy to perform. Therefore, diagnostic and operative laparoscopy is critically important for the safe treatment. In addition, laparoscopic removal of a RH can be used to decrease the incidence of adhesions.ConclusionWe found LIUICI technique before the resection of the RH is safe, technically feasible and minimally invasive approach for pediatric UUNCRH patients.     

Aids in diagnosis of suspect ectopic ureters in female patients

When suspected ectopic ureters cannot be visualized by conventional methods, such as excretory urogram, nephrotomograms, or by intravenous indigo carmine, then direct injection of vaginal, suburethral, or paraurethral "swellings," which are in effect dilated terminal ureters, may confirm the diagnosis.     

Patent blue versus methylene blue and indigo carmine as a better dye for chromodiscography: in vitro staining efficacy and cytotoxicity study using bovine coccygeal intervertebral discs

BACKGROUND CONTEXTChromodiscography is an integral part of full-endoscopic discectomy (FED), comprising ordinary discography with radiopacity produced by contrast medium and intradiscal stain for visualizing annular defects in the endoscopic field. Nevertheless, concerns remain about the cytotoxicity of the stains used. The study of their staining efficacy is also lacking.PURPOSETo evaluate the feasibility of methylene blue, patent blue, and indigo carmine for intradiscal injection, investigate the effectiveness of each dye, and define critical concentration with adequate staining efficacy and tolerable cytotoxicity for use in chromodiscography during FED.STUDY DESIGNAn experimental in vitro study.METHODSDye stock solutions were prepared from powder. The stock was diluted with culture medium or balanced saline and used for cytotoxicity or intervertebral disc staining assays, respectively. Bovine tails were obtained from the local slaughterhouse and functional spine units of intervertebral discs were acquired by transverse incision at the disc level. Each disc was punctured over the posterolateral aspect using a surgical knife to simulate an annular defect. The intradiscal injection was performed with each dye at different concentrations using a 22G needle from the contralateral aspect of the punctured site. Staining efficacy was quantified using ImageJ software. Primary cells of bovine tails were cultivated in each dye at different concentrations. Cytotoxicity was assessed 24 hours after stain exposure using the CCK-8 toxicity assay.RESULTSStaining efficacy and cytotoxicity were proportional to the concentration of tested dyes. Lower limits of concentration producing significant staining efficacy of indigo carmine, methylene blue, and patent blue were 0.25 mg/mL, 0.25 mg/mL, and 0.05 mg/mL, respectively. Compared with controls, concentrations showing significant toxicity for indigo carmine, methylene blue, and patient blue were 1 mg/mL, 0.5 mg/mL, and 2.5 mg/mL, respectively.CONCLUSIONSPatent blue can serve as a more suitable tissue stain than either indigo carmine or methylene blue due to the widest range of tradeoff concentration within 0.05 to 2.5 mg/mL.CLINICAL SIGNIFICANCEPatent blue with the characteristic of good staining efficacy and lower cytotoxicity may be a promising option for chromodiscography during FED.     

The role of preoperative oral vitamin B in the cystoscopic assessment of ureteric patency

Introduction and hypothesis  

The objective of this study is to determine whether oral vitamin B can be used as a marker of ureteric patency at cystoscopy, and thereby reduce the need for intraoperative intravenous indigo carmine.     

Vascular orientation by intra-arterial dye injection during spinal arteriovenous malformation surgery

OBJECTIVE: Rich and complicated vascular structures on the spinal cord often interfere with obliteration of a spinal arteriovenous malformation (AVM). Vascular orientation during spinal AVM surgery is essential. The authors recently performed six consecutive spinal AVM surgeries in five patients (two with perimedullary AVMs, and three with dural arteriovenous fistulae) with the aid of intra-arterial injection of dye (indigo carmine). METHODS: Two representative cases are described. A microcatheter was placed preoperatively in the artery of interest. Subsequent to the exposure of the vascular complex, a 1-ml injection of indigo carmine (2 mg/ml) clearly demonstrated the feeding arteries and the draining veins around the AVM or dural arteriovenous fistula. RESULTS: One patient had repeat surgery because of incomplete obliteration of the AVM owing to migration of the catheter. All patients, except one who had temporary postoperative deterioration and persistent neurological deficits, had good surgical outcomes, however. No apparent side effects caused by the dye were reported. CONCLUSION: The assistance system for spinal AVM surgery is easy and safe and can be applied in other surgical institutions.     

Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery

A new method of marking small pulmonary nodules situated deep within the visceral pleura using a transbronchial approach has been developed. Once the tip of the sheath catheter has passed the tumor and reached the visceral pleura, as confirmed by computed tomography fluoroscopy, indigo carmine is injected through a bronchoscope into the lung parenchyma just beneath the visceral pleura. No complications related to the procedure were experienced. The dye-marking procedure enabled the nodules to be precisely located. This technique can provide appropriate guidance when used in conjunction with video-assisted thoracic operations.     

Ureteral reimplantation for inadvertent ureteral injury during radical perineal prostatectomy

We report on a rare case of bilateral ureteral injury in a patient undergoing radical perineal prostatectomy and a unique approach to his treatment. Potential risk factors for such an injury include previous prostatic cryotherapy, transurethral resection, or radiotherapy. Intraoperative recognition of the injury is paramount and may be facilitated by intravenous administration of indigo carmine. While distal ureter ligation, urinary diversion, and delayed ureteroneocystostomy may be regarded as standard management for ureteral injury during radical perineal prostatectomy, this case was treated with a primary bilateral transperineal ureteral reimplantation. Although technically challenging, the described case demonstrates the feasibility and success of such an approach.     

Blue dyes, blue people: the systemic effects of blue dyes when administered via different routes

We report 4 patients who had facial color changes to a blue-green-gray color and decreased oxygen saturation as measured by pulse oximetry. Patient 1 received an intravenous (IV) methylene blue solution during a urologic procedure, and the remaining three patients were administered subcutaneous indigo carmine (patient 2) or Patent Blue (Patients 3 and 4) for axillary lymph node mapping. All patients had above normal methemoglobin levels. Two (Patients 2 and 3) had hypotension, and one (Patient 3) required IV ephedrine to restore hemodynamic stability. Patient 4 had a hypersensitivity reaction characterized by systemic urticaria and blue-colored subintegumentary edema due to the subcutaneous administration.     

The diagnostic accuracy of chromoendoscopy for dysplasia in ulcerative colitis: meta‐analysis of six randomized controlled trials

Aim The diagnostic accuracy of chromoendoscopy for dysplasia in ulcerative colitis (UC) was systematically evaluated. Method Original studies in any language were searched from PubMed and Embase. Meta‐analysis of prospective studies that compared chromoendoscopy with histological diagnosis was carried out. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for each study and pooled together; summary receiver operating characteristic (ROC) and subgroup analyses were performed, while the quality of the study and heterogeneity were assessed. Results Six randomized controlled trials were included, which used methylene blue or indigo carmine dye spray. The meta‐analysis demonstrated a pooled sensitivity of 83.3% (95% confidence interval (CI), 35.9–99.6%), specificity of 91.3% (95% CI, 43.8–100%), and DOR of 17.544 (95% CI, 1.245–247.14). Subgroup analyses revealed that both the methylene blue dye spray subgroup and the unspecified endoscopist subgroup include the same studies, and their pooled sensitivity and specificity were 0.737 and 0.917, respectively. The other subgroup, which used indigo carmine dye spray, had overall higher sensitivity (0.930) and lower specificity (0.910). Conclusion Chromoendoscopy has medium to high sensitivity and a high diagnostic accuracy for dysplastic lesions in UC.