Biomedical subjects
Publications and source records attributed to A Trouwborst.
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The effects of stepwise isovolemic hemodilution on systemic and regional hemodynamics, oxygen flux, and circulating catecholamines were studied in six pigs anesthetized with midazolam and fentanyl. Reduction of the hematocrit from 28 to 9% resulted in doubling of the cardiac output, mainly due to an increase in stroke volume. Regional blood flows, measured using the radioactive microsphere technique, showed an increase in blood flow to all organs except liver (hepatic artery fraction) and adrenals, with a redistribution of cardiac output in favor of heart and brain (increase in blood flow 420 and 170%, respectively). Oxygen flux to most organs did not decrease until hematocrit decreased to 9%, while total body oxygen consumption was well maintained. Left ventricular oxygen consumption increased, but because left ventricular blood flow also increased, left ventricular extraction ratio did not increase. Circulating catecholamines did not play any role in these regulatory mechanisms.
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OBJECTIVE: To determine the accuracy of in vivo mixed venous hemoglobin saturation (Svo2) measurements with a fiber optic thermodilution catheter during acute changes in hematocrit. DESIGN: Comparison of fiberoptic in vivo Svo2 values with in vitro Svo2 values obtained with a multiwavelength spectrophotometer. SETTING: Operating room in a university hospital. PATIENTS: Six consecutive patients who are Jehovah's Witnesses. MEASUREMENTS AND MAIN RESULTS: Before and after each step of hypervolemic hemodilution and after every 500 mL of blood loss, blood gases were analyzed and hemodynamic, hemoglobin, hematocrit, and in vitro and in vivo Svo2 measurements were made. Hematocrit values were measured in the range of 40% to 18%. Plotting all in vivo Svo2 values (n = 74) against the in vitro Svo2 measurements obtained during the entire study period gives r2 = .86. The accuracy of in vivo Svo2 measurements was not affected by changes in hematocrit or cardiac output. The Svo2 catheter value at the beginning of the study differed from the in vitro Svo2 value by -0.86 +/- 2.56% and at the end of the study period of 8 to 10 hrs by 0.71 +/- 3.04%. CONCLUSIONS: The accuracy of the studied fiberoptic continuous measuring Svo2 system was not affected by changes in hematocrit or cardiac output. No significant drift in the in vitro Svo2 measurements was observed.
16 patients underwent acute hypervolaemic haemodilution with dextran 40 and Ringers lactate, to see whether this procedure could avoid preoperative blood transfusion. Packed cell volume (PCV) and oxygen extraction decreased, and cardiac index and pulmonary wedge pressure increased, although end-systolic area was unchanged. PCV was not significantly different between patients who lost less than or greater than 20% of their initial blood volume. This preoperative manoeuvre, which reduces loss of red blood cells, allowed major surgery to be completed safely without blood transfusion.
40 patients (24 male, 16 female, aged 21-59 years) of American Society of Anesthesiologists class I or II who were undergoing routine surgery took part in a randomised, double-blind comparison of the anaesthetic efficacy and potency of xenon and nitrous oxide and their effects on the circulatory and respiratory systems. During anaesthesia, for each rise in blood pressure of more than 20% of the preanaesthetic (baseline) value, the patient received 0.1 mg fentanyl. The total amount of fentanyl required per patient was used as an index of the anaesthetic potency of the study gases. Patients in the xenon group required on average only 0.05 mg fentanyl, whereas those in the nitrous oxide group required 0.24 mg fentanyl; the duration of anaesthesia was similar in the two groups. Changes in blood pressure were significantly greater throughout the study in the nitrous oxide than in the xenon group. Thorax-lung compliance fell during the study period in the nitrous oxide group but not in the xenon group. Thus, xenon is a potent and effective anaesthetic which can be safely used under routine conditions.
In conclusion, in contrast to many reports obtained from dogs, in pigs the rise in CO during moderate isovolemic hemodilution is, besides the increased venous return, more induced by increased work performance of the heart and less by a decreased SVR. The rise in CO did not compensate for the decrease in oxygen transport capacity. Our results confirm most of the reported findings in humans at the same stage of hemodilution. Besides changes in hemodynamics, in our study a gradual decreased oxygen affinity of hemoglobin could be observed. That the pig animal model for studying hemodilution and oxygen transport to the tissue is more appropriate than the dog model is open to discussion.
We report the effects of acute hypervolaemic haemodilution, induced before operation, on haemodynamics and systemic oxygenation. Major surgery in an anaemic Jehovah's Witness patient was facilitated with this technique. Some hours after operation, a perioperative decrease in haemoglobin concentration of less than 5% was observed, in spite of a blood loss of nearly 50% of the calculated blood volume.
Mixed venous oxygen saturation of hemoglobin (SvO2) and mixed venous oxygen tension (PvO2) may reflect the overall balance between oxygen consumption and delivery. Because of the potential value of monitoring SvO2 and PvO2 as indications of the state of tissue oxygenation, the aim of this study was to determine, during normoxic acute isovolemic hemodilution in pigs, the critical PvO2, critical SvO2, and critical oxygen extraction ratio (ER) at which oxygen uptake starts to decline during further induced hemodilution. During stepwise induced isovolemic hemodilution, a gradual decline in SvO2 and PvO2 was observed in all animals. The mean +/- SD of the critical PvO2 of six animals was 32.3 +/- 3.1 mm Hg. The mean +/- SD of the critical SvO2 was 44.2% +/- 7.9%. The ER increased gradually. At an ER of 0.57 +/- 0.08, oxygen uptake started to decline. A significant correlation was found between changes in SvO2 and changes in ER. These degrees of hemodilution were accompanied by an increase in cardiac index, pulmonary wedge pressure, heart rate, and left ventricular stroke work index. Only a slight decrease in systemic vascular resistance was observed. We conclude that measurements of PvO2 and SvO2 can be used as indicators of the critical point of hemodilution and that the SvO2 during hemodilution reflects the overall balance between oxygen uptake and oxygen delivery, confirmed by the strong correlation found between SvO2 and oxygen extraction ratio.
In the estimation of oxygen transport the term oxygen availability is used as the product of cardiac output and the arterial oxygen content (CaO2). Attempts can be made to modify the concept of oxygen availability by subtracting from the CaO2 the venous content at a critical PO2 as measured in mixed venous blood (Pv-O2), where oxygen diffusion into tissue becomes compromised and oxygen uptake (VO2) may decrease. The real arterial available oxygen content (CavlO2) can be calculated by estimating the saturation at the critical Pv-O2. For our concept S35 was chosen as such a dynamic baseline. Similar modification of oxygen extraction ratio (ERav) defined as VO2 divided by the real oxygen availability (O2av) should give, more than the classic ER, a realistic indices of oxygen availability in relation to oxygen consumption. It can be hypothesized that VO2 starts to decline when ERav is around 1.0. During isovolemic hemodilution VO2 started to drop when ERav reached 1.08 +/- 0.09. The S35 changed from 55.0 +/- 2.1% to 41.5 +/- 4.1%, correlated with changes in Pv-O2. A direct correlation was also found between the increase of the classic ER and the change in S35. We conclude that the S35, the CavlO2 and the ERav can be of value in monitoring the systemic oxygenation and that the concept also includes the effect of changes in oxyhemoglobin characteristics on oxygen delivery.
A new concept in monitoring systemic oxygenation that includes the effect of changes in oxyhemoglobin dissociation curve (ODC) has been introduced. Using the S35 (saturation of hemoglobin at PO2 = 35 mmHg), real arterial available oxygen content (CavlO2) can be calculated being the maximum amount of oxygen that can be extracted from hemoglobin before oxygen diffusion into tissue becomes compromised and oxygen uptake (VO2) may decrease. The relation between VO2 and CavlO2 expressed by the extraction ratio of the arterial available oxygen content (ERav) gives a realistic indices of oxygen supply in relation to oxygen consumption. In the present study, during extracorporeal circulation (ECC), a severe shift to the left of the ODC could be observed. THe classic parameters for monitoring systemic oxygenation as mixed venous saturation (Sv-O2) and extraction ratio (ER) did not change. The S35 increased because of the shift to the left of the ODC with consequent decrease in CavlO2. The ERav reached critical values during ECC together with hemodilution and hypothermia. A severe decrease in mixed venous PO2 (Pv-O2) was also observed. The authors conclude that besides Pv-O2, the S35, the CavlO2 and especially the ERav are of value in monitoring the systemic oxygenation during hypothermic ECC.
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82 healthy subjects undergoing Extra-corporeal Shock Wave Lithotripsy (ESWL) under epidural anesthesia were given 1000 ml of either gelatine (Geloplasme), dextran 40, 50 g/l (Isodex) or Ringer's lactate. The purpose of the study was to determine the efficacy of the three described solutions in respect to blood volume changes. A clear differentiation is only possible under absolutely defined physiological conditions and therefore in contrast to other studies, none of these patients was suffering from any shock syndrome or had any blood loss, so no capillary leakage or transcapillary refill problem was present. Plasma volume (PV), colloid oncotic pressure (COP) and hematocrit (Hct) were measured before and 15, 120 and 240 min. after infusion. PV increased both in the gelatine and dextran groups with a higher initial increase in the dextran group. COP increased after 15 min. and Hct decreased after 15 min. in the gelatine and dextran groups. With regard to absolute contraindications this study suggests that dextran 40 can be recommended as plasma substitute due to its higher initial increase in PV, its moderate duration of effect and its low incidence of anaphylactic reaction after a preceding infusion of 20 ml dextran Mw 1000 (Promiten).
Exposure of rats to high concentrations of oxygen (greater than 95%) at 1 ATA pressure (101 kPa) is lethal within three days. Rats treated with a small dose of endotoxin are protected against these lethal effects of hyperoxia. Recently, we found that the lysine salt of acetylsalicylic acid antagonises this protective action of endotoxin. This suggests that prostaglandin metabolism plays an important role in the protective action of endotoxin against pulmonary oxygen toxicity. Therefore, we measured the plasma levels of 6KPGF1 alpha, a stable degradation product of prostacyclin (PGI2), PGE2 and thromboxane B2, the stable degradation product of thromboxane A2, in rats exposed to air or greater than 95% oxygen for 48 hours. We compared these with the plasma levels of rats treated with endotoxin (Salmonella typhimurium lipopolysaccharide 1 mg/kg) and exposed to air or greater than 95% oxygen for 48 hours. We found that exposure of rats to greater than 95% oxygen for 48 hours leads to a significant rise in the 6KPGF1 alpha levels. Rats exposed to greater than 95% oxygen for 48 hours and treated with endotoxin had significantly higher PGE2 and significantly lower 6KPGF1 alpha plasma levels than saline-treated rats exposed to greater than 95% oxygen for 48 hours.
War surgery presents conditions and problems that are radically different from those of peacetime surgery. Categorization of the injured may be necessary (triage), while a short or erratic supply of drugs, materials and personnel may exist. In this study, the hospital mortality following military action was 6.4 per cent. In the group of patients with combined thoracoabdominal injuries mortality was high. However, the inflow of this type of patient was relatively low. In 50 per cent of the cases, ketamine/benzodiazepine anaesthesia without intubation and artificial ventilation was sufficient, with the result that the use of oxygen and nitrous oxide was minimized.