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PubMed2005

Thyrotoxic periodic paralysis: a report of 3 Malaysian cases and a review of its pathology.

UNLABELLED: Thyrotoxic periodic paralysis (TPP) is a medical emergency characterised by sudden onset of muscle weakness with hypokalemia that resolves with the treatment of hyperthyroidism. We report three cases of thyrotoxic periodic paralysis seen at the Accident and Emergency Care Department, University of Malaya Medical Centre in a period of four months. We also review the clinical presentation, pathophysiology, biochemical features and management of TPP. All three patients were young Asian males, presenting with muscle weakness of sudden onset. The first patient presented with lower limb weakness and had symptoms of thyrotoxicosis and goitre. He had a previous similar episode which resolved spontaneously. The second patient presented with quadriplegia, respiratory acidosis and had no signs and symptoms of thyrotoxicosis. The electrocardiogram of this patient showed normal sinus rhythm with U wave in V3 and a flat T wave, which are characteristic of hypokalaemia. The third patient, who was a known case of thyrotoxicosis, was admitted thrice for hypokalemic paralysis during the study period. All cases had low serum potassium, suppressed TSH and elevated T4 confirming thyrotoxic periodic paralysis. Potassium therapy was useful during the crisis; however prophylactic potassium has not been shown to prevent attacks as seen in one of our cases. CONCLUSION: Thyrotoxic periodic paralysis should be considered in the differential diagnosis of sudden onset paralysis in young male patients. Determination of the plasma potassium levels and thyroid hormones help in the diagnosis. The definitive treatment for TPP is the achievement of euthyroid state.

Administration, Oral↗

PubMed1991

Effects of prostaglandin E2 on the newborn respiratory system.

To test the hypothesis that prostaglandin (PG) E2 is a respiratory depressant in the newborn lamb, 12 chronically catheterized, unanesthetized lambs (age 2 to 6 days) were infused with progressively increasing doses of PGE2 (0.1, 0.5, 1.0 and 5.0 ug/kg/min: 30 min for each dose) into the ascending aorta. PGE2 caused significant, progressive decrease in ventilation (due to decreased tidal volume and breathing rate) heart rate, blood pressure and percent of the time spent in low voltage electrocortical activity (LVA). PGE2 also caused respiratory acidosis, hypoxemia and increased frequency and duration of apneic events (greater than 3 sec). During the infusion, there was a dose related increase in plasma concentration of PGE2. At 30 min post-infusion, all measured variables showed recovery, although arterial pH carbon dioxide tension and plasma PGE2 remained significantly different from control values and the percent time in LVA was even higher than during control. Infusion of the vehicle alone (n = 5) caused no significant changes in any of the measured variables. The results, taken in combination with previous fetal studies, indicate that PGE2 has marked inhibitory effects on breathing movements both before and after birth.

Animals↗

PubMed1991

[Recurrent surgery for pulmonary venous obstruction after total correction of TAPVC (IIb)].

A 15-months-old boy underwent the intra-cardiac repair with a glutaraldehyde-preserved equine pericardium for total anomalous pulmonary venous connection (Darling's type IIb). Because of rapidly progressive dyspnea, tachycardia and respiratory acidosis, he required emergent reoperation at 234 postoperative days. The pseudointima was thickened heavily and detached from glutaraldehyde-preserved equine pericardium. New channel was created with a piece of EPTFE sheet to prevent obstruction of pulmonary venous flow. However, about four months after second surgery, cough and tachycardia progressed again remarkably. Intra-atrial channel was obstructed between EPTFE sheet and the partition from pulmonary venous orifice to the atrial septal defect in the third operation. The intra-atrial channel was enlarged by cut-back method using EPTFE sheet again. His postoperative hemodynamics were satisfactory

Adolescent↗

PubMed1991

Cardiovascular effects of halothane anesthesia after diazepam and ketamine administration in beavers (Castor canadensis) during spontaneous or controlled ventilation.

Fourteen adult beavers (Castor canadensis) weighing 16.5 +/- 4.14 kg (mean +/- SD) were anesthetized for surgical implantation of radio telemetry devices. Beavers were anesthetized with diazepam (0.1 mg/kg) and ketamine (25 mg/kg) administered IM, which provided smooth anesthetic induction and facilitated tracheal intubation. Anesthesia was maintained with halothane in oxygen via a semiclosed circle anesthetic circuit. Values for heart rate, respiratory rate, esophageal temperature, direct arterial blood pressure, end-tidal halothane concentration, and end-tidal CO2 tension were recorded every 15 minutes during the surgical procedure. Arterial blood samples were collected every 30 minutes to determine pH, PaO2, and PaCO2. Values for plasma bicarbonate, total CO2, and base excess were calculated. Ventilation was spontaneous in 7 beavers and controlled to maintain normocapnia (PaCO2 approx 40 mm of Hg) in 7 others. Vaporizer settings were adjusted to maintain a light surgical plane of anesthesia. Throughout the surgical procedure, all beavers had mean arterial pressure less than 60 mm of Hg and esophageal temperature less than 35 C. Mean values for arterial pH, end-tidal CO2, PaO2, and PaCO2 were significantly (P less than 0.05) different in spontaneously ventilating beavers, compared with those in which ventilation was controlled. Respiratory acidosis during halothane anesthesia was observed in spontaneously ventilating beavers, but not in beavers maintained with controlled ventilation. All beavers recovered unremarkably from anesthesia.

Acid-Base Equilibrium↗

PubMed1991

[A case of myocardial infarction associated with pulmonary edema during curettage for hydatidiform mole].

We experienced a case of myocardial infarction associated with pulmonary edema in a patient with hydatidiform mole probably due to methylergometrin and prostaglandin F2 alpha (PGF2 alpha) administered during the operation. A 26-year-old woman was scheduled to have curettage for hydatidiform mole under general anesthesia. She had no previous history of cardiopulmonary disease. During the operation, 0.4 mg of methylergometrin was administered intravenously to induce uterine contraction. Because the contraction was not sufficient, 2 mg of PGF2 alpha was given into the uterine muscle. A few minutes later blood pressure and heart rate increased abruptly and arterial blood gas analysis showed hypoxia and respiratory acidosis. Pulmonary edema was confirmed by chest X-P. After ordinary treatment for pulmonary edema, she was transferred to ICU. Postoperative examinations of ECG, serum enzymes and echocardiography revealed anterior subendocardial infarction. About one month later, methylergometrin test was performed during coronary angiography and this induced coronary vasospasm. PGF2 alpha is also known to cause peripheral as well as pulmonary vasoconstriction. Acute myocardial infarction induced by methylergometrin and PGF2 alpha may be a possible cause of this episode.

Adult↗

PubMed1990

An evaluation of three intravenous anesthetic regimens in New Zealand rabbits.

Intravenous anesthetics can be readily administered to rabbits through the marginal ear vein. In this study, three intravenous anesthetic protocols were evaluated in New Zealand White rabbits. The three anesthetic regimens were: (a) pentobarbital (40 mg/kg); (b) ketamine-xylazine (25-5 mg/kg); (c) midazolam-xylazine-alfentanil (1-1-0.1 mg/kg). The anesthetics were injected slowly over defined time intervals. Reactions to noxious stimuli were determined before and after administration of the anesthetics. Additionally, the effects of the anesthetic agents on the rabbit's cardiopulmonary system were evaluated. Rabbits anesthetized with midazolam-xylazine-alfentanil did not have a pedal withdrawal or ear pinch reflex throughout the testing period. The ketamine-xylazine combination produced a shorter duration of non-responsiveness to noxious stimuli. Rabbits anesthetized with pentobarbital had the greatest variability in response to noxious stimuli. Apnea occurred in at least one rabbit in each group. A side effect unique to the midazolam-xylazine-alfentanil group was the occurrence of opisthotonus or seizure activity during or shortly after the administration of alfentanil. Hypotension, hypercapnia and respiratory acidosis were characteristic of the cardiopulmonary effects of the anesthetics. When choosing an anesthetic regimen for rabbits, intravenous infusion should be considered as an option. Advantages include ease of administration, possibility of redosing as required, and minimal requirements for equipment. Disadvantages of intravenous anesthetic infusion in rabbits include potential for lethal overdose and metabolic alterations after administration.

Alfentanil↗

PubMed1990

[Hyperkalemia--life-threatening early complication of asphyxia in premature infants].

16 premature infants with hyaline membrane disease all under mechanical ventilation developed severe electrolyte disturbances during the first 48 hours. The serum potassium concentration increased over 8 mmol/l. After a delay of several hours the serum calcium concentration decreased to 1.0-1.4 mmol/l. The metabolic-respiratory acidosis (pH 6.92-7.19) was present in nearly all patients. The typical hyperkalemic cardiac arrhythmia appeared in 7 patients; six of them died. The quick shifting of potassium from the extracellular into the intracellular space by the glucose-insulin infusion was indispensable for the survival of our patients. The serum potassium concentration decreased by 2.9-5.1 mmol/l in 4 hours. When the cardiac arrhythmia is present calcium gluconate and bicarbonate must be infused immediately followed by the glucose-insulin infusion.

Acid-Base Equilibrium↗

PubMed1990

Chronic cor pulmonale. Etiology and management.

Cor pulmonale is right ventricular enlargement secondary to pulmonary hypertension. Although most often caused by parenchymal lung disease, derangements of the ventilatory drive, the respiratory pumping mechanism, or the pulmonary vascular bed may also result in right ventricular hypertrophy and dilatation. Arterial hypoxemia (and resultant polycythemia), hypercapnia, and respiratory acidosis all contribute to the increased afterload on the right ventricle. Diagnosis is often difficult, since pulmonary vascular disease, pulmonary hypertension, and cor pulmonale have few specific manifestations, especially early in their evolution. Treatment is primarily directed at the underlying pulmonary or ventilatory disorder, rather than at the right ventricular failure per se. Supplemental oxygen is essential to avoid hypoxia; corticosteroids, anticoagulants, vasodilators, and other specific therapies are used as indicated to treat the underlying pulmonary disorders. When medical therapies fail, lung or heart-lung transplantation has become a possibility for selected patients.

Chronic Disease↗

PubMed1990

[Cardiovascular effects of apnea test in the diagnosis of brain death].

Cardiovascular effects of apnea test were investigated in 12 patients suspected of brain death. Arterial blood gas and cardiovascular hemodynamics were measured just before and after 10-minute apnea. Apnea test induced respiratory acidosis without hypoxemia. Cardiac index increased by 34% (2.3 to 3.1 l.min-1.m-2; P less than 0.01) and systemic vascular resistance index decreased by 30% (3608 to 2519 dynes.sec.cm-5.m-2; P less than 0.01), whereas heart rate and mean arterial pressure were unchanged. Significant increases in mean pulmonary arterial pressure (17.6 to 29.1 mmHg; P less than 0.01), pulmonary vascular resistance index (381 to 616 dynes.sec.cm-5.m-2; P less than 0.01) and right ventricular stroke work index (4.0 to 10.5 g.m.m-2; P less than 0.01) suggest that apnea test increases right ventricular afterload.

Adult↗

PubMed1990

Moderate exercise and hemodilution during sleep deprivation.

The effect of 52 h of sleep deprivation (SD) upon blood constituents was studied in 12 young women aged 21.5 +/- 0.4 years. Subjects were individually isolated without time cues, performing a sequence of cognitive tasks. Significant decreases in hematocrit (p less than 0.002) and red cell count (p less than 0.04) developed, mainly over the first 28 h of SD, reaching a subsequent plateau or partial recovery. The calculated plasma volume also increased by 10.7 +/- 3.1% at 52 h, with recovery to a 6.9 +/- 3.2% increase the following day. About 1 L of water was retained over the first 30 h of SD, with a subsequent partial elimination of this excess. Plasma albumin and total protein concentrations were largely sustained in the face of the plasma expansion. The plasma pH showed a progressive fall from a baseline value of 7.381 +/- 0.014 to 7.332 +/- 0.006 at 52 h, while plasma bicarbonate decreased from a baseline figure of 31.2 +/- 0.7 to 26-27 mM/L (p less than 0.05). After 8 weeks, all subjects repeated the experiment, with the introduction of 30 min of exercise in the 40th h of wakefulness. Hematocrit and plasma volume changes were similar to those of the first experiment up to the time of exercise, but hematocrit decreased and plasma volume increased after the exercise bout, rather than reaching a plateau. Plasma pH increased with exercise, but returned to the previous low level at 52 h. Any arousing effect of the exercise bout was transient. The plasma expansion reflects metabolic and/or respiratory acidosis, plus possible effects of a prolonged period without recumbency.

Adult↗

PubMed1990

A statistical study of autopsied cases of neonatal intraventricular hemorrhage.

We have performed a statistical study of 1218 autopsies of neonates to extract the factors related to fatal neonatal intraventricular hemorrhage (IVH). Prematurity indicated by a short gestational period or a low birth weight was the most significant factor for IVH. Many other factors considered to be related to IVH were also related closely to prematurity. Therefore, we pose the following question throughout the study: Did the factors independently relate to IVH without any confounding effects of prematurity? To obtain the answer, we tried a statistical adjustment for gestational age to eliminate the confounding effects of prematurity. After the adjustment was made, we concluded that the following 10 items, in order, were the actual factors related to fatal IVH: prematurity, subependymal hemorrhage, subarachnoidal hemorrhage, respiratory distress syndrome, hyaline membrane disease, respiratory acidosis, intracerebral hemorrhage, cyanosis, respirator care, and low Apgar score. There were two distinctive categories in the factors that were eliminated by the adjustment. One was a group that has no significance whatsoever in any subdivided gestational groups, such as meconium aspiration syndrome, due to purely the result of the confounding effect. The other was a group that showed its statistical significance only in a certain period of gestation, such as breech presentation.

Autopsy↗

PubMed1989

Medetomidine--ketamine--diazepam anesthesia in the rabbit.

Orthopaedic operations were performed in 340 rabbits when developing biodegradable rods for the fixation of fractures. The rabbits were anaesthesized by injecting medetomidine combined with ketamine and diazepam (MKD) subcutaneously. The mortality due to the anaesthesia was zero. Arterial blood gas analyses showed a moderate decrease in the haemoglobin oxygen saturation and compensated respiratory acidosis, which was well tolerated by the animals. It is concluded that MKD anaesthesia is well suited for orthopaedic operations in the rabbit.

Adrenergic alpha-Agonists↗

PubMed1989

The cardiorespiratory effects of diazepam-ketamine and xylazine-ketamine anesthetic combinations in sheep.

The cardiorespiratory dynamics and anesthetic effects of intravenously administered diazepam-ketamine (0.375 mg kg-1/7.5 mg kg-1) and xylazine-ketamine (0.1 mg kg-1/7.5 mg kg-1) were investigated in six domestic sheep (Ovis aries). The depth of analgesia and sedation was evaluated and the effects of the anesthetic drug combinations on hemodynamics and pulmonary mechanics were monitored before, and up to 90 minutes after, drug administration. Diazepam-ketamine and xylazine-ketamine induced effective anesthesia for periods lasting 15 minutes and 25 minutes, respectively. Both drug combinations caused transient respiratory acidosis. However, no profound effects on respiration or pulmonary function were observed. Neither anesthetic regimen caused significant effects on heart rate or pulmonary hemodynamics, but they caused significant decreases in cardiac output. Xylazine-ketamine resulted in a significant decrease in mean systemic arterial blood pressure (Psa) with a concurrent decrease in systemic vascular resistance (SVR). Diazepam-ketamine caused a significant increase in SVR without affecting Psa. Xylazine-ketamine may be contraindicated in animals with compromised heart function because of its hypotensive effects. Otherwise, both drug combinations, in the doses used, can provide short-term anesthesia suitable for minor surgical procedures and painful experimental maneuvers.

Anesthesia↗

PubMedDate not supplied

[Quantitative hyperpnea in EEG (author's transl)].

After summarizing the phenomena of respiratory physiology involved in the hyperpnea test, the author studies the quantitative relation between the drop in PECO2 (pressure of CO2 in expired air) and changes in the EEG during hyperpnea. Normal subjects are divided into two groups of a hundred (6 to 19 1/2 years of age; 20 to 59 1/2 years of age). The PECO2 at rest is higher among the young subjects than among the adults, and its decline during hyperpnea is sharper. Thus, children show discrete respiratory acidosis in comparison with adults. The EEG of normal adults is practically unchanged during hyperpnea whereas, in the young group, moderate changes in the profile were observed in 45 out of 100 cases (classified empirically as normal). The PECO2 reaches a lower level in subjects showing EEG changes than in those showing none. All the reported differences are statistically significant (p less than 0.01). The probability of hyperpnea modifying the EEG profile becomes progressively less with age, and may be related to the reduced production of CO2 in older subjects. Epileptic subjects (primary generalized epilepsy) produce more CO2 than normal subjects during the hyperpnea test. The statistical data reported in the study show the importance of the size of the drop in ventilatory CO2 in the determination of EEG changes. The rest of hyperpnea in EEG can therefore be validly interpreted only if capnographic variations are measured. A standard quantitative hyperpnea test of this type should be devised, with specification of the hypocapnia level to be achieved.

Adolescent↗

PubMed1989

Successful extubation of newborn infants without preextubation trial of continuous positive airway pressure.

Sixty newborn infants who had been mechanically ventilated through 3.0- or 3.5-mm endotracheal tubes were studied to examine the necessity of a preextubation trial of continuous positive airway pressure (CPAP). Thirty randomly assigned study infants were directly extubated from intermittent mandatory ventilation rates of six per minute; 30 randomly assigned control infants were extubated after a six-hour trial of continuous positive airway pressure of 3 cm H2O. Changes in respiratory rate, in PCO2, and in PO2/FIO2 were similar. All 30 study infants tolerated direct extubation without significant apnea or respiratory acidosis. Two study and eight control infants developed apnea during six hours after intermittent mandatory ventilation was discontinued (chi 2 = 4.3, P less than .05). Five control and no study infants had apneic episodes greater than or equal to 0.5 per hour (chi 2 = 5.5, P less than .02). The results of this study suggest that newborn infants may tolerate direct extubation from low intermittent mandatory ventilation rates without a preextubation trial of CPAP. A preextubation trial of CPAP appears to be unnecessary and may cause more frequent apnea in newborn infants if used for more than several hours.

Apnea↗

PubMed1989

[Treatment of cardiac arrest. Recent aspects of cardiopulmonary resuscitation].

Opinions are still not unanimous about the mechanism behind circulation during external cardiac compression and this leads to uncertainty regarding the correct frequency, force of compression and its duration. Adrenaline and other alpha-stimulators increase blood flow during external cardiac compression and increase survival. Cardiac arrest results in anaerobic metabolism and combined metabolic and respiratory acidosis. On account of relatively low minute volume during external cardiac compression decrease in end-tidal carbon dioxide concentration is observed together with arterial alkalosis on account of hyperventilation and venous acidosis. No communications exist about the favourable effect of administration of bicarbonate during cardiac arrest. On the other hand, several conditions suggest that bicarbonate increases the intracellular acidosis with poorer possibilities for resuscitation with this form of treatment. Ischaemia results inter alia in intracellular accumulation of calcium which initiates potential cell destructive processes. No investigations are available which favour employment of calcium during cardiac arrest. Conversely animal experiments suggest the possibility of favourable effects from calcium-entry blockers. Ischaemia and, in particular, reperfusion release cell and vessel damaging free oxygen redicals. Intensive investigations are being conducted at present about the value of anti-oxidants for cerebral and myocardial protection.

Heart Arrest↗

PubMed1989

[Regional cerebral blood flow in patients with bronchial asthma].

The regional cerebral blood flow was studied in 75 patients with bronchial asthma. The Xe133 inhalation method was used. Two groups were distinguished: with a severe course (41), average severe course (34). It was established that patients with a severe course of bronchial asthma showed a reduction of the cerebral blood flow and phenomena of respiratory acidosis with an increase of oxygen utilization by the tissues.

Acid-Base Equilibrium↗

PubMed1989

Status asthmaticus in a medical intensive care.

This paper describes 19 consecutive episodes (18 patients) of status asthmaticus managed in a medical intensive care. Eleven patients required mechanical ventilatory support [MV] and 2 (11%) died. Most patients had acute respiratory acidosis although arterial blood gases alone could not predict the need for MV. The peak inspiratory airway pressure measured during MV was a useful index of the severity of underlying lung disease. The most serious complication of MV was barotrauma. On follow up studies, two distinctive patterns of chronic asthma could be identified. One group of patients had highly labile pulmonary function with unpredictable and wide changes in peak flow rates while another group had poorly reversible obstruction.

Adult↗