Leland H. Hanowell

Right Ventricular Volumes Overestimate Left Ventricular Preload in Critically Ill Patients

BACKGROUND Studies have shown right ventricular end-diastolic volume (RVEDV) to be a more accurate estimate of left ventricular preload than pulmonary artery wedge pressure. We prospectively evaluated the ability of RVEDV to predict left ventricular end-diastolic volume (LVEDV) in critically ill patients. METHODS Thirty critically ill patients in the surgical intensive care unit underwent concurrent measurement of RVEDV and LVEDV. RVEDV was measured using a residual fraction Swan-Ganz catheter (RF Swan). LVEDV was measured using transesophageal echocardiography with acoustic quantification. Intracardiac, intra-abdominal, and ventilatory pressures were also measured. RESULTS RVEDV as measured by the RF Swan was significantly larger (by a factor of 2) than LVEDV (p < 0.0001 analysis of variance). However, the RVEDV and LVEDV were strongly correlated (r = 0.71, p < 0.0001, Pearsons correlation). CONCLUSIONS RVEDV from the RF Swan markedly overestimated left ventricular preload. If RVEDV is used as an absolute value for determining preload, patients may be underresuscitated. Transesophageal echocardiography in conjunction with RF Swan can be used to more accurately determine preload and cardiac performance than RF Swan alone in critically ill patients.

Effect of intraoperative ketorolac on postanesthesia care unit comfort

The efficacy of intraoperatively administered ketorolac for the prophylactic treatment of pain in the postanesthesia care unit (PACU) was examined in a prospective, double-blinded study. Thirty patients undergoing general anesthesia for orthopedic or lower abdominal surgery were randomized into two groups. Both groups received equivalent doses of opioids intraoperatively. Upon surgical closure, one group received intramuscular (IM) ketorolac 60 mg (2 mL) and the other group received normal saline 2 mL, IM. The saline control group more frequently required opioid-analgesic supplementation in the PACU than did the ketorolac group (P < 0.05). Time to first-required opioid dose in the PACU was 22 +/- 8 versus 76 +/- 11 min for the control group and ketorolac group, respectively (P < 0.001). The ketorolac group reported significantly lower pain scores 1 hr after PACU admission (P < 0.01). Time to PACU discharge was not different between groups. Intraoperatively administered ketorolac is an effective adjunct in the management of postoperative pain.

Autotransfusor Removal of Fentanyl from Blood

The removal of narcotics from blood processed by commercially available autoinfusion devices, though not previously investigated, would be anticipated given the removal of significant quantities of serum during cell processing. Therefore, we attempted to determine if significant quantities of the narcotic fentanyl are removed from intraoperatively harvested blood during saline washing of red cells before autologous transfusion.

Leftward deviation of the interatrial septum during left heart bypass for repair of a thoracic aortic aneurysm

T RANSESOPHAGEAL echocardiography (TEE) has been associated with a high degree of sensitwity and specificity in evaluation of aortic dissection and aneurysm. Kusumoto et al 1 described the relationship of transatrlal pressure gradients and echocardiographically imaged responses of the interatrlal septum. Little is reported regarding mtraoperative TEE findings during left heart bypass for repair of thoracic aortic pathology. Left heart bypass is frequently used for thoracic aortic surgeries requiring aortic cross-clamping in an effort to avert spinal cord and renal ischemia. The echocardiographic findings of left heart bypass for aortic repair and the utdity of TEE in assessing left heart bypass and intracardmc volume are described.

Quantified EEG Detects Ischemia: A Case Report

We have monitored 86 carotid endarterectomy and other neurovascular surgeries involving the carotid arteries with intraoperative digitized EEG over the past 59 months. A basic technique is described for the detection of intraoperative cerebral ischemia.