Muni Keoplung

The Jaundiced Heart: Evidence of Blunted Response to Positive Inotropic Stimulation

Obstructive jaundice has been known to cause severe hemodynamic disturbance. The present study was therefore designed to assess the cardiac involvement in jaundiced patients. The multiple-gated blood pool cardioscintigraphic studies were done in 9 jaundiced patients who had either cholestatic or obstructive jaundice (mean total bilirubin 29.30 +/- 3.30 mg/dL), and in 8 normal volunteers (total bilirubin less than 1 mg%). None of the patients had evidences of obvious cirrhosis, intrinisic heart disease, or septicemia. Following intravenous dobutamine there was comparable change of blood pressure and heart rate in both groups. However the response of left ventricular ejection fraction (LVEF) to dobutamine (10 micrograms/kg/min x 5 min) was strikingly blunted in the jaundiced patients as compared to that seen in the normal controls (3.56 +/- 0.9 vs. 12.7 +/- 2.2%, p less than 0.005). Our present data thus show that there is blunted myocardial contractile response to the inotropic stimulation in jaundiced patients. Such myocardial refractoriness to beta-1 stimulation may contribute to the susceptibility of jaundiced patients to postoperative shock and acute renal failure.

Intrarenal infusion of gallopamil in acute renal failure : a preliminary report

SummaryIn order to ascertain the protective role of a potent calcium entry blocking agent in human acute renal failure, 10 patients were randomised to treatment with either intrarenal gallopamil plus intravenous furosemide (frusemide) 0.5 mg/kg/h for 24 hours, or furosemide alone. Gallopamil was infused into each kidney at the rate of 40 to 80 µg/min for 4 hours. During 7 days of post-treatment follow-up, the gallopamil treatment group exhibited a significantly higher urine output [257 ml/h vs 81 ml/h (p < 0.001) after 2 days, and 199 ml/h vs 120 ml/h (p < 0.005) after 7 days] and creatinine clearance [20 vs 4 ml/min (p < 0.005) after 2 days, and 38 vs 14 ml/min (p < 0.001) after 7 days] than the furosemide-only control group. Furthermore, gallopamil treatment accelerated the decline of serum creatinine after renal failure and reduced the requirement for dialysis.Although patient numbers were small, these results indicate that the addition of intrarenal gallopamil to intravenous furosemide treatment enhances the recovery of renal function after acute renal failure.

Beneficial Effect of Intrarenal Verapamil in Human Acute Renal Failure

Cellular Ca2+ influx during the reperfusion period after an ischemic insult has been proposed to be a crucial pathogenetic factor in the development of experimental acute renal failure (ARF). The present study, therefore, examined the potential beneficial effect of intrarenal verapamil, a calcium entry blocking agent, on ARF in patients. Twelve patients were enrolled in the study. Six ARF patients (experimental group)--ARF caused by malaria (4 patients) and leptospirosis (2 patients)--had a catheter placed in their renal artery; verapamil was infused at 100 micrograms/min for 3 h and intravenous furosemide, 0.8 mg/kg/h x 24 h was also administered. Another six ARF patients (control group)--ARF caused by malaria (5 patients) and leptospirosis (1 patient)--were treated with intravenous furosemide alone. Baseline renal function was comparable in both groups; GFR (3.16 +/- 3.24 vs 0.7 +/- 1.5 mL/min, NS), serum creatinine (Scr), (9.1 +/- 2.1 vs 11.3 +/- 2.2 mg/dL, NS), and urine volume (V) (41.79 +/- 4.77 vs 34.54 +/- 13.52 mL/h, NS), were comparable in the experimental and control groups. Twenty-four hours posttreatment, the increment of GFR (9.66 +/- 4.25 vs 1.32 +/- 0.50 mL/min, P less than .02) and V (181.8 +/- 61.7 vs 79 +/- 18 mL/h, P less than .04), were significantly greater in the experimental group as compared to the control group. The course of ARF was also shorter in the experimental group (6.5 +/- 2.1 vs 13 +/- 1.1 days, P less than .05), who also required less dialysis. Thus, combination of a renal arterial infusion of verapamil and intravenous furosemide significantly improves the renal function in tropical ARF as compared to intravenous furosemide alone.

Heat Stroke-Induced Multiple Organ Failure

The effect of excessive heat accumulated in the body is life threatening. It could damage not only body fluid electrolyte haemostasis, but kidney, liver, and hematologic function. The example reported herein was a Thai laborer, previously healthy, 32 years of age. He joined the tricycle race from Chiang Mai to Lumpoon, which is about 30 km. The tournament was held on a late morning of high humidity and a temperature of 35 degrees C. After biking 25 km, he began having heavy perspiration and suffered from severe myalgia and high fever. He suddenly lapsed into unconsciousness and fell down. He was admitted to the Lumpoon Hospital because of convulsions, and 2 days afterward, anuria, anemia, thrombocytopenia, coagulopathy, and liver impairment were detected. He was later transferred to the Faculty of Medicine for further intensive treatment. Lab analyses showed marked azotemia (BUN 96 mg%, Cr 10.6 mg%), elevation of muscle enzyme (CPK greater than 1000 U/L, SGOT greater than 650 U/L), liver failure (SGPT greater than 650 U/L, DB/TB = 23.0/30.0 mg%) and disseminated coagulopathy; platelet 17,000/mm3, PT 51.1 sec (control 12.5), and PTT 73.5 sec (control 37.7). He was treated with bicarbonated hemodialysis trice weekly. Blood-exchange transfusion was performed 3 times during the first 2 weeks with 10 units of fresh whole blood in each exchange. His ventilation required support by a ventilator. After a month, his consciousness, the liver function, and hematologic conditions became to recuperate. By 6 weeks postadmission, renal function eventually improved. This report is intended to warn the unprepared athlete entering an extreme, long-lasting exercise in an inappropriate climate.