Shinzou Sumita

Sepsis attenuates the intensity of the neuromuscular blocking effect of d-tubocurarine and the antagonistic actions of neostigmine and edrophonium accompanying depression of muscle contractility of the diaphragm.

Background: Prolonged effects of non‐depolarizing muscle relaxants in septic patients have been reported, although the influence of sepsis on neuromuscular transmission has not yet been clarified satisfactorily. These studies were intended to elucidate the influence of sepsis on neuromuscular transmission and on the action of drugs being utilized for regulation of muscle tone (a neuromuscular blocker and anti‐cholinesterase (anti‐ChE) drugs).

Acute pulmonary edema associated with transfusion of packed red blood cells

We experienced a patient who suffered noncardiogenic acute pulmonary edema after transfusion of packed red blood cells which contained antigranulocyte antibodies. The data suggested that complement activation and the release of polymorphonuclear protease were involved in the pathogenesis of the complication in the present patient. Furthermore, blood coagulative system was also activated after the transfusion. The underlying mechanisms of the complication are discussed.

Rupture of pulmonary artery induced by balloon occlusion pulmonary angiography

A case of pulmonary artery rupture induced by balloon occlusion pulmonary angiography (BOPA) is reported. A flow-directed pulmonary artery catheter had been inserted for hemodynamic monitoring in a septic shock patient complicated by acute respiratory distress syndrome. To check for pulmonary damage, BOPA was performed immediately after hemodynamic measurement. Just as the hand injection of contrast medium was ending, the patient began to cough and a small amount of hemoptysis was observed. The angiogram showed the extravasation of contrast medium from the distal pulmonary artery to the situation of catheter tip. Pulmonary hemorrhage was controlled with mechanical ventilatory support with 10 cmH2O positive end-expiratory pressure and no specific therapy was required. This complication should be kept in mind and using a power injector to avoid injurious transient high pressure pulse is recommended.

Accidental delayed dilation of traumatic arteriovenous fistula following hemodialysis catheterization using a guide wire — left subclavian artery to jugular venous arch fistula

Sir: Traumatic arteriovenous fistulas (AVF) represent a rare complication of central venous catheterization. Such AVF are usually diagnosed by bruit and thrill over the area of central venipuncture after a delay ranging from several days to even years following the puncture [1-3]. AVF have also been observed to disappear spontaneously [2, 4], and the attending physician may not know of their existence in some cases. We report a rare case of traumatic AVF, which had closed spontaneously in all probability but seems to have been accidentally dilated by the introduction of a guide wire during hemodialysis catheterization. A 59-year-old female (height 138 cm, body weight 38 kg) was transferred to our intensive care unit (ICU) because of suffering from panperitonitis with septic shock. The physician had noted arterial puncture during multiple attempts of left supraclavicular subclavian venipuncture 17 days before ICU admission. At ICU admission, physical examination did not show any bruit or thrill in the left subclavicular area. On 7th ICU day, renal function deteriorated and it was necessary to place the patient on hemodialysis. Right subclavian vein was punctured by infraclavicular approach for the insertion of a subclavian double lumen hemodialysis catheter (COOK Incorporation, Bloomington, IN). A guide wire was introduced through needle, but there was resistance at the a depth of 13 cm. At second attempt of guide wire introducing, aspirated blood from the cannulated needle seemed to be bright red. At third attempt, the guide wire entered the vessel smoothly and a vessel dilator was passed over the guide wire without any abnormal resistance. The hemodialysis catheter was then introduced through the peel-away introducer sheath. Aspirated blood from the catheter was bright red and under arterial pressure. Angiography was performed by injection of contrast medium through the proximal lumen of the catheter and demonstrated the left subclavian artery (Fig. 1 a). Peripheral and carotid pulses were normal, and blood pressure was equal in both arms. A vascular surgeon examined the patient and recommended neither surgical repair nor embolization. After confirming that there was no cerebrovascutar steal, continuous arteriovenous hemofiltration was instituted using hemodialysis catheter. The patients died on 17th ICU day due to septic shock. Before removal of the catheter, a second angiography was done and demonstrated a fistula between left subclavian artery and jugular venous arch (Fig. 1 b).

Influence of continuous positive airway pressure on EMG activities of the cricothyroid and posterior cricoarytenoid muscles of the canine larynx.

ObjectivesWe investigated the effect of different levels of continuous positive airway pressure (CPAP) on the cricothyroid (CT; a tensor muscle of the vocal folds) and posterior cricoarytenoid (PCA; sole abductor muscle of the vocal folds) muscles in dogs.DesignProspective, controlled animal study.SubjectsNine mongrel dogs of both sexes.SettingUniversity research laboratory.InterventionsAfter insertion of a cuffed tracheotomy tube low in the neck the compound EMG responses of the CT and PCA muscles during spontaneous respiration were measured simultaneously under different levels (2, 4, 6, and 8 cmH2O) of positive end-expiratory pressure (PEEP).Measurements and resultsThe CT showed a progressive increase in phasic expiratory EMG activity with the application of graded levels of PEEP. Application of PEEP over 4 cmH2O produced significant increases in the phasic CT activity (P<0.05). In contrast to the CT, the PCA failed to increase phasic inspiratory EMG activity statistically until a 8 cmH2O of PEEP was applied (P<0.05). The phasic experatory CT and inspiratory PCA activities were 297.9±77.6 and 124.5±22.9, respectively, at the application of 6 cmH2O of PEEP (percentage of control, mean±SD).ConclusionThis study confirms the difference in sensitivity between adductor and abductor laryngeal muscles, demonstrating that the intrinsic laryngeal muscles do not all behave similarly after the application of CPAP.

Intraoperative coronary artery spasm with hemorrhagic shock state

The balance between the myocardial oxygen supply and demand is the single most important factor in the system controlling coronary circulation. Since oxygen demand by the heart determines coronary blood flow, a perioperative increase in myocardial oxygen demand often induces myocardial ischemia in patients with fixed atheromatous obstruction of the coronary arteries [1]. In contrast, coronary artery spasm, which is not preceded by significant changes in the factors influencing myocardial oxygen demand, is recognized as an important cause of decreased myocardial blood flow [2]. Myocardial oxygen supply is also decreased in severe anemia with hypovolemia, such as during a state of hemorrhagic shock [3]. Accordingly, coronary artery spasm combined with hemorrhagic shock induces severe myocardial ischemia, which may be lifethreatening even in patients without ischemic heart disease. We present a patient in whom coronary artery spasm during the state of hemorrhagic shock resulted in ventricular tachycardia during surgery. The patient was successfully treated without myocardial infarction.