Successful outcome of intrathoracic injection of autologous amniotic fluid in fetal reduction: report of two cases

Potassium chloride is reported to kill both monochorionic twins after injection into only one. In this study, two women undergoing in vitro fertilization and embryo transfer were pregnant with triplets containing monochorionic twinning, which were detected by ultrasound with the presence of a "twin-peak" sign. Instead of potassium chloride, intrathoracic injection of amniotic fluid was employed to sacrifice one of the monochorionic fetuses in dichorionic triplets. Our aim was to sacrifice one of the monochorionic twins in order to prevent adverse perinatal outcomes and to avoid the harmful effect of potassium chloride on monochorionic cotwins. One twin pregnancy was terminated with preterm premature rupture of membranes at 25 weeks of gestation. In the second one, two healthy babies were delivered by cesarean section at 36 weeks of gestation. The female baby weighed 2100 gm and the male baby 2600 gm, respectively. Intrathoracic injection of amniotic fluid to create a tamponade is an alternative management for fetal reduction.

THE HEPATOSPLANCHNIC CONTRIBUTION TO HYPERLACTATEMIA IN ENDOTOXIC SHOCK: EFFECTS OF TISSUE ISCHEMIA

We investigated the role of the hepatosplanchnic region in the hyperlactatemia observed during endotoxic shock. The study included 18 dogs anesthetized with pentobarbital and mechanically ventilated. After baseline measurements, including gut lactate production (GLP), liver lactate uptake (LLU), liver lactate extraction (LLE), and hepatosplanchnic lactate production (HSLP), each dog received 2 mg/kg of E. coli endotoxin. After a second set of measurements, cardiac tamponade was induced in 12 dogs (EDTX + Tamp) by repeated injections of normal saline into the pericardial sac to progressively reduce cardiac output and hepatic blood flow. The six remaining dogs served as septic controls (EDTX). From a net lactate consumer before endotoxin infusion, the gut became a lactate producer after the endotoxin infusion, with GLP increasing from -11.4 +/- 27.0 to 32.9 +/- 38.2 x 10(-3) mEq/min (P < 0.05). LLU increased from 48.1 +/- 26.2 to 86.6 +/- 45.2 x 10(-3) mEq/min (P < 0.05), so that LLE and HSLP did not change. In the EDTX + Tamp group, LLE became negative, and HSLP became positive only when hepatic oxygen delivery reached its critical value during cardiac tamponade. In the EDTX group, LLE remained positive and HSLP negative. In endotoxic shock, GLP is increased, but the liver can metabolize this additional load of lactate, so that the hepatosplanchnic area is not a major source of lactate unless the liver becomes profoundly hypoxic.

Effect of Ibuprofen on Interleukin-1??-Induced Abnormalities in Hemodynamics and Oxygen Metabolism in Rabbits

We showed previously that the administration of interleukin (IL)-1beta induces circulatory shock and impairs the oxygen consumption (VO2)/oxygen delivery (DO2) relation by increasing the slope of the supply-independent line in rabbits. We tested the effect of ibuprofen, a specific inhibitor of the development of shock in this model, on the VO2/DO2 abnormality. Eighteen rabbits were divided randomly into three groups (n = 6 each) and intravenously given 10 microg/kg of IL-1beta alone or 10 microg/kg of IL-1beta followed by 10 mg/kg of ibuprofen or saline (control). All rabbits were subjected to stepwise cardiac tamponade by inflation of a handmade balloon placed into the pericardial sac to reduce DO2. The VO2/DO2 relation was then analyzed by the dual line method. The IL-1beta group had a significantly lower mean arterial pressure than that of the other groups before cardiac tamponade, and this reduction in mean arterial pressure was suppressed completely by treatment with ibuprofen. The cardiac index did not differ between groups. The slope of the supply-independent line was increased significantly by administration of IL-1beta, and this increase was attenuated significantly by treatment with ibuprofen (IL-1beta only: y = 0.14x + 6.1, ibuprofen: y = 0.06x + 8.5, control: y = 0.01x + 9.0). We conclude that ibuprofen reversed the IL-1beta-induced shock by restoring the systemic vascular resistance to normal and thereby normalized the VO2/DO2 relation in the supply-independent range of DO2.

Dopamine does not correct oxygen consumption/oxygen delivery relation abnormality during vasomotor shock induced by interleukin-1beta

We previously showed that interleukin 1beta (IL-1beta) induces vasomotor shock and impairs the oxygen consumption (VO2)/oxygen delivery (DO2) relation by increasing the slope of the supply-independent line in rabbits. In the present study, we investigated the inotropic effect of dopamine on the VO2/DO2 abnormality induced by IL-1beta. Twelve rabbits were divided into two groups (n = 6, each) and were given 10 microg/kg of IL-1beta or saline (control) intravenously. After baseline measurements were obtained, dopamine was infused continuously at a rate of 20 microg/kg/min throughout the study in both groups. All rabbits were subjected to stepwise cardiac tamponade to reduce the DO2 to <5 mL/min/kg by inflation of a handmade balloon placed into the pericardial sac. The VO2/DO2 relation was then analyzed by the dual-line method. Dopamine failed to correct the IL-1beta-induced decrease in mean arterial pressure to the baseline level. Dopamine significantly increased cardiac index in both groups, resulting in significant increases in DO2 (IL-1beta, 28.5 +/- 6.0 mL/min/kg from baseline 24.1 +/- 3.5 mL/min/kg; control, 27.7 +/- 2.9 mL/min/kg from baseline 22.9 +/- 2.9 mL/min/kg), but did not affect VO2 (IL-1beta, 10.0 +/- 0.5 mL/min/kg from baseline 9.9 +/- 0.7 mL/min/kg; control, 10.2 +/- 0.4 mL/min/kg from baseline 10.2 +/- 0.2 mL/min/kg). The IL-1beta group showed a significantly greater supply-independent line slope than that of controls (IL-1beta, y = 0.14x + 6.3; control, y = 0.06x + 8.6) during stepwise decreases in DO2. These results indicate that continuous infusion of dopamine at 20 microg/kg/min increases DO2 but does not correct the vasomotor disturbance or VO2/DO2 abnormality caused by IL-1beta.

[Acute myeloid leukemia with infective endocarditis]

We present here a patient with acute myeloid leukemia (M2) who developed fatal infective endocarditis. On admission, the patient (67-year-old male) had mitral stenosis and atrial fibrillation. Complete remission was achieved after induction chemotherapy. During the course of consolidation therapy, he developed sepsis caused by coagulase-negative staphylococcus, which was successfully treated with antibiotics. Thereafter, blood culture yielded multidrug-resistant staphylococcus epidermidis. An echocardiogram revealed mitral valve regurgitation with vegetation. He was diagnosed as having infectious endocarditis. In spite of prolonged antibiotic therapy, destruction of the mitral valve progressed, and the patient underwent valve replacement therapy. He died of cardiac tamponade 5 days after the surgery.

Long-term usefulness of percutaneous intrapericardial fibrin-glue fixation therapy for oozing type of left ventricular free wall rupture: a case report

This report describes a long-term survival case of left ventricular free wall rupture treated with percutaneous intrapericardial fibrin-glue fixation therapy. A 82-year-old woman was admitted to the emergency room because of vomiting and syncope diagnosed as acute posterolateral myocardial infarction complicated by cardiac tamponade. After her hemodynamic condition was stabilized by drawing off the bloody pericardial effusion, fibrin-glue was injected into pericardial space with the expectation that the glue would cover the oozing site of the left ventricular epicardium. After this therapy, the patient recovered and did not have any no recurrent cardiac events for 1 year. Serial echocardiographic studies revealed a preserved left ventricular function and no development of left ventricular restriction. This case suggests that percutaneous intrapericardial fibrin-glue fixation therapy is an effective treatment for the oozing type of left ventricular free wall rupture and that there is no risk of left ventricular restriction during long-term follow-up.

Successful therapy of transplant-associated veno-occlusive disease with a combination of tissue plasminogen activator and defibrotide

A 36-year-old man underwent matched unrelated donor bone marrow transplantation for chronic myeloid leukaemia. He developed severe hepatic veno-occlusive disease as an early post-transplant complication. Tissue plasminogen activator was initially felt to be contraindicated since the patient had concomitant pericarditis. Defibrotide was therefore commenced as treatment for veno-occlusive disease. The pericarditis improved but the veno-occlusive disease continued to worsen (peak bilirubin 353 micromol/l). Tissue plasminogen activator followed by a heparin infusion was therefore administered. However, he proceeded to develop haemorrhagic cardiac tamponade that required drainage. Thrombolysis was therefore discontinued and treatment with defibrotide resumed after an interval of 48 h. The veno-occlusive disease gradually resolved and defibrotide was discontinued once the bilirubin had plateaued. He was discharged home on day +52 post-transplant.

Diaspirin cross-linked hemoglobin improves oxygen extraction capabilities in endotoxic shock

We studied the effects of diaspirin cross-linked hemoglobin (DCLHb), a cell-free hemoglobin derived from human erythrocytes, on blood flow distribution and tissue oxygen extraction capabilities in endotoxic shock. Eighteen pentobarbital sodium-anesthetized, mechanically ventilated dogs received 2 mg/kg of E. coli endotoxin, followed by saline resuscitation to restore cardiac filling pressures to baseline levels. The animals were randomly divided into three groups: six served as control, six received DCLHb at a dose of 500 mg/kg (group 1) and six DCLHb at a dose of 1,000 mg/kg (group 2). Cardiac tamponade was then induced by saline injection in the pericardial sac to progressively reduce cardiac index and thereby allow study of tissue oxygen extraction capabilities. DCLHb had a dose-dependent vasopressor effect but did not significantly alter cardiac index or regional blood flow. During cardiac tamponade, critical oxygen delivery was 12.8 +/- 0.7 ml. kg(-1). min(-1) in the control group, but 8.6 +/- 0.9 and 8.2 +/- 0.7 ml. kg(-1). min(-1) in groups 1 and 2, respectively (both P < 0.05 vs. control group). The critical oxygen extraction ratio was 39.1 +/- 3.1% in the control group but 58.7 +/- 12.8% and 60.2 +/- 9.0% in groups 1 and 2, respectively. We conclude that DCLHb can improve whole body oxygen extraction capabilities during endotoxic shock in dogs.

[Prevention and principles of management in case of cardiac tamponade after catheterisation of the subclavian vein in parenteral nutrition]

The authors described different complications after the subclavian vein catheterisation, focusing on the cardiac tamponade. The authors presented the prevention and treatment principles respectively in case of the cardiac tamponade and reported experiences in this field.

[A case of lung cancer with pericardial effusion without cardiac tamponade]

Cardiac tamponade as an initial manifestation of primary lung cancer is uncommon. All such cases had shown symptoms of cardiac tamponade at the first visit of the hospital. We report a case of lung cancer with pericardial effusion without cardiac tamponade. Echocardiography, revealed little pericardial effusion and it has not increased for 3 months. Pericardiotomy revealed adenocarcinoma and lung cancer was confirmed by bronchial biopsy. It is necessary to further examine patients with even slight amounts of pericardial effusion.

Cardiac angiosarcoma responding to multidisciplinary treatment

Early detection of cardiac angiosarcoma is usually difficult and the prognosis is very poor. We experienced a 32-year-old man with cardiac angiosarcoma who responded to multidisciplinary treatment with recombinant interleukin-2, postoperative chemotherapy (cyclophosphamide, vincristine, doxorubicin, Dacarbazine) and radiation. At 30 months after surgery, there was no evidence of recurrence or metastasis in spite of incomplete resection.

RUPTURE OF THE CORONARY SINUS WITH HEMOPERICARDIUM. A RARE COMPLICATION OF CORONARY ARTERIOVENOUS FISTULA

Sudden death is reported in a previously healthy 52-year-old man resulting from a rare complication of a coronary arteriovenous fistula. It is believed that the primary defect was congenital and that the sequence of events was dilatation and thrombosis of the coronary sinus, necrosis of the sinus wall, perforation, and fatal tamponade.