Nitric oxide release during hypothermic versus normothermic cardiopulmonary bypass

Cardiopulmonary bypass (CPB) produces hemodynamic and inflammatory disorders involving changes in vascular permeability and regional blood flow and alterations of coagulation and complement systems. It has been reported that an abnormal release of vasoactive substances during CPB, like bradykinin or nitric oxide, could play a role. The aim of this study was to investigate the changes in nitric oxide (NO) release occurring in patients undergoing CPB, under both hypothermic and normothermic conditions. Forty patients (mean age 61.4 +/- 8.4 years) undergoing coronary bypass surgery were studied. In 20 patients (group A) systemic hypothermic CPB and antegrade cold intermittent crystalloid cardioplegia were used. The remaining 20 cases (group B) underwent surgery under systemic normothermic CPB and with antegrade warm blood intermittent cardioplegia. Nitric oxide was measured as the nitrite plasma level (NPL) by the Gries reaction. The time course of changes in NPL were obtained by collecting five whole blood samples: before CPB, 10 and 30 min after the start of CPB, and 10 and 60 min after the end of CPB. Although there were no significant variations of NPL shortly after the start of CPB (10 min after), values measured 30 min after CPB commencement and 10 min after the end of CPB showed a significant increase (P < 0.0001) in both groups. Considering the two groups separately, NPL changes seemed to be similar, so independent of temperature; however, in group B higher values of NPL were measured during (30 min) and after (60 min) CPB (P < 0.0001). In conclusion, during CPB there is a progressive increase, independent of temperature in NO release.

The use and clinical importance of a substrate-specific electrode for rapid determination of blood lactate concentrations

OBJECTIVE

To determine the validity and clinical importance of a newly developed amperometric, enzymatic, substrate-specific electrode for the rapid measurement of circulating lactate concentrations.

DESIGN

A prospective multiexperiment study.

SETTING

The critical care medicine research laboratory, intensive care unit (ICU), emergency department (ED), and general wards of a university-affiliated hospital.

PATIENTS

A total of 1218 patients and control subjects were studied on one or more occasions.

INTERVENTIONS

Blood lactate concentrations, descriptive data, physiological parameters, and outcome results were determined in various patient populations.

MAIN OUTCOME MEASURES AND RESULTS

Experiment 1: Lactate determinations performed with the new substrate-specific electrode were compared with two laboratory reference methods. Blood samples from 80 ICU patients and 165 ED patients formed the basis of this first experiment. There was excellent agreement between the test instrument and the two reference methods as reflected by bias (with reference method 1, 0.19 mmol/L; reference method 2, 0.09 mmol/L), precision (with reference method 1, +/- 0.47 mmol/L; reference method 2, +/- 0.34 mmol/L), and correlation data (with reference method 1, r = .92; reference method 2, r = .98). Experiment 2: The new test microchemistry instrument was used to analyze blood samples from 927 patients. The mean (SE) blood lactate concentrations in the various patient populations were 1.26 (0.04) mmol/L for control subjects (n = 85), 1.52 (0.03) mmol/L for general ward patients (n = 489; P < .001 vs normal subjects), 2.34 (0.15) mmol/L for ICU patients (n = 180; P < .001 vs normal subjects and general ward patients), and 2.44 (0.15) mmol/L for ED patients (n = 173; P < .001 vs normal subjects and general ward patients). None of the normal subjects and only one (0.2%) of 489 nonhypotensive general ward patients had a blood lactate value greater than 4 mmol/L. Circulating lactate concentrations greater than 4 mmol/L were 98.2% specific in predicting the need for hospital admission in patients presenting to the ED. Furthermore, lactate concentrations greater than 4 mmol/L were 96% specific in predicting mortality in hospitalized nonhypotensive patients. Experiment 3: Blood samples from 46 hypotensive ICU and ED patients and from 353 nonhypotensive ICU and ED patients (the latter samples were derived from experiment 2) were analyzed. A statistically significant difference was noted between the mean (SE) lactate concentration in hypotensive patients in the ICU and ED (4.75 [0.75] mmol/L) when compared with nonhypotensive ICU and ED patients (2.28 [0.10] mmol/L; P < .001). Furthermore, blood lactate values greater than 4 mmol/L were 87.5% specific in predicting mortality in hypotensive patients.

CONCLUSIONS

Lactate determinations performed using the new test instrument are precise and accurate. Blood lactate concentrations greater than 4 mmol/L are unusual in normal and noncritically ill hospitalized patients and warrant concern. In hospitalized (non-ICU) nonhypotensive subjects, as well as in critically ill patients, a blood lactate concentration greater than 4 mmol/L may portend a poor prognosis.

Relationship between hypotensive effects and plasma concentrations of clonidine in spontaneously hypertensive rats: continuous treatment and sudden termination of clonidine infusion

1. Clonidine was administered subcutaneously (62.5, 125 and 250 micrograms/kg/day) for 8 days using an osmotic infusion pump in spontaneously hypertensive rats (SHR). Clonidine, administered at 125 and 250 micrograms/kg/day at 48 hr after infusion, respectively, and thereafter were maintained at this level throughout the infusion period. 3. After terminating clonidine infusion, a rapid drug elimination from the plasma was manifested in both groups (125 and 250 micrograms/kg/day) with plasma clonidine levels, resulting in a decrease below 0.5 ng/ml at 4 and 6 hr, respectively. Four hours after terminating clonidine infusion at 125 and 250 micrograms/kg/day, transient but not remarkable increases in blood pressure and heart rate were observed only in the latter group compared with the values before termination. 4. These findings reveal that marked hypotensive effects were induced by relatively high doses (125 and 250 micrograms/kg/day) of clonidine in SHR, but no remarkable withdrawal symptoms after termination of clonidine infusion were observed. Therefore, unwanted withdrawal symptoms probably occur when an extremely high dose (250 micrograms/kg/day or more) of clonidine was infused for a long period (8 days or more) in SHR.

Effect of acute lung injury and coexisting disorders on plasma concentrations of atrial natriuretic peptide

OBJECTIVE

To clarify how plasma atrial natriuretic peptide concentrations vary with the severity of acute lung injury. The influence of coexisting diseases which trigger acute lung injury was also examined.

DESIGN

Prospective study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

Fifty patients who had standard risk factors for acute lung injury including sepsis syndrome, major surgery, prolonged hypotension, aspiration of gastric contents, and burns. Twenty-five of these patients had acute lung injury (group 3) caused by these disorders; the remaining 25 patients had risk factors only (group 2). Ten age-matched normal volunteers were selected as controls (group 1).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Plasma atrial natriuretic peptide concentration was measured in these patients and compared with the severity of acute lung injury. In group 3, a significant increase in the mean plasma atrial natriuretic peptide concentration was observed (188 +/- 78 pg/mL, p < .01) compared with group 2 (54 +/- 28 pg/mL) and the age-matched control group (30 +/- 8 pg/mL). This increase was related to the onset of acute lung injury and returned to control concentrations after recovery. Plasma atrial natriuretic peptide concentrations in group 3 correlated highly with a lung injury score representing the severity of acute lung injury (r2 = .45, p < .01), but did not correlate with other cardiopulmonary variables.

CONCLUSION

The results suggest that severity of lung injury, but not other predisposing disorders, may be the key factor leading to the increase in plasma atrial natriuretic peptide concentrations observed in these patients.

Plasma endothelin-1 response to acute hypotension induced by vasodilating agents

Cyclic GMP (cGMP) dependent vasodilating agents (natriuretic peptides, nitric oxide) inhibit secretion of endothelin-1 (ET-1) in cultured endothelial cells. However, in circulatory conditions associated with acute hypotension, a marked increase in plasma ET-1 has repeatedly been observed. Therefore, after administration of cGMP-dependent agents in hypotensive dose, the net effect of these opposing influences on ET-1 release may shed light on the mechanisms determining circulating levels of this peptide. We have studied the effect of a hypotensive dose of atrial natriuretic peptide (n = 16), 8-Br-cGMP (n = 5), and papaverin (n = 7) on plasma ET-1 in anesthetized dogs. All agents produced marked increases in the peptide level at the end of infusion (178, 280, and 240% of the last preinfusion level, respectively) and a mean arterial blood pressure (MAP) decrease of 19, 18, and 42 mmHg (1 mmHg = 133.3 Pa), respectively. In all three protocols, plasma ET-1 continued to rise when the hypotensive agent was discontinued and remained elevated for 2-3 h postinfusion, even though MAP was normalized. There was a close positive correlation between the maximal increment in plasma ET-1 and the maximal decrease in MAP (r = 0.67, p < 0.001). These results show that acute hypotension due to directly acting vasodilators is a potent stimulus for systemic release of ET-1, even when due to agents known to inhibit ET-1 production in cultured endothelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Increase in plasma beta endorphins precedes vasodepressor syncope

BACKGROUND

Endogenous opioids have a tonic inhibitory effect on sympathetic tone and have been implicated in the pathophysiology of vasodepressor syncope. Plasma beta endorphin concentrations increase after vasodepressor syncope induced by exercise or by fasting.

AIMS

To take frequent samples for plasma beta endorphin estimation during tilt testing, and to determine whether plasma beta endorphin increased before the start of syncope.

PATIENTS

24 patients undergoing tilt testing for investigation of unexplained syncope.

SETTING

Tertiary referral centre.

METHODS

Blood samples were obtained during 70 degrees head up tilt testing. Plasma beta endorphin concentrations were estimated by radioimmunoassay (mean(SD) pmol/l).

RESULTS

Patients with a positive test showed a rise in beta endorphin concentrations before syncope (baseline 4.4(1.5) v start of syncope 8.5(3.1), p < 0.002). In contrast, patients with a negative test showed no change in beta endorphin concentrations (baseline 3.4(1.0) v end of test 4.5(2.3), NS). After syncope all patients showed a large secondary increase in beta endorphins (32.3(18.6)).

CONCLUSION

An increase in plasma beta endorphins precedes vasodepressor syncope. This finding supports a pathophysiological role for endogenous opioids.

The fate of hypertonic saline administered during hemodialysis

The possibility of postdialysis hypernatremia is one reason nephrology nurses do not administer hypertonic saline (HS) to treat hypotension or muscle cramps during the last hour of hemodialysis (HD). A single group time series quasi-experimental design was used to evaluate the effect of 50 mEq of HS given during the last hour of HD on interdialytic weight and serum sodium (PNa) and dialysate sodium (DNa) levels. Ten subjects experiencing hypotension or cramps during the last hour of HD, but not during the final 15 minutes, received 50 mEq of HS. One preinjection PNa and DNa sample was obtained, followed by the collection of 8 PNa and 42 DNa samples during the 5 minutes subsequent to the HS injection. Interdialytic weight was evaluated for differences. The results indicated that a statistically significant, but minor amount of sodium was removed in the dialysate (8.77% mEq/L + .96). In addition, the amount of sodium retained over a longer time scale was clinically insignificant, as evidenced by no significant change in the interdialytic weight following administration of 50 mEq of HS. PNa rose 12.7 + 1.3 mEq/L to a peak of 152.2 + 1.6 mEq/l in 54 + 2 seconds, returning to 3 + 0.3 mEq above baseline at 5 minutes. In conclusion, administration of HS up to the final 15 minutes of HD is safe therapy for hypotension and muscle cramps because it does not cause an increased interdialytic weight gain.

[Autonomic dysfunction in chronic hypotension associated with uremia]

BACKGROUND

Chronic hypotension is a not uncommon complication among hemodialyzed patients which is responsible of an important morbidity. The autonomic nervous system (ANS) dysfunction seems to play a key role in the pathogenesis of chronic hypotension.

METHODS

In order to study whether ANS dysfunction is responsible for chronic hypotension in hemodialyzed patients, the authors evaluated the integrity of the whole baroreflex arc by the Valsalva's manoeuver, of parasympathetic efferent pathway by the deep-breathing test and of sympathetic efferent pathway by the hand-grip test in 16 hemodialyzed patients with chronic hypotension, 17 normotensive hemodialyzed patients and 17 normal control subjects. Plasma catecholamine levels were also measured in these patients.

RESULTS

In normotensive patients, Valsalva's manoeuver response (p < 0.005) and deep-breathing test response (p < 0.05) were lowered, while hand-grip test response was preserved. In chronic hypotensive patients, in addition to an impaired deep-breathing test (p < 0.05), a further reduced Valsalva's manoeuver response and a lower pressor response to hand-grip test were observed (p < 0.001). Catecholamine levels were higher in both groups of patients (p < 0.01) with respect to control subjects, specially in chronic hypotensive patients.

CONCLUSIONS

In hemodialyzed patients (both normotensive and hypotensive) the whole baroreflex function and parasympathetic response are impaired. The lower pressor response to hand-grip test observed in hypotensive patients, in spite of the higher catecholamine levels, suggest that in these patients the cardiovascular dysfunction cannot be ascribed to a reduced sympathetic "outflow" but to a resistance of the target organs (heart and vessels) to the sympathetic stimulation.

Left heart and arterial baroreceptors interact in control of plasma vasopressin, renin, and cortisol in awake dogs

Arterial hypotension induced by constriction of the ascending aorta (AA) causes increases in left atrial pressure (LAP) and plasma atrial natriuretic peptide (ANP), but no change in plasma arginine vasopressin (AVP), plasma renin activity (PRA), or cortisol. In the present study, we tested the hypothesis that the rise in left heart pressure during constriction of the AA suppressed the stimulation of AVP, renin, and cortisol secretion in response to arterial hypotension. Dogs were prepared with inflatable cuffs around the AA, the pulmonary artery (PA), and the thoracic inferior vena cava (IVC) and with catheters in the left and right atria and abdominal aorta. In one series of experiments, the AA was constricted to lower mean arterial pressure (MAP) 10 or 20% below control for 15 min. Then, either the PA or the IVC was constricted to bring LAP back to control levels but without altering the degree of arterial hypotension. Constriction of the AA alone led to significant increases in LAP and plasma ANP but no change in plasma AVP, cortisol, or PRA. Reducing LAP to control levels by constriction of either the PA or IVC led to significant and similar increases in plasma AVP, cortisol, and PRA. Plasma ANP fell significantly 10 min after LAP was normalized by constriction of the IVC but not when LAP was normalized by constriction of the PA, because PA constriction caused a significant rise in right atrial pressure that stimulated ANP secretion. The increases in plasma AVP and PRA after normalizing LAP by constriction of the PA were compared with the increases obtained during identical falls in MAP induced by constriction of the IVC alone, a maneuver that lowers LAP below control. The increases in plasma AVP in the two conditions were identical, indicating that the stimulation of left heart baroreceptors alone can account for the suppression of AVP secretion in response to unloading arterial baroreceptors. In contrast, there was a greater rise in PRA during hypotension caused by constriction of the IVC alone compared with the condition in which LAP was normalized but plasma ANP remained elevated. This suggests that increased left heart pressure inhibits renin secretion in response to arterial hypotension by reflex mechanisms and by increased plasma ANP concentration.

The effects of epidural anesthesia on uterine vascular resistance, plasma arginine vasopressin concentrations, and plasma renin activity during hemorrhage in gravid ewes

In an earlier study, epidural anesthesia increased uterine vascular resistance and fetal acidosis during hemorrhage in gravid ewes. But, it is unclear whether epidural anesthesia modifies the uterine vascular resistance response during hemorrhage, independent of changes in arterial blood pressure. The purpose of this study was to determine the effects of epidural anesthesia on: 1) the mean arterial pressure/uterine vascular resistance relationship; and 2) arginine vasopressin concentrations and plasma renin activity during hemorrhage in gravid ewes. Twenty-four experiments were performed in 12 chronically instrumented animals between 0.8 and 0.9 of timed gestation. The experimental sequence included: 1) T = 0 min: epidural administration of 0.5% bupivacaine (epidural group) or normal saline (control group); 2) T = 30 min: maternal hemorrhage 0.5 mL.kg-1 x min-1 until maternal mean arterial pressure was 60% of baseline measurements (time H); 3) T = H to H + 60 min: adjust hemorrhage to maintain maternal mean arterial pressure at 60% of baseline. At 30 min, epidural bupivacaine resulted in a median sensory level of T-8 in the epidural group. At that time, uterine vascular resistance was similar in both groups despite lower (P = 0.0001) mean arterial pressure in the epidural group. Between H and H + 60 min, uterine vascular resistance was lower (P = 0.045) in the epidural group than in the control group. Also, fetal PCO2 was lower (P = 0.020) in the epidural group than in the control group, but fetal pH and PO2 did not differ significantly between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged absence of ovarian hormones in the ewe reduces the adrenocorticotropin response to hypotension, but not to hypoglycemia or corticotropin-releasing factors

The ACTH responses to hypotension, hypoglycemia, CRF, arginine vasopressin (AVP), and the combination of CRF and AVP were compared to determine whether there was a general decrease in ACTH responses to these stimuli in ovariectomized ewes compared to intact animals. The ovariectomized ewes were studied either 2-4 weeks post-ovariectomy (acute) or 4-7 months post-ovariectomy (chronic). Each ewe was subjected to saline control infusion, nitroprusside-induced hypotension (100 micrograms/min for 10 min), insulin-induced hypoglycemia (25 U porcine insulin), CRF (1 microgram/min for 60 min), AVP (0.2 microgram/min), and a combination of CRF plus AVP. In each experiment, plasma ACTH concentrations were measured at 10-min intervals for 1 h. The peak ACTH concentrations were significantly lower in response to hypotension in the chronic ewes compared to those in either the intact or acute group. The ACTH response to hypoglycemia was not significantly reduced in either ovariectomized group. The ACTH responses to CRF, AVP, and the combination of both were not significantly reduced in either ovariectomized group. The results suggest that the effect of ovariectomy on the ACTH response to stress occurs at a site within the brain and does not involve altered pituitary responsiveness to CRF or AVP.

Vasopressin response to hyperosmolality and hypotension during ovine pregnancy

The arginine vasopressin (AVP) responses to hyperosmolality and to hypotension were compared in pregnant and nonpregnant ewes. When the responses to infusion of normal or hypertonic saline were compared, plasma AVP and Na+ concentrations were lower in pregnant ewes than nonpregnant ewes, but the relation between plasma AVP and Na+ concentrations was not altered in the pregnant state. In a second study the AVP response to hypotension, induced by the infusion of 2.5, 5.0, or 10.0 micrograms nitroprusside.kg-1.min-1, was compared in pregnant and nonpregnant ewes. Despite significantly lower mean arterial blood pressures in the pregnant ewes, the mean plasma AVP concentration after infusion of nitroprusside was not increased during pregnancy. Therefore, the relation between mean arterial pressure and AVP was significantly shifted to the left in the pregnant ewes, indicating lower AVP concentrations for a given level of arterial pressure during pregnancy. The results suggest that pregnancy alters the regulation of AVP by arterial pressure but does not affect the regulation of AVP by plasma sodium concentration in the ewe.

Corticotropin responses to hypoglycemia and hypotension during ovine pregnancy

The adrenocorticotropic hormone (ACTH) responses to hypoglycemia and to hypotension were compared in pregnant and nonpregnant ewes. In the first study pregnant and nonpregnant ewes were each subjected to hypoglycemia induced by injection of 0.05, 0.10, or 0.25 U regular insulin/kg body wt or to saline infused as a control. In the second study pregnant and nonpregnant ewes were subjected to hypotension induced by the infusion of 2.5, 5.0, or 10.0 micrograms nitroprusside.kg-1.min-1 or to dextrose infused as a control. ACTH responses to hypoglycemia were significantly increased in the pregnant ewes, and the relation between plasma glucose and plasma ACTH was shifted to the right, indicating greater ACTH responses for a given level of hypoglycemia in the pregnant state. The mean ACTH response to infusion of nitroprusside was reduced during pregnancy, despite significantly lower mean arterial blood pressure in the pregnant ewes. When the relation between mean arterial pressure and ACTH was compared in the two groups of ewes, the relation was significantly shifted to the left in the pregnant ewes, indicating lower ACTH responses to a given level of pressure during pregnancy. The results suggest that pregnancy does not uniformly alter ACTH responses to stimuli, suggesting multiple, stimulus-specific effects of pregnancy on the hypothalamo-pituitary-adrenal axis.

Resuscitation of canine hemorrhagic hypotension with large-volume isotonic crystalloid: impact on lung water, venous admixture, and systemic arterial oxygen saturation

The objective of this study was to test the hypothesis that after hemorrhagic hypotension, reinfusion of the shed blood with threefold that volume of lactated Ringer's (LR) solution will significantly increase lung water and venous admixture and hence decrease systemic arterial oxygen saturation. A prospective, randomized, fixed-volume hemorrhage laboratory study was performed at the Oklahoma University Health Sciences Center on 18 anesthetized mongrel dogs. After 40 mL/kg of blood were withdrawn through a femoral artery catheter, the dogs were randomized either to the control group (n = 9) that received a reinfusion of the shed blood, or to the LR treatment group (n = 9) that received an intravenous mixture of the shed blood with 120 mL/kg of LR. After fluid resuscitation, pulmonary artery occlusion pressure (PAOP) and cardiac output (CO) were significantly increased in the LR group compared with control animals (PAOP, 18.7 +/- 1.1 vs 13.4 +/- 2.9 mm Hg; CO, 8.14 +/- 1.08 vs 4.59 +/- 0.47 L/min; P < .05 each). However, lung water, venous admixture, and systemic arterial PO2 were similar between groups. In this fixed-volume hemorrhage model, hemodiluting the reinfused shed blood with threefold the volume of LR did not significantly influence lung water, venous admixture, or systemic arterial oxygen saturation.

Vasoactive agents and blood pressure regulation in sequential ultrafiltration and hemodialysis

Hypotension is a common and sometimes dangerous side effect of hemodialysis. Its etiology is multifactorial and largely unknown. Earlier studies on the role of endogenous blood pressure regulating agents such as catecholamines and renin have rendered conflicting results. We studied the influence of ultrafiltration and isovolemic hemodialysis separately on the plasma concentrations of the following blood pressure regulating agents: adrenaline, noradrenaline, dopamine, neuropeptide Y, calcitonin gene-related peptide (CGRP), renin (PRA), angiotensin II, vasopressin, aldosterone and cortisol. During isolated ultrafiltration, plasma levels of two strong vasoconstrictors (noradrenaline and angiotensin II) and one strong vasodilator (calcitonin gene-related peptide, CGRP) increased significantly (noradrenaline 3.24 +/- 0.60 nM to 4.31 +/- 0.55 nM; p = 0.032, angiotensin II 19.74 +/- 3.46 pmol/l to 28.49 +/- 7.24 pmol/l; p = 0.047) No symptomatic hypotension occurred. At the end of isovolemic hemodialysis, plasma levels of all the vasoconstricting agents had decreased to pretreatment values, but those of CGRP had continued to rise (from 85.3 +/- 17.6 pmol/l to 114.5 +/- 25.3 pmol/l, p = 0.031). During isovolemic hemodialysis, blood pressure fell to symptomatic levels, but was restored at the end of treatment. The study shows that hemodialysis patients respond to fluid removal by ultrafiltration with an increase in plasma levels of CGRP, noradrenaline and angiotensin II. The net effect is an appropriate vasoconstriction and adequate blood pressure is maintained during isolated ultrafiltration.(ABSTRACT TRUNCATED AT 250 WORDS)

Contribution of in vivo microvascular PO2 in the cat carotid body chemotransduction

To understand the interplay between microcirculatory control and carotid body (CB) function, we simultaneously measured carotid body microvascular PO2 (CBM PO2) and chemosensory activity in the cat in vivo under several experimental conditions. Cats were anesthetized with pentobarbital sodium, paralyzed, and artificially ventilated. CBs were exposed, and steady-state CBM PO2 was measured by the O2-dependent quenching of the phosphorescence of Pd-meso-tetra-(4-carboxyphenyl)porphine, which was administered intravenously. A few fibers of the carotid sinus nerve were used to record chemosensory discharges. At arterial PO2 (PaO2) of 103.4 +/- 4.1 Torr, CBM PO2 was 52.5 +/- 3.6 Torr (n = 9). Graded lowering of PaO2 from 160 to 50 Torr resulted in nearly proportional decreases in CBM PO2, but at lower PaO2 the decrease in CBM PO2 became more substantial. As PaO2 decreased, chemosensory discharge increased in parallel with CBM PO2. Hypercapnia and hypocapnia did not significantly change the relationship between PaO2 and CBM PO2, although the chemosensory discharge responded significantly. CBM PO2 and chemosensory discharge were not affected by hemorrhagic hypotension until arterial blood pressure fell below approximately 50 Torr and then CBM PO2 decreased and chemosensory discharge increased. The lack of a significant effect of hemorrhagic hypotension indicated that O2 delivery to CB was almost independent of the systemic blood pressure. Taken together, the observations suggest that CB microcirculation and PO2 are subject to control by intrinsic mechanisms and that CBM PO2 is compatible with oxidative metabolism playing a role in O2 chemoreception during hypoxia.

The lack of association between femoral shaft fractures and hypotensive shock

A retrospective review of all patients with femur fractures was performed to determine whether isolated femoral shaft fractures were associated with hypotensive shock. One hundred patients were identified who had either an isolated femoral shaft fracture (group F, 62 patients) or a femoral shaft fracture in addition to other non-shock producing fractures or minor injuries (group A, 38 patients). No patients in this study were in class III or IV (hypotensive) shock; however, 11% progressed from no shock to class I and 13% from class I to class II. Logistic regression showed no association between class II shock and age, sex, or weight. The presence of additional fractures (p = 0.004) and total fluids received from fracture to stabilization (p = 0.014) had a highly significant association with class II shock in a joint analysis. Mechanism of injury, although significant as an independent variable, was highly associated with the presence of additional fractures and so is not required in the joint model. Femur fractures alone or in combination with other minor injuries should not be considered the cause of hypotensive shock in the traumatized patient. In the traumatized patient who presents with a closed femoral shaft fracture and hypotension, an alternative source of hemorrhage should be sought.

In vivo study of bleeding time and arterial hemorrhage in hypothermic versus normothermic animals

This in vivo study confirmed impaired hemostasis during hypothermia in a swine model. Group I (normothermic, n = 8) and group II (hypothermic, n = 8) animals were anesthetized and instrumented for continuous peritoneal irrigation and monitoring of heart rate and blood pressure. The effects of hypothermia, hypotension, and inotrope on bleeding time and bleeding from two types of arterial injuries were evaluated. Our findings were that (1) bleeding time was significantly prolonged in hypothermic animals; (2) the differences in blood loss from partially torn artery (PTA) and completely cut artery (CCA) at both normothermic and hypothermic temperatures did not reach statistical significance; and (3) blood loss from PTA was greater than CCA when norepinephrine (Levophed) was infused to elevate blood pressure in hypotensive animals at normal core temperature.

Effect of elevated atrial pressure on plasma renin activity in hypotensive fetal lambs

In adults, renin secretion is stimulated by reductions in arterial pressure and inhibited by increases in atrial pressure. In the late gestation fetus, a fall in arterial pressure stimulates renin secretion, but it is unknown whether elevation of atrial pressure will alter such an increase. Therefore we studied the effect of elevated atrial pressure on renin secretion in the presence of nitroprusside-induced arterial hypotension. Thirteen fetal lambs at 127.9 +/- 0.9 days of gestation were prepared 5 days before study with inflatable pulmonary artery occluders and right atrial, vascular, and amniotic catheters. Each fetus underwent two protocols (hypotension and hypotension with occlusion) using a randomized block design. Nitroprusside reduced arterial pressure by 34% in both groups. Right atrial pressure during the course of hypotension was significantly higher in the occlusion group (F = 14.2, P = 0.001). Plasma renin activity increased similarly in both groups during hypotension (F = 6.0, P = 0.003). Elevated right atrial pressure did not alter hypotension-induced renin secretion in the fetus.

Blood volume at the onset of hypotension during TURP performed under epidural anaesthesia

An analysis was made of the development of hypotension in the course of 60 transurethral resections of the prostate (TURP) performed under epidural anaesthesia. Hypotension was defined as a decrease in the systolic pressure down to 85 mmHg or less, or a total drop of 60 mmHg or more within 15 min. Indirect estimations of the blood volume according to the haemoglobin dilution method indicated that patients who developed hypotension from the epidural anaesthesia had a larger decrease in blood volume than other patients. During the operation, hypotension was associated with a blood volume of 300 ml or more below baseline, while 400 ml above baseline was required to ensure a stable circulation when the legs were lowered and removed from the stirrups after the TURP. Low central venous pressures, which were measured in 30 of the patients, were also associated with hypotension during and after TURP. There was a significant linear relationship between the total changes in blood volume and CVP measured at the end of each 10-min period of TURP (P < 0.001). However, no correlation between heart rate and hypotension was found.