Normovolaemic haemodilution and hyperoxia have no effect on fractal dimension of regional myocardial perfusion in dogs

Hypervolaemic haemodilution makes myocardial perfusion more homogenous as reflected by reduced fractal dimension of regional myocardial perfusion. The clinically more commonly performed acute normovolaemic haemodilution, however, has not yet been studied in this respect. Hyperoxic ventilation with 100% oxygen is used in conjunction with haemodilution to compensate for low oxygen content by increasing physically dissolved oxygen in plasma. Since hyperoxia is known to cause disturbance in microcirculatory regulation we studied the effects of acute normovolaemic haemodilution to haematocrit (hct) 20 +/- 1% and hyperoxia on regional myocardial perfusion heterogeneity in 22 anaesthetized dogs using fractal and correlation analysis. Regional myocardial perfusion was assessed with radioactive microspheres. The results of the study were that heart rate, blood volume and arterial pressure were unchanged during haemodilution. Cardiac index was 3.6 +/- 0.7 L min-1 m-2 before and 4.6 +/- 0.7 L min-1 m-2 after haemodilution (P < 0.05). Fractal dimension (D) of regional myocardial perfusion was 1.17 +/- 0.10 at baseline. Neither haemodilution (D = 1.19 +/- 0.10) nor hyperoxia (D = 1.17 +/- 0.10) altered fractal properties of regional myocardial perfusion. Spatial correlation of blood flow to adjacent tissue samples before haemodilution was 0.58 +/- 0.15. Haemodilution and hyperoxia did not significantly influence spatial correlation (0.57 +/- 0.12 vs. 0.60 +/- 0.09; ns). We conclude that neither acute normovolaemic haemodilution nor haemodilution in combination with hyperoxic ventilation alter physiological myocardial perfusion heterogeneity.

Effects of hyperoxic ventilation on hemodilution-induced changes in anesthetized dogs

BACKGROUND

In subjects who have undergone acute preoperative normovolemic hemodilution (ANH), intraoperative hemorrhage is generally treated by immediate return of autologous blood collected during ANH. Simply increasing blood oxygen content by hyperoxic ventilation (HV, inspiratory fraction [FIO2] 1.0) might compensate for the acute anemia, allow further ANH, and delay onset of autologous blood return.

STUDY DESIGN AND METHODS

This study 1) evaluated the effects of HV (FIO2 1.0) upon ANH to a hemoglobin (Hb) concentration of 7 g per dL in anesthetized dogs ventilated with room air and 2) compared the effects of subsequent profound ANH (Hb, 3 g/dL) with and without an intravenous perfluorocarbon emulsion (perflubron 60% wt/vol) versus those of autologous red cell transfusion. The results of the entire study are presented in two parts. Organ tissue oxygenation was assessed in skeletal muscle and liver, and systemic oxygenation status was evaluated. Myocardial contractility was deduced from left ventricular pressure-volume relationship. Seven of 22 dogs underwent further hemodilution while breathing 100-percent O2, for a determination of the Hb concentration at which HV-induced effects were abolished.

RESULTS

HV completely reversed the ANH-induced increase in cardiac index (4.6 +/- 0.7 vs. 3.8 +/- 0.9 L/min/m2 before and during HV; p < 0.05) and partially reversed the decrease in systemic vascular resistance (1784 +/- 329 vs. 2087 +/- 524 dyn x cm-5 x sec x m-2; p < 0.05). Despite unchanged global O2 delivery, organ tissue oxygenation improved during HV (mixed venous partial pressure of O2: 40 +/- 3 vs. 59 +/- 7 torr; coronary venous pressure of O2: 30 +/- 4 vs. 43 +/- 6 torr; p < 0.05; liver surface: 31 +/- 11 vs. 39 +/- 13 torr; skeletal muscle surface: 30 +/- 14 vs. 41 +/- 22 torr; p < 0.05). This improvement was due to an increased contribution of physically dissolved O2 in plasma to O2 delivery (3.2 +/- 0.2% before HV vs. 14.6 +/- 1% during HV; p < 0.05) and O2 consumption (whole body: 6 +/- 1% vs. 47 +/- 8%, p < 0.05; myocardium: 4.3 +/- 0.9% vs. 31 +/- 6%, p < 0.05). The beneficial effects of HV were lost after an additional volume-compensated exchange of 19 percent of blood volume (Hb, 5.6 g/dL).

CONCLUSION

In anesthetized dogs ventilated with room air and hemodiluted to a Hb of 7 g per dL, simple oxygen therapy by HV (FIO2 1.0) rapidly improves tissue oxygenation and permits extended hemodilution to Hb of 5.8 g per dL until the HV-induced effects are lost.

Hemodilution and hyperoxia locally change distribution of regional pulmonary perfusion in dogs

In seven anesthetized dogs, the effects of acute normovolemic hemodilution (ANH) to a hematocrit of 20 and 8% and the effects of hyperoxic ventilation (100% oxygen) on distribution of regional pulmonary blood flow (rPBF; radioactive microspheres) were investigated. Normovolemia was monitored with blood volume measurements (indocyanine green dilution kinetics). Before ANH, fractal dimension (D) of rPBF in the whole lung was 1.19 +/- 0.09 (mean +/- SD). Spatial correlation (rho) of rPBF in the whole lung was 0.6 +/- 0.08. D is a resolution-independent measure for global rPBF distribution, and rho is the averaged flow relationship of directly neighboring lung samples. With regard to the entire lung, neither ANH nor hyperoxia changed D or rho. With regard to horizontal, isogravitational planes, ANH induced opposite changes of rPBF heterogeneity depending on the vertical location of the plane and the parameter used. In ventral planes, a change in relative dispersion (SD/mean) indicated decreased homogeneity. However, rho suggested more homogeneous perfusion. Hyperoxia restored baseline rPBF distribution. Our data suggest that ANH causes different alterations of heterogeneity of rPBF depending on location within the lung.

Hemodilution and intravenous perflubron emulsion as an alternative to blood transfusion: effects on tissue oxygenation during profound hemodilution in anesthetized dogs

BACKGROUND

Intravenously administered perfluorocarbon (PFC) emulsions increase oxygen solubility in plasma. PFC might therefore temporarily replace red cells (RBCs) lost during intraoperative hemorrhage. In patients who have undergone hemodilution, the return of autologous blood may be delayed by the administration of PFC, and autologous RBCs may be saved for transfusion after surgical bleeding is stopped and PFC is cleared by the reticuloendothelial system.

STUDY DESIGN AND METHODS

In 22 anesthetized, hemodiluted dogs (hemoglobin [Hb] 7 g/dL) breathing 100-percent O2, an intraoperative volume-compensated blood loss was simulated. The efficacy of three therapeutic regimens in maintaining tissue oxygenation was compared: 1) RBC group (n = 7): maintenance of a Hb > 7 g per dL by transfusion of autologous RBCs; 2) PFC group (n = 7): bolus application of a second-generation PFC emulsion (60% wt/vol perflubron) and further acute normovolemic hemodilution (ANH) to a Hb of 3 g per dL; and 3) control group (n = 7): further ANH alone to a Hb of 3 g per dL. Systemic and myocardial oxygenation status and tissue oxygenation were assessed.

RESULTS

Autologous RBCs transfused to maintain a Hb of 7 g per dL preserved hemodynamics and tissue oxygenation during blood loss. In the PFC and control groups, heart rate and cardiac index increased significantly in response to further ANH. Tissue oxygenation was not different in the PFC and the RBC groups. Direct comparison of the PFC and control groups revealed better tissue oxygenation in the PFC group, as reflected by significantly higher mixed venous, coronary venous, and local tissue pO2 on liver and skeletal muscle.

CONCLUSION

Bolus intravenous administration of 60-percent (wt/vol) perflubron emulsion and further hemodilution from a Hb of 7 g per dL to one of 3 g per dL were as effective as autologous RBC transfusion in maintaining tissue oxygenation during volume-compensated blood loss designed to mimic surgical bleeding.

A pilot study of the effects of a perflubron emulsion, AF 0104, on mixed venous oxygen tension in anesthetized surgical patients

A pilot study of a perfluorochemical (PFC) emulsion was undertaken to determine whether administration of a perflubron emulsion could result in measurable changes in mixed venous oxygen tension. Seven adult surgical patients received a 0.9-g PFC/kg intravenous dose of perflubron emulsion after acute normovolemic hemodilution (ANH). Hemodynamic and oxygen transport data were collected before and after ANH, immediately after PFC infusion, and at approximate 15-min intervals throughout the surgical period. There were no clinically significant hemodynamic changes associated with the administration of the PFC emulsion. There was a significant increase in mixed venous oxygen tension (PVO2) after the PFC infusion, while cardiac output and oxygen consumption were unchanged. As surgery progressed, the hemoglobin concentration decreased with ongoing blood loss while PVO2 values remained at or above predosing levels. Peak perflubron blood levels were 0.8 g/dL immediately postinfusion, and approximately 0.3 g/dL at 1 h. This pilot study demonstrates that administration of perflubron emulsion results in measurable changes in mixed venous oxygen tension during intraoperative ANH.

Effects of a perfluorocarbon emulsion for enhanced O2 solubility on hemodynamics and O2 transport in dogs

Perfluorocarbon emulsions raise blood O2 solubility and thus augment O2 transport, but their cardiopulmonary effects at higher doses may limit their use. We therefore examined effects of increasing doses of perfluorooctylbromide emulsion (Oxy) on 1) pulmonary gas exchange, 2) pulmonary and systemic hemodynamics, and 3) mixed venous PO2 (PVO2). After hematocrit reduction to 24-26% by exchange with 5% albumin, anesthetized ventilated dogs breathing 100% O2 were given Oxy (n = 6) or 5% albumin (n = 5) intravenously in four successive 3 ml/kg doses. After each dose, arterial and venous PO2, PCO2, and pH, [O2], hematocrit, heart rate, and systemic, pulmonary arterial, and airway pressures were measured. Ventilation-perfusion relationships and cardiac output (QT) were determined by the multiple inert gas method. Oxy at 12 ml/kg almost doubled blood O2 solubility, increasing arterial [O2] by 1.28 ml/100 ml but did not affect O2 consumption and ventilation-perfusion relationships. QT rose by 21% after 3 ml/kg, then fell with increasing doses (-18% from baseline after 12 ml/kg); O2 delivery remained constant. Oxy at > 6 ml/kg increased systemic blood pressure and systemic vascular resistance considerably. Mean pulmonary arterial pressure and pulmonary vascular resistance increased slightly. Airway pressures were unaffected. PVO2 rose from 66 to 77 Torr (6 ml/kg), then fell to 72 Torr (12 ml/kg), in accord with theoretical-predictions. In this model, Oxy 1) dose not impair pulmonary gas exchange in doses up to 12 ml/kg, 2) leads to progressively higher systemic vascular resistance and fall in QT at > 3-6 ml/kg, possibly because of increased blood viscosity, and 3) augments PVO2, as predicted from the increase in plasma O2 solubility.

Effect of supplemental perfluorocarbon administration on hypotensive resuscitation of severe uncontrolled hemorrhage

Recent animal studies of acute hemorrhage in the presence of a vascular injury have demonstrated improved survival and decreased hemorrhage volume with hypotensive resuscitation, but this has occurred at the expense of tissue perfusion. It was hypothesized that addition of an oxygen-carrying perfusate would improve tissue oxygen delivery during hypotensive resuscitation. Hypotensive resuscitation of severe uncontrolled hemorrhage was compared with and without supplementation with Oxygent HT, an emulsion of perflubron (perfluorooctylbromide; PFOB; Alliance Pharmaceutical Corporation, San Diego, CA), an oxygen-carrying perfusate. Fifteen swine (15 to 22 kg) with 4-mm aortic tears were bled to a pulse pressure of 5 mm Hg and then resuscitated (estimated blood loss, 40 to 50 mL/kg). All animals were resuscitated with normal saline (6 mL/kg/min) infused as needed to maintain a mean arterial pressure of 40 mm Hg. One group (PFC) of animals also received an infusion of 6 mL/kg perfluorooctylbromide emulsion. Another group served as controls and received an equal volume of placebo (normal saline). Animals were observed for 120 minutes or until death. Data were compared using repeated measures analysis of variance (ANOVA) the Student's t test, and Fisher's exact. A P value < .05 was considered significant. Two-hour mortality rates were 12.5% and 43% for PFC-treated animals and controls, respectively (P > .05; 95% confidence interval [95% CI] for this difference in mortality is -13% to 74%). Oxygen content and delivery were significantly greater in the treatment group. In conclusion, administration of an oxygen-carrying perfusate significantly improves oxygen delivery in hypotensive crystalloid resuscitation of severe uncontrolled hemorrhage.

Improvement in circulatory and oxygenation status by perflubron emulsion (Oxygent HT) in a canine model of surgical hemodilution

To examine the effect of a low dose of Oxygent HT on hemodynamics and oxygen transport variables in a canine model of profound surgical hemodilution, two groups of adult anesthetized splenectomized beagles were hemodiluted with Ringer's solution to Hb 7 g/dL. The treated group received 1 mL/kg Oxygent HT (90% w/v perflubron emulsion [perfluorooctyl bromide], Alliance Pharmaceutical Corp.) and both groups (7 controls and 10 treated) were further hemodiluted using 6% hydroxyethyl starch until cardiorespiratory decompensation occurred. Pulmonary artery catheterization data and oxygen transport variables were recorded at Hb decrements of 1 g/dL breathing room air. There was no difference among groups during initial hemodilution. However, in the Oxygent HT group there was a statistically significant improvement in mean arterial pressure, CVP, cardiac output, PvO2, SvO2, DO2, and pulmonary venous admixture shunt during profound hemodilution to Hb levels of 6, 5, and 4 g/dL. A low dose of Oxygent HT offered benefit in improving hemodynamics and oxygen transport parameters even under air breathing conditions in a model of surgical hemodilution. This effect was most apparent at lower levels of Hb.

Mechanisms and efficacy of fluorochemical oxygen transport and delivery

Fluorochemicals for medical use are metabolically inert liquids with a high solubility for gases, and can dissolve 50 percent or more of their own volume of oxygen (O2) at ambient pressures. The solubility is directly proportional to the oxygen tension (PO2) and transport is thus not saturable, unlike the O2 saturation of hemoglobin (Hb) which follows the well known "S" shaped relationship with PO2. Intravenously-injected emulsions of fluorocarbons transport only about one seventh as much O2 as Hb on a gram for gram basis, even when high concentrations of O2 are respired. However, because of the high O2 extraction from fluorocarbons in these circumstances, their contribution to O2 consumption is more than 65% of that of Hb. O2 delivery to the tissues depends on the product of the cardiac output and the arterial oxygen content. When red cells are transfused, blood viscosity increases and cardiac output decreases. This lessens the efficacy of blood in comparison to that of fluorocarbons, and increases the relative transport of O2 in the metabolically readily-accessible plasma compartment. This provides an interesting application for low dose fluorocarbons during surgery in combination with autologous blood use. The efficacy of fluorocarbons in this setting can be predicted by computer modelling.

Enhanced oxygen delivery by perflubron emulsion during acute hemodilution

A high-concentration 90% w/v perflubron (perfluorooctyl bromide [PFOB]) emulsion (Oxygent HT) is being evaluated as an oxygen carrier for use during surgery. This study was done to assess oxygen delivery by Oxygent HT during acute normovolemic hemodilution. Anesthetized mongrel dogs, instrumented with femoral and pulmonary artery catheters, were hemodiluted to a hematocrit of 25% with 3:1 (v/v) of Ringers-lactate (R-L). Dogs were then ventilated with 100% O2 and hemodiluted to a Hct approximately 11% with 1.5 (v/v) of colloid (autologous plasma and 5% albumin). Dogs then received either 3.3 mL/kg Oxygent HT (n = 5) or 3.3 mL/kg R-L (n = 4), and were monitored for 3 hours. Total oxygen delivery (DO2), blood oxygen content, cardiac output, mixed venous PO2, and mixed venous Hb saturation was higher in Oxygent HT treated dogs compared to the R-L controls. The percentage of total DO2 contributed by perflubron-dissolved oxygen was about 8-10% and accounted for 25-30% of total oxygen consumption (VO2). The percentage of VO2 contributed by Hb-carried oxygen was significantly higher in R-L controls (46 +/- 4%) than in the treated dogs (15 +/- 3%), indicating that the availability of the perflubron-dissolved oxygen allowed for a reserve of oxygen to remain available in the red blood cells.

Comparison of ventilatory support with intratracheal perfluorocarbon administration and conventional mechanical ventilation in animals with acute respiratory failure

We investigated the efficacy of intratracheal perfluorocarbon (PFC) administration combined with mechanical ventilation to support gas exchange in adult animals with acute respiratory failure. These were compared with a similar group of animals treated with continuous positive-pressure ventilation (CPPV) with respect to respiratory parameters and postmortem lung histology. After lung lavage with saline, 18 adult rabbits were divided into three groups (n = 6 per group). All groups received conventional CPPV. Additionally, one group received intratracheal PFC administration at a volume of 18 ml/kg (corresponding to functional residual capacity) (PFC group); another received 18 ml/kg of saline administration (saline group), and the last had no further treatment (CPPV group). All groups were ventilated for 3 h using 100% oxygen, with the same ventilator settings of tidal volume of 12 ml/kg, respiratory frequency of 30/min, and positive end-expiratory pressure of 6 cm H2O. In the PFC group, PaO2 increased from 67.2 +/- 11.4 to 424.2 +/- 14 mm Hg and remained stable for 3 h with well-preserved PaCO2 values. Only in the PFC group were significant decreases in airway pressures and increase in respiratory system compliance seen. In the CPPV group, PaO2 stayed around 60 mm Hg and PaCO2 gradually increased. PFC treatment with conventional mechanical ventilation in acute respiratory failure proved to be a successful supportive technique to improve gas exchange at low inflation pressures.

Intratracheal perfluorocarbon administration combined with mechanical ventilation in experimental respiratory distress syndrome: dose-dependent improvement of gas exchange

OBJECTIVES

To test the efficacy of intratracheal instillation of a perfluorocarbon, combined with conventional mechanical ventilation, as well as to establish the dose response of this application on pulmonary parameters in adult animals with acute respiratory failure.

DESIGN

Prospective, randomized, placebo-controlled study.

SETTING

Anesthesiology laboratory of a university.

SUBJECTS

Twelve, adult male New Zealand rabbits.

INTERVENTIONS

After inducing respiratory failure by repeated lung lavage with saline, one group of animals was treated with perfluorocarbon, while another group was treated with saline to serve as controls (n = 6 per group). Treatment consisted of intratracheal instillation of incremental doses of 3 mL/kg of each liquid up to a total volume of 15 mL/kg. Animals were mechanically ventilated for 15 mins after each treatment dose with volume-controlled ventilation, a tidal volume of 12 mL/kg, frequency of 30 breaths/min, FIO2 of 1.0, and a positive end-expiratory pressure of 6 cm H2O.

MEASUREMENTS AND MAIN RESULTS

Arterial blood gases and lung mechanics were determined. In the perfluorocarbon group, PaO2 increased with increases in dosage from 75 +/- 15 to 420 +/- 27 torr (10.0 +/- 2.0 to 55.9 +/- 3.6 kPa); PaCO2 decreased from 49 +/- 6 to 43 +/- 5 torr (6.5 +/- 0.8 to 5.7 +/- 0.6 kPa) after the first dose, and remained stable thereafter. Airway pressures were significantly lower after treatment compared with pretreatment values.

CONCLUSION

The remarkable improvements in pulmonary parameters suggest that this type of ventilatory support offers an effective and simple method of perfluorocarbon application in acute respiratory failure.

Increased plasma O2 solubility improves O2 uptake of in situ dog muscle working maximally

A perfluorocarbon emulsion [formulation containing 90% wt/vol perflubron (perfluorooctylbromide); Alliance Pharmaceutical] was used to increase O2 solubility in the plasma compartment during hyperoxic low hemoglobin concentration ([Hb]) perfusion of a maximally working dog muscle in situ. Our hypothesis was that the increased plasma O2 solubility would increase the muscle O2 diffusing capacity (DO2) by augmenting the capillary surface area in contact with high [O2]. Oxygen uptake (VO2) was measured in isolated in situ canine gastrocnemius (n = 4) while working for 6 min at a maximal stimulation rate of 1 Hz (isometric tetanic contractions) on three to four separate occasions for each muscle. On each occasion, the last 4 min of the 6-min work period was split into 2 min of a control treatment (only emulsifying agent mixed into blood) and 2 min of perflubron treatment (6 g/kg body wt), reversing the order for each subsequent work bout. Before contractions, the [Hb] of the dog was decreased to 8-9 g/100 ml and arterial PO2 was increased to 500-600 Torr by having the dog breathe 100% O2 to maximize the effect of the perflubron. Muscle blood flow was held constant between the two experimental conditions. Plasma O2 solubility was almost doubled to 0.005 ml O2 x 100 ml blood-1 x Torr-1 by the addition of the perflubron. Muscle O2 delivery and maximal VO2 were significantly improved (at the same blood flow and [Hb]) by 11 and 12.6%, respectively (P < 0.05), during the perflubron treatment compared with the control. O2 extraction by the muscle remained the same between the two treatments, as did the estimate of DO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen delivery from fluorocarbon emulsions--aspects of convective and diffusive transport

Perfluorocarbons (PFCs) deliver oxygen due to their physical characteristics and the convective delivery to tissues; this has been amply demonstrated in numerous animal models and in clinical trials. PFC emulsions have also been used for organ perfusion and augmentation of oxygenation to cell cultures. By reason of their small particle size, PFC emulsions penetrate collateral capillaries of an ischemic microcirculation, both supplying oxygenation and possibly restoring flexibility of acidotically stiffened erythrocytes by reinstituting aerobic metabolism. There is also evidence that PFCs can augment tissue oxygenation by increasing oxygen solubility in the plasma phase of blood; this improves diffusion gradients between plasma and tissues even at relatively low doses of PFC. This hypothesis is supported by the ability of PFCs to increase oxygen tensions in tissues such as blood, brain, liver, kidney, pancreas, skeletal muscle, retina etc. PFCs can also on occasions increase critical oxygen extraction coefficients and should therefore be effective in supporting oxidative metabolism in states of extreme cardio-respiratory insufficiency. This theory represents a new concept in oxygen delivery and may define a new class of therapeutic agents that can improve tissue oxygen supply in various pathological states involving low oxygen delivery and ischemia.

Resuscitation fluids and oxygen transport in haemorrhagic shock

This study examined the cardiovascular and oxygen transport/consumption relationships in haemorrhagic shock and resuscitation using Human Albumin and Gelatin solutions in a porcine haemorrhagic shock model. Immature pigs (17-25 kg) were anaesthetised and ventilated with nitrous oxide, oxygen and isoflurane. Aortic pressure monitoring and monitoring of pulmonary pressures and cardiac output via a Swan-Ganz catheter were instituted. A controlled haemorrhage of 40% of blood volume at 1% blood volume per minute was followed 30 minutes later by resuscitation with 60% of blood volume of 4.5% Human Albumin (Immuno) or 4% Modified Fluid Gelatin (Gelofusine). Haemorrhage caused marked decreases in (CI), mean arterial pressure and oxygen delivery (DO2). Oxygen consumption (V02) remained unchanged. Resuscitation with Albumin and Gelatin raised CI to values 60% to 70% above control though only Albumin restored DO2. Deterioration was more rapid in the Gelatin group due to the estimated half a life of 3 hours in this model. Oxygen extraction was 10% higher in the Gelatin group 2 hours after resuscitation. The role of oxygen radicals in haemorrhagic shock is discussed.

Myocardial oxygen supply under critical conditions, the effects of hemodilution and fluorocarbons

This article reviews the factors influencing myocardial oxygen supply and demand. The regulative mechanisms in coronary blood flow, especially in critical conditions, are explained. Myocardial oxygenation in coronary artery disease is discussed with special reference to pharmacological intervention. An extensive evaluation of the effects of hemodilution on both the healthy and diseased heart is presented. Effects of hemodilution with fluorocarbons for the treatment or prevention of myocardial ischemia are shown with the aid of intramyocardial oxygen partial pressure measurements.

Development of the coronary vasculature in hypoxic fetal rats treated with a purified perfluorocarbon emulsion

OBJECTIVE

To quantitatively define the coronary vascular bed in the 21-day-old rat fetus with gestational normoxia and hypoxia; to determine if maternal supplemental oxygen and/or oxygen-carrying perfluorocarbons (PFCs) influence development of coronary vessels; and to compare the results using purified and unpurified PFC treatment.

DESIGN

Unilateral uterine artery ligation was introduced on gestational day 17 in pregnant animals. Control fetuses were from unligated uterine horns. Experimental intervention occurred during gestational days 17 to 21, with fetuses recovered on day 21. Developing coronary vessels were analyzed quantitatively via light microscopy.

ANIMALS

Pregnant Sprague Dawley rats.

INTERVENTIONS

Following ligation, pregnant rats received no further treatment, supplemental oxygen inhalation alone, or daily intravenous purified PFC treatment, with or without supplemental oxygen.

MAIN RESULTS

Hypoxia caused an increase in resorptions (P less than 0.001), and decreased fetal body weight (P less than 0.001) and heart weight (P less than 0.05). Although the area occupied by developing coronary vessels (sinusoids) was substantially increased, maturation was unchanged. Oxygen supplementation alone did not appreciably influence fetal resorptions or body weight in ligated horns, but did increase fetal heart weight. Sinusoidal area decreased (P less than 0.01), with no effect on sinusoidal maturity. Purified PFC treatment did not alter maternal weight gain or fetal body weight, and moderately decreased resorptions in ligated horns. Fetal heart weight was augmented with purified perflurochemical, while unpurified perfluorochemical treatment diminished heart weight. Both PFC emulsions substantially decreased sinusoidal area.

CONCLUSIONS

Perflurocarbon treatment associated with supplemental oxygen is capable of improving the hypoxic effects on fetal heart and coronary vessel development if the emulsion used is appropriately purified.

Post-operative headache--a multifactorial analysis

ASA Grade I and II patients admitted for day-case urological surgery received no premedication or an oral dose of temazepam 10 mg. Anaesthesia was induced with methohexitone and maintained with nitrous oxide, oxygen and halothane or enflurane via a Mapleson A circuit. The incidence of post-operative headache was investigated by an independent observer. Eighty patients were studied (50 male and 30 female) of whom 32 (40%) had post-operative headaches. Post-operative headache was significantly correlated with female sex and frequent 'normal' headache occurrence. The lack of previous surgical experience was a significant risk factor and a loose insignificant association existed with age, the use of halothane and the presence of pre-operative headache. Temazepam premedication had no effect and was associated with significantly more patients complaining of feeling cold.

Aprotinin reduces hypothermic mortality--an experimental model

In order to test the postulate that post-hypothermic damage may be caused by protease activation, the effect of the administration of aprotinin on hypothermic mortality was investigated in anaesthetized rabbits. A group of 6 animals received 40.000 KIU aprotinin intravenously prior to the induction of hypothermia by surface cooling and this was followed by a further 35.000 KIU each hour for 5 h. The animals were cooled to 29 degrees C and then rewarmed. A control group received equal volumes of physiological saline. The aprotinin treated animals survived, whereas all the control group died within 7 days, 5 of them within 24 h. The haemodynamic, biochemical and haematological changes in the two groups are reported.

Protection against myocardial ischaemia by prior haemodilution with fluorocarbon emulsions

The possible prophylactic effects of Fluosol-DA 20% (FDA) haemodilution against myocardial hypoxia were studied in two groups of anaesthetized immature pigs. Precalibrated 200-micron diameter oxygen microelectrodes were inserted to the myocardium of the left ventricle. One group of animals was haemodiluted with FDA and both groups received 100% oxygen (plus halothane). The lower one-third of the left anterior descending coronary artery was occluded; this caused no significant cardiovascular changes. Analysis from the microelectrodes in the most hypoxic areas of the myocardium revealed significant decreases in myocardial oxygen tension (PmO2) in the control group 15 min after occlusion in the FDA-diluted group. Analysis of other electrodes suggested greater hyperaemic compensatory response in ischaemic border areas in the FDA-treated group.

Myocardial oxygen tensions during ischaemia in fluorocarbon diluted pigs

Previous work by the authors has shown that, following ligation of the left anterior descending coronary artery (LAD), myocardial oxygen tension (PmO2) in expected areas of maximal ischaemia is maintained at the expense of ischaemic border zones of the infarct area. Post-ischaemic haemodilution with the fluorocarbon containing plasma substitute Fluosol-DA 20% (FDA) could significantly improve PmO2 and pre-ischaemic haemodilution can delay myocardial ischaemia. We now present an analysis of the pattern of PmO2 changes to be seen when myocardial ischaemia is induced following prior haemodilution with FDA. Two groups of juvenile Yorkshire pigs were anaesthetised with intraperitoneal thiopentone, intubated and ventilated with halothane, nitrous oxide and oxygen. After placement of cardiovascular monitoring lines, a thoracotomy was performed. The pericardium was opened and 4 steel-protected gold microelectrodes were placed in the terminal supply area of the LAD in such a way that 2 electrodes were in the area of myocardial ischaema to be produced. One group of pigs were bled (20 ml/kg) and the loss was replaced with equal volumes of FDA. The animals were ventilated with halothane and oxygen and the terminal LAD was ligated. Electrode outputs were recorded on a flat bed recorder and analysed. LAD occlusion in the control animals resulted in similar changes in PmO2 to those described above.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiorespiratory consequences of fluorocarbon reactions in dogs

Cardiorespiratory responses to 2 ml intravenous doses of fluorocarbon emulsions were investigated in dogs anaesthetised with pentobarbitone and artificially ventilated with air. Systemic and pulmonary artery pressures were measured using catheters in the femoral artery and external jugular vein. Oxygen consumption was obtained by analysis and measurement of expired gases and cardiac output was calculated using the Fick principle. Venous return from the hind limb was isolated using tourniquets at thigh and ankle regions and venous effluent was measured. Homogeneity of muscle blood flow was calculated using a saline washout technique. 24 of 28 dogs reacted to Oxypherol (FC-43) and 7 of 11 reacted to Fluosol-DA (FDA) (n.s.); 2 of 3 dogs unresponsive to FDA reacted to FC-43. The reactions consisted of severe, statistically significant, systemic hypotension with decreases in cardiac output and limb blood flow. Pulmonary and systemic vascular resistances were increased and body and limb muscle oxygen delivery and oxygen consumption were decreased. Reactions tended to be more severe following FC-43. Effects were maximal at 3-4 minutes after fluorocarbon administration. Changes had usually recovered at 40-60 minutes though oxygen debts were still being repaid. It is clear that acute myocardial depression was produced. Homogeneity of limb muscle flow was still significantly reduced at "recovery" and this we attribute to complement activation and embolisation of the microvasculature.

Ketamine-induced dysrhythmia and its antagonism: a case report

Ketamine is normally considered as being anti-dysrhythmic. A case report is presented here in which small subanaesthetic doses of ketamine were administered to reinforce spinal analgesia. Initial doses were followed by a dysrhythmia, which appeared to be repeatedly counteracted by further small doses of the drug. The cardiac pharmacology of ketamine is discussed, as is the relevance of the chance finding of mitral valve prolapse.

Fluorocarbons. Current status and future applications

This article presents information on medical applications of fluorocarbons. These inert chemicals have a high solubility for the respiratory gases and, in emulsified form, are present in the oxygen-transporting plasma substitutes now undergoing clinical trials. Oxygen content is directly related to arterial partial pressure of oxygen (PaO2). Thus, although oxygen transport of Fluosol-DA 20% (FDA) is only 0.75 ml per 100 ml per 10 kPa, oxygen delivery at the tissues will be adequate in the presence of a high PaO2. FDA has a low viscosity at low shear rates and this, together with a very small emulsion particle size of 0.1 micron, helps provide improved tissue oxygenation in conditions of ischaemic hypoxia. Fluorocarbon plasma substitutes may be employed as 'blood', but may also be used for a wide range of purposes in clinical practice. This review describes some current and potential future applications.

Peripheral vascular responses to fluorocarbon administration

To detect the local effect of hyperoxia on skeletal muscle vasculature, 2.5-ml boluses of oxygenated or deoxygenated fluorocarbon emulsion (F-O2 or F-N2) were washed through the hindlimb of anesthetized dogs at prevailing arterial pressure. Instantaneous hematocrit changes at the outflow were registered and stored in digital form with the red cells serving as the nondiffusible tracer in the resulting washout curves. A gamma density function was fitted and the gamma index (1/square root of alpha) was derived as a measure of skewness or perfusion heterogeneity. After recovery from the initial hypotensive reaction to fluorocarbon emulsion, washout curves for F-O2 and F-N2 were registered and blood samples were taken during 40 min of normoxia followed by 40 min of hypoxic hypoxia. The initial reaction to fluorocarbon significantly increased the gamma index so that the experiments began with a high index of perfusion heterogeneity in the limb vasculature. No significant difference was seen between F-O2 and F-N2 in normoxia but F-O2 maintained greater heterogeneity during hypoxia. The increased heterogeneity observed after the fluorocarbon reaction correlated highly with the severity of the hypotensive reaction which was also found to correlate inversely with the ability of the limb musculature to increase the O2 extraction ratio with onset of hypoxia. This blunting of microcirculatory reactivity to hyperoxia and hypoxia was attributed, in part, to the initial transient fluorocarbon reaction, possibly mediated by complement activation.

Critical oxygen delivery levels during shock following normoxic and hyperoxic haemodilution with fluorocarbons or dextran

Fluosol-DA 20% (FDA), an emulsion of fluorocarbons in a glucose electrolyte solution can deliver physiologically significant amounts of oxygen (O2) to the tissues and improve ischaemic hypoxia. To investigate its effect on critical oxygen delivery level (QO2c), four groups of six phenobarbitone anaesthetised air-ventilated splenic clamped mongrel dogs were haemodiluted to a haematocrit (Hct) of 25%; two groups with FDA and two with 6% dextran solution. Oxygen consumption (VO2) was derived from expired gas measurement and analysis, or by using a spirometer and carbon dioxide absorption. Whole body O2 flux (QO2) was calculated from mixed venous and arterial O2 contents and the Fick-derived cardiac output. QO2 was progressively decreased by haemorrhaging in steps of 1.5-2.5 ml per kg. Hct was kept at 25% using packed cells. VO2/QO2 pairs were calculated at each step and QO2c was determined for each animal by least squares fitting of data with 2 straight lines. Analyses of variance were performed. QO2c was significantly less in the FDA and O2 (F+O) group than either the dextran and O2 (D+O) or dextran and air (D+A) groups. Analysis of O2 extraction at QO2c, which effectively normalized results for differences in resting, VO2, had significantly better extraction in the FDA and air (F+A) than the D+A group. When fluorocarbon- and plasma-dissolved oxygen was subtracted, the O2 extraction in the F+A group was significantly better than in the D+A and F+O groups. The results imply that normoxic FDA haemodilution in animals respiring air can improve O2 delivery and that hyperoxia interferes with this process.

Hemodynamics and coagulation in experimental auxiliary liver transplantation during fulminant hepatic failure

In pigs, ischemic liver cell necrosis was induced by 6 hours' occlusion of the hepatic artery and the portal vein 3 days after construction of a side-to-side portacaval shunt and division of the hepatic ligaments. Two thirds of the liver of an MLC-compatible donor was heterotopically transplanted 13 hours (group I), and 3 hours (group II) after induction of liver failure. In group I (N = 11), three animals died of liver failure before or shortly after induction of anesthesia. Of the remaining pigs, two animals survived more than 2 weeks. In group II (N = 10), intraoperative hypotension was prevented by reduction of the interval between liver failure and transplantation and by thermodilution catheter monitored fluid replacement. A significant decrease in cardiac output and an increase of pulmonary and systemic vascular resistance were observed during auxiliary partial liver transplantation (APLT). In the immediate postoperative period, six pigs died of deficiencies in hemostasis that were caused by consumptive coagulopathy related to severe host liver damage rather than fibrinolysis. Two pigs in group II survived in good condition 12 and 42 days after APLT. In the longer surviving pigs of both groups, either the graft or the host liver recovered. Processes that might be responsible for the observed hemodynamic changes and coagulation disorders are discussed. These results indicate that APLT is technically feasible in severely ill pigs with acute hepatic failure.

The role of ascorbic acid in etomidate toxicity

Etomidate, a short-acting hypnotic used in anaesthesia, has been shown to block steroidogenesis in man. The free imidazole radical in etomidate binds to cytochrome P450. Serious side-effects of etomidate have only been observed in guinea-pigs and in man, both species relying for restoration of ascorbic acid pools upon resynthesis and upon the daily dietary intake of vitamin C. It has been shown that ascorbic acid and not ACTH can increase serum cortisol concentration during etomidate infusion. Ascorbic acid even restores the ACTH/cortisol ratio to pre-operative values. It is therefore suggested that etomidate blocks ascorbic acid metabolism. Resynthesis of ascorbic acid cannot occur because of the blockade of cytochrome P450. Depletion of the ascorbic acid pool would then cause inhibition of steroidogenesis. This is the case in man and probably also in the guinea-pig. All other species can synthesize their own ascorbic acid from alpha ketogluconic acid.

Effects of haemodilution with fluorocarbons or dextran on oxygen tensions in the acutely ischaemic myocardium

The effect of haemodilution with dextran or with oxygen transporting fluorocarbons (Fluosol-DA 20%) on myocardial oxygen tension (PmO2) during experimental myocardial ischaemia was studied in pigs. Polarographic oxygen microelectrodes were introduced 3 mm to the left ventricle wall and the distal one-third of the left anterior descending coronary artery (LAD) was occluded. Anaesthesia was maintained with 0.5% halothane in oxygen to ensure maximal oxygen content of the fluorocarbons. The animals were divided into three groups of five animals each. In group I no treatment was given and in groups II and III, after bleeding 20 ml kg-1, haemodilution was performed with Fluosol-DA 20% or 5% dextran respectively. Occlusion of the LAD caused no significant changes in cardiovascular vascular variables and only in group III (dextran) were significant effects of haemodilution observed. LAD occlusion caused highly significant decreases in PmO2. After haemodilution, PmO2 in the Fluosol group II (in contrast to groups I and III) was no longer significantly different from pre-occlusion values. After 5 h of occlusion, mean PmO2 in this group had returned to 92.2% of the pre-occlusion values, whereas in groups I and III it was 27.8% and 33.7%, respectively.

Transperitoneal oxygenation with fluorocarbons

This work investigated the improvement of arterial oxygenation in hypoxic rats during peritoneal perfusion with the oxygen-carrying perfluorocarbon blood substitute FC43. Three groups of six Wistar rats were ventilated with hypoxic gas mixtures to obtain an arterial oxygen tension (PaO2) of approximately 55 mm Hg. Two groups were subjected to peritoneal perfusion at 20 ml/min with oxygenated FC43 or the gelatine solution Haemaccel. A third group was sham operated but not perfused. In both perfused groups PaO2 increased significantly, more so in the FC43 group. Carbon dioxide tensions significantly decreased only in the FC43 group. Significant increases in arterial oxyhemoglobin saturation were seen after 15 min in the FC43 group and after 60 min in the Haemaccel group. More than 15% of oxygen consumption could be delivered by peritoneal perfusion with FC43.

Effect of intrathecal and intracarotid administration of ketamine on blood pressure and heart rate in rats

Intrathecal and intracarotid effects of ketamine were investigated in anaesthetized rats. Ketamine was administered in the subarachnoid space in doses ranging from 300 to 1500 micrograms X kg-1. In these doses ketamine produced a short-lasting hypotension and bradycardia which may be due to inhibition of sympathetic outflow from thoraco-lumbar region. On the other hand when ketamine (5 mg X kg-1) was injected into the cerebral circulation it produced a rise in blood pressure and heart rate, probably through a cholinergic mechanism.