Cortisol and antidiuretic hormone responses to stress in cardiac surgical patients.

The hormonal responses to anaesthesia and cardiac surgery were studied in patients undergoing valve or coronary bypass surgery. Marked increases in antidiuretic hormone levels as a result of surgical stress were seen, and were of approximately equal magnitude in both groups. Although both groups also showed marked increases in plasma cortisol levels in response to operations, this response appeared to be relatively blunted in valve surgery patients, especially at the end of operation and in the intensive care unit. This blunted cortisol response may be a manifestation of exhaustion of adrenocortical reserves in valvular surgical patients whose sympathoadrenal system has already been chronically stimulated by a low output state. The important role of the neuroendocrine system in maintaining homeostasis postoperatively has long been recognized; this relative cortisol deficiency may be aetiologically related to poor postoperative recovery in critically ill valvular surgery patients.

Arterial hypoxemia in patients with anterior and posterior nasal packings.

Previous clinical reports indicate that nasal packing is frequently associated with arterial hypoxemia. Anesthesia and surgery in hypoxemic patients can be hazardous, especially when it is associated with acute blood loss. Nine patients with severe epistaxis, who failed to respond to anterior and posterior nasal packing, were anesthetized for emergency internal maxillary artery ligation. Arterial blood-gas and pH changes during the procedure were evaluated. The results indicate some degree of arterial hypoxemia and high alveolar/arterial PO2 difference without significant change in PaCO2 and pH in most of the patients observed. Arterial PO2 was within normal range 24 hours after operation. The anesthetic management is described and the various causes of such arterial hypoxemia are reviewed. It is important to recognize the presence of arterial hypoxemia and treat accordingly during surgery for such patients.

Cardiac index and incidence of heart failure cells.

Inverse correlations were established between the percentage of iron-laden macrophages (heart-failure cells), found in the sputum of patients with various types of heart ailment, and cardiac index. Less than 2% iron-laden macrophages were seen when cardiac index was in the region of 3 liter/min/sq mm of body surface area (BSA). This fraction increased to approximately 75% when the cardiac index attained 1 liter/min/sq mm of BSA. Since there was noticeable heterogeneity of data when the cardiac index was below 3 liters/min/sq mm of BSA and above 1 liter/min/sq mm of BSA, it was concluded that a second factor was probably at play: this was the degree of activity of the reticuloendothelial system of the subjects concerned.

Tracheobronchial cytologic changes and abnormal serum heme pigments in hemorrhagic shock.

Significantly elevated numbers of iron laden histiocytes have been shown to appear in the tracheobronchial secretions of subjects in hemorrhagic shock and in patients undergoing open heart-surgery during cardiopulmonary bypass (3,4). Abnormal heme pigments have also been demonstrated in the serum of dogs bled to hemorrhagic shock (6) and have been felt to be toxic. Because the ingestion of abnormal heme pigments by histiocytes may be part of a defense mechanism, we have attempted to correlate the percentage of iron laden histiocytes found in the tracheobronchial secretions of patients in hemorrhagic shock (Prussian blue method) with the presence of degradation of products of hemoglobin found in their serum by scanning spectrophotometry. There were, generally speaking, few iron laden histiocytes when hemoglobin degradation was advanced, and always numerous iron laden histiocytes when abnormal heme pigments were absent or spectrophotometric findings revealed minor degrees of degradation. Our findings probably reflect the process in the reticuloendothelial systems which eliminates toxic products accumulating in the circulation in low-flow states.

Addiction, alcoholism, and anesthesia.

The two major groups of drug abusers are hard drug addicts and alcoholics. Pulmonary disease and hepatic dysfunction are common in both groups. Choice of anesthetic agents for drug abusers centers around associated illnesses and their severity. The alcoholic often needs vitamin therapy and sedation, but attempting to change drug habits in the face of an acute illness is dangerous. An organized plan of approach is more important than choice of therapeutic agent.

Bronchial cytologic changes during cardiopulmonary bypass: iron transport by histiocytes in low flow states.

We previously reported (1) that tracheobronchial secretions of patients in hemorrhagic shock contained significantly more iron laden histiocytes than secretions of matched controls and demonstrated by histiologic studies in rats bled to hemorrhagic shock that these animals' lungs contained significantly more iron laden histiocytes than those of a control group. Two explanations appeared plausible: 1) abnormal hemoglobin breakdown products of systemic hypoperfusion during shock (2, 3, 5) may have accumulated in the pulmonary circulation where they were phagocytozed by pulmonary histiocytes, or 2) circulating iron laden histiocytes may have been arrested in the lung, which is well known to act as a filter during low-flow states (4). The present study reports on assay of bronchial secretions of 12 open-heart surgery patients under cardiopulmonary bypass from specimens obtained 1) immediately after onset of anesthesia; 2) during; and 3) after termination of cardiopulmonary bypass. The percentage of iron laden histiocytes rose from 15.6+/-6.0 after intubation, to 49.6+/-6.8 after 1 hour on bypass with occluded pulmonary arteries (p less than 0.0025), remaining close to the latter value after pulmonary circulation was restored. Hypoperfusion, accumulation of metabolites, or falling pH at the tissue level are probable explanations for these findings.

Tracheobronchial and pulmonary cytologic changes in shock.

Smears were made from tracheobronchial washings of patients undergoing general endotracheal anesthesia for surgery. Morphologically abnormal histiocytes were noticed in specimens obtained from subjects during hemorrhagic shock. These cells were overloaded with Papanicolaou stain (a greenish orange compound) which compressed the nucleus against the cell membrane. Cytochemical staining methods were undertaken to discover the composition of this substance. In secretions suctioned from ten patients in shock, large numbers of histiocytes were found to have ingested inorganic iron detectable by the Prussian blue method. Only two patients from a matched control group had smears in which this phenomenon was discovered. The maximum proportion of histiocytes containing Prussian blue granules was 40% for patients in shock and only 2% in normal controls. Histologic studies conducted on rats submitted to hemorrhagic shock were carried out to investigate this phenomenon. Iron-laden histiocytes were found in the kidneys, spleen, and lungs of both shocked and control animals. However, substantially more histiocytes containing Prussian blue positive granules were discovered in the lungs of rats in shock than in controls. It may, therefore, be that iron is deposited in the lungs in low flow states.

Tracheobronchial epithelial multinucleation in malignant disease.

Multinucleated tracheobronchial ciliated epithelial cells seen in smears from 112 patients suffering from a wide variety of malignant tumors were found to be 2.08 times more numerous than in a control group comparable in sex, age (decades), and smoking habit but without prediagnosed malignancies. The recognition of this phenomenon may lead to the development of a new test for the diagnosis of occult cancer and may open new pathways for investigation of cancer-host relationships.

Electrocution in the operating room.

PIP: The manner in which a patient sustained an electrical shock injury from improperly wired equipment during the course of an operation was described in order to acquaint others with a potentially hazardous situation. A patient requiring surgical treatment had the ground plate of an electrocautery unit placed under her buttocks and the electrodes of an EKG unit attached to her shoulders and her precordium. During the course of the operation, the EKG monitor was subject to electrical interference. In an effort to correct the problem, the surgeon instructed the nurse to unplug the monitor and reinsert the plug into a 2nd wall receptable. As the plug was reinserted, the physician suffered a minor shock and the patient experienced an intense shock. She became cyanotic and her pulse stopped. The patient was revived and later recovered completely. Inspection of the equipment revealed that the EKG's power plug was incorrectly wired. The chassis ground was connected to the neutral plug instead of the ground plug. Furthermore, the 2nd wall receptacle was wired with reversed polarity. When the plug was inserted into the 2nd receptacle, a 110 volt alternating current developed between the precoidal EKG lead and the ground plate. If the monitor had been plugged into the 2nd receptacle prior to the operation, the monitor would not have functioned. The technician probably would have assumed that the machine was not in working order and would have substitued another machine. In order to minimize electrical shocks, EKG leads should be applied only to the extremities and not to the precordium region.^ieng