Device-based impedance measurement is a useful and accurate tool for direct assessment of intrathoracic fluid accumulation in heart failure.

AIMS: Heart failure patients are often equipped with implanted devices and are frequently hospitalized due to volume overload. Reliable prediction of imminent fluid congestion has the potential to provide early detection of cardiac decompensation and therefore might be capable of enhancing therapy management. We investigated whether implant-based impedance (Z) measurement is closely correlated with directly assessed extravascular lung water and might thus be useful for patient monitoring. METHODS AND RESULTS: In sheep, pulmonary fluid congestion was induced. Continuous haemodynamic monitoring was performed and extravascular lung water index (EVLWI) assessed. An implanted device with a right ventricular lead measured Z using different electrode configurations. All animals developed gradual pulmonary fluid accumulation leading to inclining lung oedema: EVLWI did increase from 9.5 +/- 1 to 21.1 +/- 5.1 mL/kg (+127%). A concomitant decrease of Z by up to 23%, depending on the electrode configuration, was observed and regression analysis between Z and EVLWI yielded a significant inverse correlation. CONCLUSION: Changes of Z show a strong inverse correlation with changes of directly measured EVLWI. This allows the application of Z as a measure of intrathoracic fluid status and has the potential to optimize patient care, especially in the context of evolving telemedicine concepts.

Transvaginal ultrasonographic assessment of Hyskon or lactated Ringer's solution instillation after laparoscopy: randomized, controlled study.

We sought to evaluate two common fluids placed in the pelvis after pelvic surgery for their ability to remain in the pelvis for a time thought adequate for prevention of adhesions. Thirteen patients undergoing operative laparoscopy were randomized to receive 250 ml 32% dextran 70 (Hyskon), 250 ml lactated Ringer's solution, or no fluid (control) at the end of surgery. Serial transvaginal ultrasonograms were obtained at 1 hr, 3 hr, 6 hr, 24 hr, 96 hr (4 days), and 168 hr (7 days) after surgery. Patients were asked about side effects of fluid instillation. The volume of lactated Ringer's solution declined rapidly after instillation, with no significant difference from control at 24 hr (12 ml versus 7 ml). The volume of Hyskon did not decline rapidly by 24 hr and remained higher than the volume in controls or those receiving lactated Ringer's solution (188 ml, P = 0.003). Although the volume of Hyskon remained higher than that of lactated Ringer's solution or fluid volume in control patients by days 4 and 7, this difference did not reach statistical significance (45 ml versus 7 ml and 14 ml respectively, P = 0.39, on day 4). Patients in all groups noted abdominal pain. One patient who received Hyskon developed severe vulvar edema and another developed dyspnea. We conclude that the volume of Hyskon in the peritoneal cavity after laparoscopy does not decline as rapidly as does that of lactated Ringer's solution; however, significant side effects may limit its usefulness. Transvaginal ultrasonography is useful in monitoring fluids placed in the pelvis for prevention of adhesions.

Combined drug therapy with diltiazem, dextran, and hydrocortisone (DDH therapy) for late cerebral vasospasm after aneurysmal subarachnoid hemorrhage: assessment of efficacy and safety in an open clinical study.

Late cerebral vasospasm after subarachnoid hemorrhage (SAH) is a disastrous phenomenon for the patients and a definite treatment has not been established. We studied 48 consecutive patients receiving high-dose diltiazem (5 micrograms/kg/min) injection combined with dextran and hydrocortisone to late cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). All but 2 patients underwent surgery within 72 hours after SAH. Diltiazem was continuously given via a central venous line for up to 2 weeks in conjunction with simple cisternal drainage. 5% of dextran solution (500 ml/day) was infused for 7-10 days. Hydrocortisone was given 1,600 mg on the first day, then the dose was gradually decreased over 14 days. Symptomatic vasospasm (SVS) occurred in 5 patients (10.4%), 4 patients recovered, but 1 had severe neurological deficit. A low density area on CT-scan was observed in 2 patients. Thirty patients (62.5%) had good recovery, 10 patients (20.8%) had moderate disability, 3 (6.3%) had severe disability and 3 (6.3%) had vegetative survival. Two patients died of the initial brain damage. There were no severely hypotensive side effects. However, 3 patients showed atrioventricular blockage on electrocardiogram. These side effects subsided after the dose of the drug was decreased or administration was stopped altogether. These findings show that high-dose calcium antagonist diltiazem therapy combined with dextran and hydrocortisone injection is safe and effective for prevention of late cerebral symptomatic vasospasm after SAH.

Effectiveness and safety of low molecular weight heparins (LMWH) in the prevention of venous thromboembolism (VTE).

Several recently published clinical trials have shown that prophylaxis against postoperative venous thromboembolism with LMWHs is justified on the basis of proven efficacy, safety, better patient acceptability and saving of nursing time. The cost effective analyses also indicate substantial savings can be achieved by using LMWHs, particularly in the high-risk patients. It is believed that emphasis is now on the clinicians who must protect all high-risk patients.

Use of plasma volume expanders in myocardial revascularisation.

The optimal solution for priming cardiopulmonary bypass machines and for postoperative resuscitation following myocardial revascularisation should be inexpensive, free of risk of transmitting disease, and free of other detrimental side effects. Colloid solutions are preferred over crystalloid solutions because of elevations in extracellular sodium and water that occur with cardiopulmonary bypass. Albumin, plasma protein solution, hetastarch (hydroxyethyl starch) and dextran are available for use if blood is not necessary and mediastinal blood is not available. Hetastarch is associated with a lower risk of bleeding and less risk of allergic reaction than dextran, and its cost is substantially less than that of albumin. However, high doses increase the risk of bleeding complications.

Hemodilución isovolémica con plasma en el accidente cerebrovascular isquémico agudo / Isovolemic hemodilution with plasma in acute ischemic stroke

Para evaluar la utilidad de la hemodilución isovolémica con plasma (HIP) en el accidente cerebrovascular isquémico agudo (ACIA) estudiamos 20 pacientes de los dos sexos y sin límite de edad randomizados en 2 grupos, hemodilución (GH) n=10 y control (GC) n=10, con 2 criterios de inclusión: 1)presentar un defecto neurológico agudo de origen isquémico de menos de 48 hs de evolución, y 2) tener hematocrito de 39 a 555. el defecto neurológico se evaluó simple ciego mediante 2 escalas ad hoc (tabla I) al ingreso, al 6to. día y a los 3 meses de ingreso. En todos se efectuó TC cerebral al ingreso. La hemodilución se realizó con el propio plasma de los pacientes (excepto la primera) de acuerdo al hematocrito de cada día durante 5 días o hasta que éste descendía a 38%. Los grupos fueron comparables según sexo, edad, factores de riesgo, horas de evolución y hematocrito inicial (tabla3). No hubo diferencias significativas entre los grupos en los puntajes de las evaluaciones, GH vs GC: 1ra 39,2+11,21 vs 39,1+11,85 (p 0,20), 2da 39,6+14,2 vs 44,8+5,5 (p 0,10-0,25) y 3ra 48,1+18,1 vs 54,2+6,1 (p 0,10-0,25). Ocurrieron 3 muertes, dos en el GH y una en el GC. Nuestros resultados son coincidentes con otros ensayos donde se usó dextrán 40, que a diferencia del plasma posee propiedades antitrombóticas y un mayor poder expansor que induce una hemodilución moderadamente hipervolémica. Creemos que nuestro estudio probaría la ineficacia de la hemodilución isovolémica pura para mejorar el ACIA