- Critical Care Medicine
Professor - Med Center Line, Anesthesiology, Perioperative and Pain Medicine
Associate Medical Director, Intensive Care Units, Stanford University Medical Center (1979 - 2005)
Co-Director, Intensive Care Units, Stanford University Medical Center (2005 - Present)
Anesthesia CCM fellowship Program Director, Stanford University Medical Center (2005 - Present)
Chief, Division of CCM, Dept of Anesthesiology, Perioperative and Pain Medicine (2005 - 2012)
Chief, Division of CCM, Dept of Anesthesiology, Perioperative and Pain Medicine (2015 - Present)
Medical Education:Saint Louis University School of Medicine (1974) MO
Internship:USC/LAC Medical Center (1975) CA
Residency:UCI Medical Center (1976) CA
Residency:Stanford University Medical Center (1978) CA
Fellowship:Stanford University Medical Center (1979) CA
Fellowship:Massachusetts General Hospital (1979) MA
Board Certification: Anesthesia, American Board of Anesthesiology (1981)
Board Certification: Critical Care Medicine, American Board of Anesthesiology (1987)
Community and International Work
Anesthesia for Exotic Animal Species
San Francisco/San Diego Zoo, Gorilla Foundation
Opportunities for Student Involvement
Overseas Medical Outreach
Opportunities for Student Involvement
Current Research and Scholarly Interests
Dr. Mihms two areas of research interest involve cardiorespiratory monitoring techniques and applications and the perioperative management of patients with pheochromocytoma.
- Independent Studies (5)
Graduate and Fellowship Programs
Critical Care Medicine (Fellowship Program)
Malignant Pheochromocytoma Presenting as Incapacitating Bony Pain
2012; 12 (4): 286-289
Among adrenal incidentalomas, pheochromocytomas are rare. Malignant pheochromocytoma is even less common, and it typically presents with classic hormonal symptoms, such as palpitations, labile blood pressures, and headaches. Bony metastasis usually occurs late in disease, but we report an unusual case of incapacitating bony pain as the initial presentation of malignant pheochromocytoma. Our patient is a 70-year-old woman with neurofibromatosis type 1 and a history of primary hyperparathyroidism, who tested negative for the ret mutation. She came to medical attention with chest pain and palpitations and was incidentally found to have an adrenal mass. Serum and urine testing was consistent with pheochromocytoma. Her blood pressure was easily controlled as she awaited elective adrenalectomy; however, she quickly developed severe, diffuse bony pain. She represented with hypercalcemia, spontaneous fractures, and incapacitating pain that required such high doses of pain medications that she had to be intubated. Further imaging and bone marrow biopsy confirmed metastatic neuroendocrine tumor. She received one round of chemotherapy with no change in her bony pain, which was her primary complaint. Unfortunately, her treatment options were limited by the heavy sedation required for comfort, and in the end, it was her bony pain rather than hormonal symptoms that made her disease untreatable.
View details for DOI 10.1111/j.1533-2500.2011.00499.x
View details for Web of Science ID 000302468900004
View details for PubMedID 21884564
The Effects of Respiratory Failure on Delivery in Pregnant Patients With H1N1 2009 Influenza
OBSTETRICS AND GYNECOLOGY
2010; 115 (5): 1033-1035
The majority of hospitalizations for H1N1 complications have been in people with high-risk comorbidities, including pregnancy. Here we describe the obstetric and critical care treatment of three patients with confirmed H1N1 influenza virus infection complicated by acute respiratory failure.We describe the clinical and therapeutic courses of three patients with confirmed H1N1 2009 influenza virus infection complicating singleton, twin, and triplet gestations, each of which were complicated by respiratory failure.These three cases illustrate that a high index of suspicion, prompt treatment, timing and mode of delivery considerations, and interdisciplinary treatment are integral to the care of pregnant patients with H1N1 influenza infections complicated by acute respiratory failure.
View details for DOI 10.1097/AOG.0b013e3181da85fc
View details for Web of Science ID 000277185800022
View details for PubMedID 20410779
Catecholamine-Secreting Paragangliomas: Recent Progress in Diagnosis and Perioperative Management
SKULL BASE-AN INTERDISCIPLINARY APPROACH
2009; 19 (6): 377-385
Catecholamine-secreting paragangliomas (CSPs) present challenges for the managing team of surgeons and anesthesiologists. Without proper preoperative management and planning, the patient is at high risk for complications and significant morbidity. A review of the literature looking at all aspects of the care of patients with CSP was performed to provide a consensus on the comprehensive care of these difficult patients. A case study is also provided to illustrate the management algorithm. Specific recommendations are made with regards to preoperative workup, including serum and urine testing, tumor localization, angiography, and embolization. Preoperative and intraoperative management techniques by the surgical and anesthesiology teams are discussed, including pharmaceutical interventions and fluid management. Aspects of postoperative care are also discussed. Management of patients with CSP requires significant attention to detail by a multidisciplinary team of surgeons and anesthesiologists. By following the recommendations included within this article, the morbidity associated with removal of these tumors can be significantly reduced or eliminated.
View details for DOI 10.1055/s-0029-1224771
View details for Web of Science ID 000271904200001
View details for PubMedID 20436839
- Unexpected findings during the anesthetic management of a patient with a cardiac paraganglioma JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA 2008; 22 (4): 570-572
- Blood pressure control with fenoldopam during excision of a pheochromocytoma ANESTHESIOLOGY 1999; 91 (2): 558-560
- Pheochromocytoma: decreased perioperative mortality Anesthesiology Clinics of North America 1998; 16 (3): 645-62
- SHORT-ACTING BETA-ADRENERGIC-BLOCKADE AS INITIAL-DRUG THERAPY IN PHEOCHROMOCYTOMA CRITICAL CARE MEDICINE 1990; 18 (6): 673-674
PULSE OXIMETRY AND END-TIDAL CO2 MONITORING OF AN ADULT ASIAN ELEPHANT
JOURNAL OF ZOO ANIMAL MEDICINE
1988; 19 (3): 106-109
View details for Web of Science ID A1988U793700002
- Anesthetic management of a parturient with VACTERL association undergoing Cesarean delivery CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE 2013; 60 (6): 570-576
Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature.
Annals of intensive care
2013; 3 (1): 32-?
We report a case of propofol infusion syndrome (PRIS) in a young female treated for status epilepticus. In this case, PRIS rapidly evolved to full cardiovascular collapse despite aggressive supportive care in the intensive care unit, as well as prompt discontinuation of the offending agent. She progressed to refractory cardiac arrest requiring emergent initiation of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR). She regained a perfusing rhythm after prolonged (>8 hours) asystole, was weaned off ECMO and eventually all life support, and was discharged to home. We also present a review of the available literature on the use of ECMO for PRIS.
View details for DOI 10.1186/2110-5820-3-32
View details for PubMedID 24059786
- Questioning Diuretic Use in Acute Negative-pressure Pulmonary Edema ANESTHESIOLOGY 2011; 114 (2): 461-461
- Ultrasound-Guided Internal Jugular Vein Cannulation NEW ENGLAND JOURNAL OF MEDICINE 2010; 363 (8): 796-796
Combined endovascular and open operative approach for mycotic carotid aneurysm
JOURNAL OF VASCULAR SURGERY
2010; 51 (6): 1514-1516
Mycotic aneurysms of the extracranial carotid artery are rare and warrant surgical intervention. Management involves open and endovascular approaches. We report the case of a 67-year-old woman with an Escherichia coli soft-tissue infection of the right retropharyngeal space and subsequent mycotic carotid aneurysm and thrombosis of the internal jugular vein. The patient presented with a pulsatile mass and right middle cerebral artery stroke. Our surgical management involved coil embolization of the aneurysm to provide for vascular control, with resection of the common carotid artery, internal carotid artery, and extracranial carotid artery branches, along with the internal jugular vein.
View details for DOI 10.1016/j.jvs.2009.12.067
View details for Web of Science ID 000277974200026
View details for PubMedID 20304585
A Hemodynamic Profile for Consciousness During Cardiopulmonary Resuscitation
ANESTHESIA AND ANALGESIA
2009; 109 (5): 1598-1599
We report the quantification of a hemodynamic profile sufficient to support consciousness during cardiopulmonary resuscitation. A 62-yr-old man experienced cardiac arrest while being evaluated for heart failure after heart transplantation. During the emergency, hemodynamic data were obtained from bedside monitors and reviewed at regular intervals. His mean arterial blood pressure and heart rate were correlated with consciousness during cardiopulmonary resuscitation. A mean arterial blood pressure of 50 mm Hg with a heart rate of 100 bpm supported consciousness during cardiac arrest. This case helps to validate the recent emphasis on hard, fast, basic life support.
View details for DOI 10.1213/ANE.0b013e3181b89432
View details for Web of Science ID 000271032500040
View details for PubMedID 19843796
Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation
Euroanaesthesia 2004 Meeting
WILEY-BLACKWELL PUBLISHING, INC. 2006: 646–50
This study examines the incidence and site of tracheal tube impingement during nasotracheal fibreoptic intubation, and the efficacy of anticlockwise tube rotation to overcome the problem. Forty-three patients underwent fibreoptic-assisted nasotracheal intubation using a preformed nasal tube, and a second fibrescope was used to observe any obstruction to passage of the tracheal tube. Impingement occurred in 10 cases, with the most common site being the right arytenoid cartilage. Rotation resulted in successful intubation in all 10 cases, but proximal rotation did not always result in an equal degree of rotation at the tube tip. We conclude that the site of impingement for nasotracheal intubation with preformed nasal tubes is located at the posterior structures of the laryngeal inlet and that anticlockwise rotation is a simple and effective solution.
View details for DOI 10.1111/j.1365-2044.2006.04652.x
View details for Web of Science ID 000238914200005
View details for PubMedID 16792609
Measurement of cardiac output by transpulmonary arterial thermodilution using a long radial artery catheter. A comparison with intermittent pulmonary artery thermodilution
2004; 59 (6): 590-594
Cardiac output can be measured accurately by transpulmonary arterial thermodilution using the PiCCO (Pulsion Medical Systems, Munich, Germany) system with a femoral artery catheter. We have investigated the accuracy of a new 50 cm 4 French gauge radial artery catheter and the ability to use the system with a shorter radial catheter. We studied 18 patients who had undergone coronary artery surgery and made three simultaneous measurements of cardiac output by arterial thermodilution and with a pulmonary artery catheter. The radial catheter was withdrawn in 5 cm increments and the measurements were repeated. We found close agreement between arterial thermodilution and pulmonary artery thermodilution with a mean (SD) bias of 0.38 (0.77) l x min(-1). Arterial thermodilution became unreliable once the catheter had been withdrawn by more than 5 cm. We conclude that cardiac output measurement with arterial thermodilution with a radial catheter is interchangeable with that derived from a pulmonary artery catheter, and that a centrally sited arterial catheter is required for accurate determination of cardiac output by transpulmonary arterial thermodilution.
View details for Web of Science ID 000221401500011
View details for PubMedID 15144300
Laparoscopic management of bladder pheochromocytoma.
2001; 57 (2): 365-?
Pheochromocytoma primarily involving the bladder is an uncommon pathologic finding. Patients may present with transient hypertension associated with palpitations and diaphoresis on micturition. A case of bladder pheochromocytoma treated by laparoscopic partial cystectomy is presented. The management principles of bladder pheochromocytoma for our specific case are discussed. Successful treatment requires that the correct diagnosis and tumor location be made in conjunction with the obligatory preoperative preparation of the patient.
View details for PubMedID 11182363
- Continuous cardiac output catheters - Delay in in vitro response time after controlled flow changes ANESTHESIOLOGY 1998; 89 (6): 1592-1595
A multicenter evaluation of a new continuous cardiac output pulmonary artery catheter system
CRITICAL CARE MEDICINE
1998; 26 (8): 1346-1350
To validate a new system of continuous cardiac output monitoring.Multicenter, prospective, nonrandomized clinical study.Four university hospitals.Forty-seven adult intensive care unit patients.Pulmonary artery catheterization.Continuous and bolus cardiac output measurements were obtained over 72 hrs. The 327 continuous cardiac output measurements compared favorably with bolus cardiac output measurements (bias = 0.12 L/min, precision = +/-0.84). The continuous cardiac measurement was not adversely affected by temperatures of <37 degrees C or >38 degrees C, high (>7.5 L/min) or low (<4.5 L/min) cardiac output values, or duration (72 hrs) of the study.This continuous cardiac output system provides a reliable estimate of cardiac output for clinical use if applied in conditions similar to this study. The combination of a continuous measure of cardiac output with other continuous physiologic monitoring (arterial and mixed venous oxygen saturation, oxygen consumption, etc.) may provide important information that no single parameter could achieve.
View details for Web of Science ID 000075423800016
View details for PubMedID 9710092
- Failure of steroid supplementation to prevent operative hypotension in a patient receiving chronic steroid therapy ANESTHESIA AND ANALGESIA 1996; 82 (6): 1294-1296
RECOVERY OF CARDIOPULMONARY REFLEXES IN MONKEYS UNDERGOING HEART-LUNG TRANSPLANTATION
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
1989; 98 (4): 510-516
After heart-lung transplantation in primates, cardiopulmonary reflexes were tested and shown to be present. The Hering-Breuer and cough reflexes were tested, as well as responses to an inhaled respiratory stimulant, vasodilator, and an intravenous anticholinesterase and antimuscarinic agent. Recovery of these responses, except to the anticholinesterase agent, suggests that reinervation occurs in autotransplanted organs in primates. The Hering-Breuer reflex was present at 1.9 and 2.2 months after the operation in two animals subjected to autotransplantation. These cardiopulmonary reflex responses were also demonstrated in two allograft recipients studied at 15 and 16.9 months after the operation. Return of protective reflexes such as coughing may be an important mechanism to prevent aspiration pneumonitis and other complications in humans.
View details for Web of Science ID A1989AU11400005
View details for PubMedID 2796358
DIAGNOSIS OF A VENTRICULAR SEPTAL-DEFECT IN A GORILLA USING INVIVO OXIMETRY
JOURNAL OF ZOO AND WILDLIFE MEDICINE
1989; 20 (2): 199-202
View details for Web of Science ID A1989AL91800010
EXTRA-ADRENAL PHEOCHROMOCYTOMA - AN UNUSUAL LOCATION
JOURNAL OF PEDIATRIC SURGERY
1988; 23 (11): 1045-1047
A 14-year-old boy with a retrohepatic para-aortic pheochromocytoma demonstrates the potential difficulties of localization in an unusual extra-adrenal site of pheochromocytoma. Ultrasonography, computed tomography, metaiodobenzylguanidine scanning, and angiography with venous sampling failed to define the true anatomic location of this tumor. Collateral venous drainage produced confusing venous sampling data and represents a potential pitfall in the interpretation of these studies.
View details for Web of Science ID A1988Q843100025
View details for PubMedID 3244086
EFFECT OF HEPARINIZATION OF CATHETERS ON PULMONARY-ARTERY OXIMETRY
JOURNAL OF CLINICAL MONITORING
1988; 4 (3): 204-209
A clinical study was performed in two phases to determine whether pulmonary artery oximeter catheters that were impregnated or bonded with heparin would affect the accuracy of measurements of in vivo mixed venous oxygen saturation (Sv-O2). In phase 1, 40 patients were catheterized with either a heparin-impregnated or a plain pulmonary artery catheter. Blood was sampled at random times to correlate in vivo with in vitro Sv-O2 measurements. In phase 2, 16 patients who were not receiving systemic heparin therapy or aspirin and who had no coagulopathies were catheterized with either a heparin-bonded or a plain pulmonary artery catheter in a blinded order. In phase 1, a total of 364 blood samples were obtained from 40 patients. Linear regression analysis of the pooled data demonstrated y = 0.98x - 0.01, r = 0.93, P less than 0.001, and n = 141 with heparin-impregnated catheters; and y = 0.87x + 8.0, r = 0.81, P less than 0.001, and n = 223 with plain catheters. The mean difference (in vivo minus in vitro) revealed a similar error (-1.3 +/- 0.4 versus -1.4 +/- 0.4, respectively, mean +/- SE). The 95% confidence limits of an individual value (+/- 8.1 versus +/- 12.3) suggested slightly greater accuracy with heparin-impregnated catheters. In phase 2, a total of 134 blood samples were obtained from 16 patients. Linear regression analysis showed nearly equal performance with heparin-bonded and plain catheters (r = 0.97 versus r = 0.98, respectively) with similar slopes (1.0 versus 1.1, respectively) but different intercepts (-0.6 versus -8.4, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1988P442000007
View details for PubMedID 3210068
PULMONARY EFFECTS OF CRYSTALLOID AND COLLOID RESUSCITATION FROM HEMORRHAGIC-SHOCK IN THE PRESENCE OF OLEIC ACID-INDUCED PULMONARY CAPILLARY INJURY IN THE DOG
1988; 68 (1): 12-20
The effects of resuscitation with crystalloid and colloid solutions in the presence of increased pulmonary capillary permeability were studied. Twenty-four hours after oleic acid administration, dogs were anesthetized and bled to produce hemorrhagic shock. One hour later, resuscitation was performed with saline, 5% albumin, or 6% hydroxyethyl starch solution to restore and then maintain cardiac output at pre-oleic acid values for 6 h. Dogs were recovered and, 24 h later, were reanesthetized for final measurements. Oleic acid administration resulted in increases in pulmonary artery pressure, pulmonary vascular resistance, and extravascular lung water (EVLW). Resuscitation from hemorrhagic shock restored pulmonary hemodynamics to pre-hemorrhage levels and did not affect EVLW, PaO2, shunt fraction, dead-space-to-tidal-volume ratio, or pulmonary compliance. There were no differences in these parameters related to the choice of resuscitation fluid. Saline resuscitation markedly reduced plasma oncotic pressure and the plasma oncotic-pulmonary artery occlusion pressure gradient. Values for these two variables were markedly lower with saline than with colloid resuscitation. The authors conclude that the pulmonary effects of crystalloid and colloid solutions are similar in the presence of moderate increases in pulmonary capillary permeability.
View details for Web of Science ID A1988L597700004
View details for PubMedID 3337363
Endotoxemia in rats--influence of lipoxygenase blocker versus leukotriene receptor antagonist (BW755C vs LY171883).
Progress in clinical and biological research
1988; 272: 283-292
View details for PubMedID 2839854
RAPID ASSESSMENT OF VENTILATION BY MEASUREMENT OF CARBON-DIOXIDE ELIMINATION DURING HIGH-FREQUENCY VENTILATION OF KITTENS
1987; 3 (6): 406-412
Monitoring of the effectiveness of ventilation is a significant problem during high-frequency ventilation (HFV). The time necessary to achieve equilibrium of the arterial tension of carbon dioxide (Paco2) following step changes in ventilation is appreciable, because of large body stores of CO2. Waiting for Paco2 to reach equilibrium is not only time-consuming but a potentially dangerous means of monitoring ventilator adjustments during HFV. Five kittens of mean +/- SD 1,082 +/- 383 gm weight were studied during HFV, both with normal lungs and lungs injured by saline lavage-induced surfactant depletion. The transcutaneous tension of carbon dioxide (Ptcco2) was monitored continuously to determine the time required to achieve equilibrium of Paco2 following a step change in ventilation. The rate of pulmonary CO2 elimination (VECO2) was measured immediately before and immediately after (less than 12 sec) step changes in ventilation and was used to predict the change in Paco2 achieved once equilibrium was reestablished. With normal lungs, equilibration time following step changes in ventilation was found to be approximately 20 minutes. After step decreases in ventilation of the injured lung, achieving equilibrium state took significantly longer, approximately 30 minutes. The Paco2 predicted was significantly related to the change in Paco2 achieved at equilibrium for both normal and injured lung studies. We concluded that direct monitoring of VECO2 during HFV may be a useful clinical monitoring technique, allowing rapid and accurate assessment of the efficiency of ventilation following step changes in ventilation and potentially assisting in optimizing ventilator settings.
View details for Web of Science ID A1987L110400004
View details for PubMedID 3122154
NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN ATELECTASIS
1987; 92 (4): 621-624
Nasal continuous positive airway pressure (CPAP) has been widely and safely used in the treatment of sleep disorders but has not been previously utilized for therapy of pulmonary atelectasis in adults. We observed three patients with significant atelectasis which was refractory to conventional chest physiotherapy. Bronchoscopy was not a viable therapeutic option in any patient. Therapy with continuous nasal CPAP was initiated at 10 to 15 cm H2O. The patients tolerated the therapy well and had prompt resolution of atelectasis. Nasal CPAP may be an effective modality for therapy of pulmonary atelectasis in spontaneously breathing patients, particularly when conventional therapies are not tolerated or are ineffectual.
View details for Web of Science ID A1987K327500012
View details for PubMedID 3308344
CARE OF THE ADULT PATIENT DURING TRANSPORT
INTERNATIONAL ANESTHESIOLOGY CLINICS
1987; 25 (2): 43-75
Interhospital transport of the critically ill patient involves maintaining the same quality of care that was present before transport. This requires planning for equipment, space, and personnel needs during transport, and instituting adequate pathophysiologically based treatment and stabilization prior to transport. Under such conditions, transport can be safely accomplished and have a positive impact on patient care.
View details for Web of Science ID A1987H793900004
View details for PubMedID 3301685
LEUKOTRIENE-D4 INCREASES EXTRAVASCULAR LUNG WATER IN THE DOG
1987; 21 (2): 121-128
The peptide leukotrienes have been detected in animals that have received endotoxin injections and also have been associated with patients suffering from the adult respiratory distress syndrome (ARDS). The ability of leukotriene D4 (LTD4) to cause pulmonary capillary permeability changes was investigated in ten anesthetized mongrel dogs. Four dogs were used as controls and six dogs received intravenous LTD4 (0.25 microgram/kg). There was a variable response in that two treated animals showed no apparent effect of LTD4. Analysis of the results from the remaining four treated animals demonstrated a significant increase in extravascular lung water (EVLW) that peaked 3 hr after LTD4 from 5.4 +/- 0.6 to 10.3 +/- 0.5 ml/kg (P less than .01). In these four dogs, EVLW increased before slight, but statistically significant, rises in pulmonary artery wedge pressure (4 +/- 1 to 9 +/- 1 mm Hg, P less than .01) and mean pulmonary artery pressure (13 +/- 1 to 17 +/- 1 mm Hg, P less than .01) occurred. During the same period, cardiac output decreased 56 +/- 7% (P less than .01), but no change in airway resistance was observed. This study is the first in vivo demonstration that LTD4 directly alters pulmonary fluid balance in the dog. We conclude LTD4 can cause increases in EVLW and may be an important mediator of the permeability changes observed in various clinical events that lead to the adult respiratory distress syndrome.
View details for Web of Science ID A1987G252100004
View details for PubMedID 3829327
Effect of the nonsteroidal antiinflammatory agent BW755C in rat and sheep endotoxemia.
Progress in clinical and biological research
1987; 236A: 347-359
View details for PubMedID 3112793
THERMAL DYE DOUBLE INDICATOR DILUTION MEASUREMENT OF LUNG WATER IN MAN - COMPARISON WITH GRAVIMETRIC MEASUREMENTS
1987; 42 (1): 72-76
The thermal dye double indicator dilution technique for estimating lung water was compared with gravimetric analyses in nine human subjects who were organ donors. As observed in animal studies, the thermal dye measurement of extravascular thermal volume (EVTV) consistently overestimated gravimetric extravascular lung water (EVLW), the mean (SEM) difference being 3.43 (0.59) ml/kg. In eight of the nine subjects the EVTV -3.43 ml/kg would yield an estimate of EVLW that would be from 3.23 ml/kg under to 3.37 ml/kg over the actual value EVLW at the 95% confidence limits. Reproducibility, assessed with the standard error of the mean percentage, suggested that a 15% change in EVTV can be reliably detected with repeated measurements. One subject was excluded from analysis because the EVTV measurement grossly underestimated its actual EVLW. This error was associated with regional injury observed on gross examination of the lung. Experimental and clinical evidence suggest that the thermal dye measurement provides a reliable estimate of lung water in diffuse pulmonary oedema states.
View details for Web of Science ID A1987F655400011
View details for PubMedID 3616974
ANESTHESIA FOR HEART-TRANSPLANTATION - A RETROSPECTIVE STUDY AND REVIEW
BRITISH JOURNAL OF ANAESTHESIA
1986; 58 (12): 1357-1364
The anaesthetic records of 261 heart transplant recipients were reviewed. Data collected included demographic characteristics, physical status, results of preoperative cardiac catheterization studies, anaesthetics agents and incidences of complications which may have been related to anaesthetic management. Forty-five patients received a volatile agent (methoxyflurane 31, enflurane 10, halothane 4) and 216 patients were anaesthetized with a high-dose narcotic technique (morphine 122, fentanyl 71, hydromorphone 14, meperidine 9). Hypotension and arrhythmias were correlated with use of volatile and narcotic anaesthetics, respectively. No mortality was associated with anaesthetic management.
View details for Web of Science ID A1986F026700004
View details for PubMedID 2878677
THE EFFECTS OF PROSTAGLANDIN-E1 ON THE ADULT RESPIRATORY-DISTRESS SYNDROME IN SEPTIC PRIMATES
AMERICAN REVIEW OF RESPIRATORY DISEASE
1986; 134 (5): 885-890
The effects of prostaglandin E1 (PGE1) on the adult respiratory distress syndrome were studied in the septic primate (Macaca fascicularis). A 30-min infusion of Escherichia coli (1 X 10(10)/kg) resulted in severe septic shock and adult respiratory distress syndrome. Primates, if living, were killed 4 h after completion of the E. coli infusion. Three groups of primates were studied (n = 4 in each group). The control group (Group 1) received PGE1 at 100 ng/kg/min throughout the experiment. The septic group (Group 2) received a 30-min infusion of E. coli. The treatment group (Group 3) received a continuous PGE1 infusion (100 ng/kg/min) along with the E. coli infusion which was begun 30 min after the PGE1 infusion was started. Control primates had hemodynamic changes consistent with the vasodilatory effect of PGE1 (heart rate and cardiac output increased; blood pressure and systemic vascular resistance (SVR) decreased). All control animals survived the experiment and had no evidence of pulmonary damage. Primates given E. coli developed severe hypotension, decreased SVR, and lung injury evidenced by pulmonary edema, decreased oxygenation, and increased extravascular lung water. Primates treated with both PGE1 and E. coli developed similar cardiovascular and pulmonary changes as the septic group. There was no statistically significant difference between Group 2 and Group 3 animals with regard to mean arterial blood pressure, SVR, extravascular lung water, alveolar-arterial oxygen difference, or survival.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1986E792100010
View details for PubMedID 3535596
THE THERMAL-DYE METHOD OF LUNG WATER MEASUREMENT IS RELIABLE AT A LOW CARDIAC-OUTPUT
JOURNAL OF SURGICAL RESEARCH
1986; 41 (3): 286-292
The measurement of lung water by the thermal-dye double indicator dilution technique was evaluated in dogs with normal and edematous lungs during a state of reduced cardiac output. The technique used cold indocyanine green dye to measure extravascular thermal volume (EVTV) as an estimate of extravascular lung water (EVLW). Anesthesia was maintained with pentobarbital. In 15 of 21 animals, pulmonary edema was first induced with oleic acid (0.75 to 0.18 ml/kg). Cardiac output (CO) was then decreased by a combination of propranolol and slow exsanguination (mean CO reduction to 36% of baseline). Extravascular lung water produced in this model ranged from 1.4 to 30.2 ml/kg. Predetermination measurements of EVTV correlated closely with EVLW as determined by gravimetric analysis (EVTV = 1.1 EVLW + 4.7 ml/kg, n = 21, r = 0.93, P less than 0.001). Thermodilution cardiac output measured in the abdominal aorta (used in the calculation of the EVTV) correlated well with simultaneous measurements of cardiac output by both indocyanine green dye dilution and pulmonary artery thermodilution (r = 0.86 and r = 0.88, respectively, pretermination). The thermal-dye technique appears to provide an accurate reflection of lung water in normal and edematous lungs, even in the presence of a low cardiac output.
View details for Web of Science ID A1986E203900010
View details for PubMedID 3762135
EFFECTS OF ANTI-C5A ANTIBODIES ON THE ADULT RESPIRATORY-DISTRESS SYNDROME IN SEPTIC PRIMATES
JOURNAL OF CLINICAL INVESTIGATION
1986; 77 (6): 1812-1816
In vitro and in vivo studies have suggested that human complement component C5a plays a key role in neutrophil injury in the adult respiratory distress syndrome (ARDS). First, using leukocyte aggregometry, we demonstrated that the addition of a recently developed rabbit anti-human polyclonal antibody to C5a des arg to endotoxin-activated plasma prevented leukocyte aggregation in vitro. We then administered the anti-C5a des arg antibody to septic primates (Macaca fascicularis). Three groups of primates, control, septic, and anti-C5a antibody treated septic, were studied (n = 4 in each group). A 30-min infusion of Escherichia coli (1 X 10(10)/kg) resulted in severe sepsis and ARDS. Primates were killed 4 h after completion of the E. coli infusion. Septic animals not treated with anti-C5a antibody had 75% mortality (3/4), decreased oxygenation, severe pulmonary edema, and profound hypotension. Septic primates treated with anti-C5a antibodies did not die and did not develop decreased oxygenation (P less than 0.05) or increased extravascular lung water (P less than 0.05). They also had a marked recovery in their mean arterial blood pressure (P less than 0.05). This study demonstrates that treatment with rabbit anti-human C5a des arg antibodies attenuates ARDS and some of the systemic manifestations of sepsis in nonhuman primates.
View details for Web of Science ID A1986C512700014
View details for PubMedID 3711336
HYPOTHERMIC PRESERVATION OF THE HEART AND LUNGS WITH COLLINS SOLUTION - EFFECT ON CARDIORESPIRATORY FUNCTION FOLLOWING HEART-LUNG ALLOTRANSPLANTATION IN DOGS
ANNALS OF THORACIC SURGERY
1986; 41 (3): 301-306
The effect of preserving the heart and lungs with hypothermia and Collins solution was studied in 13 mongrel dogs undergoing combined heart-lung transplantation. The five control animals who underwent an immediate transplant following Collins solution perfusion had small increases in extravascular lung water when measured 2.5 hours posttransplant as seen in a previous study. The eight animals who had hypothermic preservation following Collins solution perfusion had significantly higher extravascular lung water than controls (16.3 +/- 1.8 ml/kg in preserved animals; 11.2 +/- 1.7 ml/kg in controls p less than 0.05). The level of lung water reached at 2.5 hours postoperatively was similar to that reached with a previously reported, unacceptable preservation technique. Survival beyond this point was poor due to severe pulmonary edema. We conclude that the use of this solution, given under the experimental conditions which we describe, is not acceptable for hypothermic preservation of the heart and lungs for combined transplantation.
View details for Web of Science ID A1986A544400015
View details for PubMedID 3082303
OBSTRUCTIVE SLEEP-APNEA AND CARDIAC INDEX
1986; 89 (3): 331-334
Seventeen men (age range, 21 to 58 years) with severe obstructive sleep apnea syndrome (OSAS) documented by nocturnal polysomnography underwent hemodynamic investigations during sleep. We studied the evolution of the cardiac index during apneic events in both NREM and REM sleep using the thermodilution technique. Regardless of the patient's age, the sleep state, or the mechanism inducing the OSAS, the cardiac index decreased significantly from baseline during an apneic event and increased significantly from baseline at the resumption of ventilation.
View details for Web of Science ID A1986A297700007
View details for PubMedID 3948544
- LEUKOTRIENES IN PULMONARY-EDEMA FLUID AFTER CARDIOPULMONARY BYPASS ANESTHESIA AND ANALGESIA 1986; 65 (3): 306-308
- AN INTEGRATED CIRCUIT-BASED OPTICAL SENSOR FOR INVIVO MEASUREMENT OF BLOOD OXYGENATION IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING 1986; 33 (2): 98-107
NEW METHODS FOR WHOLE-BLOOD OXIMETRY
ANNALS OF BIOMEDICAL ENGINEERING
1986; 14 (1): 35-52
New techniques for determining the hematocrit (Hct) and oxygen saturation (SO2) of whole blood from backscattered light measurements are described. First, theoretical and experimental results are presented which show that the empirical linear relationship between SO2 and the infrared-red backscattered light intensity ratio on which previous instruments have been based is an inadequate description primarily because it does not account for the strong effects of Hct and transducer geometry. Then it is shown that the ratio of backscattered intensities from two appropriately positioned infrared sources can be plotted against the infrared-red intensity ratio to produce a family of calibration curves from which SO2 and Hct can be independently determined. Finally, a practical implementation of an oximetry system which employs a microelectronic catheter-tip optical sensor and a microprocessor-based signal processor is proposed.
View details for Web of Science ID A1986A915700003
View details for PubMedID 3706854
- NONINVASIVE DETECTION OF PROFOUND ARTERIAL DESATURATIONS USING A PULSE OXIMETRY DEVICE ANESTHESIOLOGY 1985; 62 (1): 85-87
PROSTAGLANDIN E-1 DOES NOT PREVENT THE ADULT RESPIRATORY-DISTRESS SYNDROME IN SEPTIC PRIMATES
AMER COLL CHEST PHYSICIANS. 1985: S19–S19
View details for Web of Science ID A1985ANG3400070
EFFECTS OF ANTI-C5A ANTIBODIES ON THE ADULT RESPIRATORY-DISTRESS SYNDROME IN SEPTIC PRIMATES
SLACK INC. 1985: A473–A473
View details for Web of Science ID A1985AEY9301880
FAILURE OF THE COLLOID ONCOTIC-PULMONARY ARTERY WEDGE PRESSURE-GRADIENT TO PREDICT CHANGES IN EXTRAVASCULAR LUNG WATER
CRITICAL CARE MEDICINE
1985; 13 (12): 1025-1028
Colloid oncotic pressure (COP), pulmonary artery wedge pressure (WP), and the COP-WP gradient were measured in seven critically ill adult patients and compared with extravascular lung water determined using the thermal-dye double-indicator dilution technique and a bedside lung water computer. Correlation coefficients for changes in extravascular lung water vs. COP, WP, and COP-WP were not significant, and in this patient population the COP-WP gradient did not predict changes in extravascular lung water.
View details for Web of Science ID A1985AWD4700008
View details for PubMedID 3905258
THE EFFECT OF HYPOTHERMIC PRESERVATION OF THE HEART AND LUNGS ON CARDIORESPIRATORY FUNCTION FOLLOWING CANINE HEART-LUNG TRANSPLANTATION
ANNALS OF THORACIC SURGERY
1985; 39 (6): 558-562
The effect of hypothermic preservation of the heart and lungs with a crystalloid solution was evaluated in 12 mongrel dogs receiving heart-lung allografts. Six animals served as controls and received an immediate heart-lung transplant. Six animals were in the experimental group and received a heart-lung transplant after 5 hours of preservation at 4 degrees C following perfusion of both organs with a crystalloid solution. Physiological function of the heart and lungs was studied for 20 hours after transplantation. While cardiac function was minimally depressed following preservation, pulmonary function testing demonstrated significantly greater increases in extravascular lung water in experimental animals, suggesting that an ischemic lung injury occurred with this preservation technique. The model allows for future evaluation of other methods of combined preservation of both the heart and lungs for transplantation.
View details for Web of Science ID A1985AJU9100014
View details for PubMedID 3923955
THERMODILUTION CARDIAC-OUTPUT MEASUREMENT - EFFECTS OF THE RESPIRATORY CYCLE ON ITS REPRODUCIBILITY
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1985; 253 (15): 2240-2242
Thermodilution cardiac output measurements are commonly employed in the management of critically ill patients. Serial measurements often show significant variation, and poor reproducibility limits their clinical utility. There are no clinical studies revealing when to perform thermodilution cardiac output measurements in relation to the respiratory cycle. We prospectively studied 32 patients in a randomized scheme comparing three thermodilution cardiac output measurements at peak-inspiration, at end-exhalation, or randomly in spontaneously breathing and mechanically ventilated patients. Saline injections initiated at peak-inspiration or end-exhalation resulted in cardiac output measurements with much smaller standard deviations than those seen with random injections. Thermodilution cardiac output measurements performed at random times in the respiratory cycle should be avoided, and we recommend initiating these measurements at end-exhalation.
View details for Web of Science ID A1985AFE4400026
View details for PubMedID 3974116
EVALUATION OF THE PORTABLE CHEST ROENTGENOGRAM FOR QUANTITATING EXTRAVASCULAR LUNG WATER IN CRITICALLY ILL ADULTS
1985; 88 (5): 649-652
The diagnosis of pulmonary edema is frequently made from characteristic findings on the chest roentgenogram that suggest an increase in lung water. Optimal radiographic technique depends on a cooperative upright patient, which is not possible with most critically ill patients. These patients may also have multiple radiographic abnormalities that make interpretation of the chest roentgenogram difficult. The ability of portable chest roentgenograms to accurately identify the presence of excess lung water and monitor changes in lung water has not previously been evaluated in critically ill adults who are intubated and ventilated and in the supine position when the films are exposed. In 12 patients the pulmonary edema seen on portable chest roentgenograms was given a score (0 to 390 points), which was then compared with a determination of extravascular lung water using the thermal-dye indicator dilution technique. A linear correlation was observed (r = 0.51; p less than 0.05; n = 73). Evaluation of a change in radiographic score vs a change in lung water showed no linear correlation (r = 0.1; p greater than 0.05). While portable chest roentgenograms exposed under the conditions described were a useful technique for demonstrating pulmonary edema, they were not accurate in monitoring modest changes in lung water in critically ill patients.
View details for Web of Science ID A1985ATP7200004
View details for PubMedID 3902385
INHIBITION OF THROMBUS FORMATION ON INTRAVASCULAR SENSORS BY ELECTRICAL-POLARIZATION
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH
1984; 18 (7): 797-807
Implantable biomedical sensors built on a silicon substrate capped with glass are currently being developed for intravascular applications. Electrical techniques for inhibiting thrombus formation on the surface of a proposed optical sensor in direct contact with blood have been investigated. Glass-on-silicon specimens (4 X 1.2 X 0.4 mm3) were coated with indium-tin oxide, a transparent conductor, and implanted in the vena cava and iliac veins of three dogs for 10, 20, or 33 days. The equilibrium surface-blood interface potentials of the specimens were modified by implanted current sources which supplied either direct current (8-15 microA) or 100 KHz alternating current (5 microA, root mean square). Light-microscopic and scanning electron-microscopic analyses showed each of the DC-polarized specimens to be free of thrombus, in contrast to nonpolarized (control) specimens on which varying amounts of adsorbed protein and thrombus deposits were found. Like the control specimens, the AC-polarized specimens formed thrombus, but the appearance of the deposits differed. These findings support the view that the polarity, magnitude and time dependence of the potential across conducting surface-blood interface significantly influence thrombogenicity. Further work is necessary to determine the roles of electrochemical and electrostatic factors in preventing thrombus formation on foreign materials.
View details for Web of Science ID A1984TK74700009
View details for PubMedID 6544780
LUNG WATER FOLLOWING RESUSCITATION WITH COLLOID AND CRYSTALLOID SOLUTIONS
WILLIAMS & WILKINS. 1984: 226–26
View details for Web of Science ID A1984SB26300074
ACUTE PHYSIOLOGICAL-CHANGES FOLLOWING HEART-LUNG ALLOTRANSPLANTATION IN DOGS
ANNALS OF THORACIC SURGERY
1984; 37 (6): 479-483
The feasibility of clinical heart-lung transplantation requires a better understanding of the physiological consequences of the operation, heart-lung denervation, and the quality of graft preservation. An acute canine model was used to evaluate heart-lung function during the first 24 hours after transplantation. Measurements of cardiopulmonary dynamics were performed in 5 donor animals and compared sequentially after transplantation in the respective recipients. Orthotopic allotransplantation was performed on cardiopulmonary bypass with moderate hypothermia after perfusion of both the heart and lung with a clinical cardioplegic solution (4 degrees C; potassium chloride, 30 mEq/L; mannitol, 20 gm/L). Postoperatively, the animals were ventilated continuously and anesthetized. Hemodynamic variables were monitored, and measurements were made of arterial and venous oxygen, carbon dioxide, saturation, and pulmonary mechanics. Cardiac output and a derived measurement of lung water were determined. Pulmonary vascular resistance, arteriovenous shunt, resistance, and compliance were calculated. At the termination of the experiment, significant differences were observed between donor and recipient lung-water levels (7.7 +/- 0.9 ml/kg versus 12.0 +/- 3.1 ml/kg, respectively; p less than 0.05); 100% arterial oxygen tension (509 +/- 37 mm/Hg versus 227 +/- 114 mm/Hg, respectively; p less than 0.01); and pulmonary compliance (38 +/- 18 ml/cm H2O versus 11 +/- 4 ml/cm H2O, respectively; p less than 0.05). Arteriovenous shunt increased from 12.2 +/- 4 to 16.5 +/- 5% (p = 0.2). This model evaluates the technique currently employed clinically and will be used in the future to compare methods of heart-lung preservation with the goal of allowing distant heart-lung procurement.
View details for Web of Science ID A1984SV28100008
View details for PubMedID 6428335
MONITORING END-TIDAL CARBON-DIOXIDE TENSIONS WITH HIGH-FREQUENCY JET VENTILATION IN DOGS WITH NORMAL LUNGS
CRITICAL CARE MEDICINE
1984; 12 (3): 180-182
The end-tidal carbon dioxide tension (PetCO2) measured after a single, large tidal-volume breath (15 ml/kg body weight) was compared to simultaneous measurements of PaCO2 in 6 dogs with normal lungs who were receiving high-frequency jet ventilation (HFJV). There was an excellent linear correlation between PetCO2 and the PaCO2 over the entire range of CO2 tensions commonly encountered in clinical practice (PetCO2 = 0.9 PaCO2 + 2.2 torr; n = 51, r = .98, p less than .001, range of PaCO2 = 12-72 torr). We conclude that when lung function is normal, a simple system of measuring PetCO2 after a large breath is an accurate method of monitoring the effectiveness of CO2 elimination during HFJV.
View details for Web of Science ID A1984SK11100005
View details for PubMedID 6421542
- HYPERTENSION AFTER INTRAOPERATIVE AUTO-TRANSFUSION IN BILATERAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA ANESTHESIOLOGY 1983; 58 (2): 182-184
- PULMONARY-ARTERY PRESSURE MONITORING IN PATIENTS WITH PHEOCHROMOCYTOMA ANESTHESIA AND ANALGESIA 1983; 62 (12): 1129-1133
- PULMONARY-ARTERY CATHETERS - THE SHAKE-FLICK TEST ANESTHESIOLOGY 1983; 59 (3): 262-263
PROLONGED TOXICITY OF ORGANO-PHOSPHATE POISONING
CRITICAL CARE MEDICINE
1982; 10 (8): 550-557
A case of poisoning with a new organophosphate (fenthion) is reported in which the initial cholinergic crisis was delayed 5 days and recurred 24 days after ingestion. Psychosis was a persistent and sometimes singular manifestation. Because of the high lipid solubility of this pesticide, toxin analysis of repeated fat biopsies was an essential component of the management of this patient.
View details for Web of Science ID A1982PB17100015
View details for PubMedID 7094603
EFFECT OF GRADED ADMINISTRATION OF PEEP ON LUNG WATER IN NON-CARDIOGENIC PULMONARY-EDEMA
CRITICAL CARE MEDICINE
1982; 10 (10): 667-669
The effect of graded application of positive end-expiratory pressure (PEEP) was studied in 10 mongrel dogs with pulmonary edema induced by oleic acid infusion. Six animals received progressive increases in PEEP (5 cm H2O) 120 min after the injection of oleic acid. These animals were compared to 4 control animals who did not receive PEEP. We found no difference between the 2 groups in lung water measured by a double indicator dilution technique during PEEP application. Lung water determined by gravimetric analysis was also not different between groups at the end of the experiment. PEEP did result in significant reductions in shunt fraction and alveolar-arterial oxygen tension difference suggesting that PEEP improves gas exchange in pulmonary edema by increasing lung volume, but not by altering lung water accumulation.
View details for Web of Science ID A1982PL42500010
View details for PubMedID 6749435
MEASUREMENT OF EXTRA-VASCULAR LUNG WATER IN DOGS USING THE THERMAL-GREEN DYE INDICATOR DILUTION METHOD
1982; 57 (2): 116-122
The measurement of extravascular lung water by a double-indicator dilution technique using cold indocyanine green dye was evaluated in dogs. Pulmonary edema was induced in 11 animals by volume overload; 12 animals served as controls. For each measurement, the two indicators (cold dye) were injected into the superior vena cava and detected in the femoral artery. The extravascular thermal volume was calculated using the mean transit times of the two indicator curves. Pretermination measurements of extravascular thermal volume correlated closely with standard gravimetric analysis of pulmonary extravascular tissue weight (EVTV - 1.15 PEW + 2.1 ml/kg, n = 21, r = 0.97, P less than 0.001; where EVTV = extravascular thermal volume and PEW = pulmonary extravascular tissue weight). Throughout the experiment, the arterial oxygen tension and alveolar-arterial oxygen tension gradient, correlated poorly with EVTV (linear correlation: r = 0.47, 0.45, respectively). The intrapulmonary shunt correlated better with EVTV (r = 0.72). Nonlinear correlation of EVTV with intravascular pressures (left ventricular filling pressures, colloid oncotic pressures, and the pulmonary artery occlusion pressure-colloid oncotic pressure gradient) were more significant than linear relationships. The critical pressures at which lung water rapidly increased in this model occurred at left ventricular filling pressures of 22-27 mmHg and at pulmonary artery occlusion pressure-colloid oncotic pressure gradients of 25-30 mmHg. The thermal dye technique appears to provide an accurate measurement of lung water changes in this pressure edema model.
View details for Web of Science ID A1982PF71000009
View details for PubMedID 7046519
- CHRONIC ALVEOLAR HYPOVENTILATION SECONDARY TO MACROGLOSSIA IN THE BECKWITH-WIEDEMANN SYNDROME PEDIATRICS 1982; 70 (5): 695-697
- PHARMACOKINETICS OF HIGH-DOSE THIOPENTAL USED IN CEREBRAL RESUSCITATION ANESTHESIOLOGY 1980; 53 (2): 169-171
THE LACK OF EFFECT OF VARIABLE BLOOD WITHDRAWAL RATES ON THE MEASUREMENT OF MIXED VENOUS OXYGEN-SATURATION
1980; 78 (3): 452-455
In a study of 12 critically ill patients, values for mixed venous oxygen saturation (SVO2) were measured from samples of pulmonary arterial blood drawn at five rates of withdrawal (1, 3, 10, 20, and 30 ml/min). Samples were drawn from properly placed pulmonary arterial catheters with the balloon deflated. Physiologic stability was documented at the beginning and end of the sampling period in all but one patient. Results in each patient demonstrated a close grouping of values for SVO2 obtained at the five rates of withdrawal (largest standard deviation, 1.9 percent). Evaluations by paired t-test comparing all rates of withdrawal with the slowest rate (1 ml/min) showed no significant differences. The rate of withdrawal of the sample is not associated with significant errors in SVO2 when samples are drawn from a properly positioned pulmonary arterial catheter.
View details for Web of Science ID A1980KG14700011
View details for PubMedID 7418464