Damage to physicians' gloves during “routine” cardiac catheterization: An underappreciated occurrence

AbstractRecently, concern for the protection of health care employees and health care recipients has led to increasing awareness of transmitted infections. However, it is evident that damage of barrier methods of controlling infection can occur and go undetected. In a prospective study conducted from January 13, 1989 through February 15, 1989, 100 sequential pairs of gloves (200 gloves) worn during routine pediatric cardiac catheterizations were evaluated for punctures. A control group of 25 pairs of unused physicians' gloves was also evaluated for the presence of spontaneous leakage.In the 25 pairs of unused gloves (50 gloves), no punctures were detected, whereas in the 200 gloves worn during the catheterization procedures, punctures were found in 38 gloves or 19% (p < 0.001). When comparing the frequency of punctures with respect to the digits, 81% of the punctures were detected within the thumb and index finger of the gloves. In the majority of instances, physicians describe stopcock manipulation as the cause of the punctures. Implication of the stopcock as a possible mechanism for glove damage can be isolated to the stop mechanism on the stopcock pivot.Although surgeons' gloves are worn in many procedures besides surgery, no previous studies have defined the incidence of glove punctures during these procedures. Recommendations include a redesign of the stopcock as a protective measure and immediate change of latex surgeons' gloves whenever damage is suspected

In acute lung injury, inhaled nitric oxide improves ventilation-perfusion matching, pulmonary vascular mechanics, and transpulmonary vascular efficiency

AbstractAcute respiratory distress syndrome continues to be associated with significant morbidity and mortality related to ventilation-perfusion mismatch, pulmonary hypertension, and right ventricular failure. It has been suggested that inhaled nitric oxide, which is a selective pulmonary vasodilator, may be effective in the treatment of acute respiratory distress syndrome; however, the effects of nitric oxide on cardiopulmonary interactions are poorly understood. We therefore developed a model of acute lung injury that mimics the clinical syndrome of acute respiratory distress syndrome. In our model, inhaled nitric oxide significantly reduced pulmonary artery pressure, pulmonary vascular resistance, and pulmonary vascular impedance. In addition, inhaled nitric oxide improved transpulmonary vascular efficiency and ventilation-perfusion matching, which resulted in increased arterial oxygen tension. Although arterial oxygen tension increased, oxygen delivery did not improve significantly. These data suggest that by improving ventilation-perfusion matching and arterial oxygen tension while lowering pulmonary vascular resistance and impedance, nitric oxide may be beneficial in patients with acute respiratory distress syndrome. However, additional measures to enhance cardiac performance may be required. ( J THORAC CARDIOVASC SURG 1995;110: 593-600

Doppler assessment of pulmonary artery flow patterns and ventricular function after the Fontan operation

To assess the relation between ventricular systolic and diastolic function and pulmonary artery (PA) flow patterns after the Fontan operation, 15 postoperative patients were prospectively evaluated with echocardiography. Blood flow velocities in the PA were recorded with pulsed Doppler echocardiography. Ejection fraction was measured by 2-dimensional echocardiography using Simpson's rule. Indexes of diastolic function were measured from the systemic atrioventricular valve inflow Doppler and included peak E and A velocities, peak filling rate normalized for stroke volume, the fractions of filling in early and late diastole (E and A area fractions), and the E/A velocity and area ratios. Compared with 15 age-matched control subjects, the 15 patients who had undergone the Fontan procedure had decreased peak E velocity (0.65 +/- 0.20 vs 0.87 +/- 0.10 m/s), decreased E/A velocity ratio (1.29 +/- 0.23 vs 1.98 +/- 0.46), decreased normalized peak filling rate (6.09 +/- 0.90 vs 6.81 +/- 0.83 s-1), decreased E area fraction (0.63 +/- 0.09 vs 0.72 +/- 0.07), increased A area fraction (0.37 +/- 0.07 vs 0.24 +/- 0.06), and decreased E/A area ratio (1.77 +/- 0.45 vs 3.33 +/- 1.15) (p &lt; 0.05). These diastolic filling abnormalities are consistent with impaired ventricular relaxation and decreased early diastolic transvalvular pressure gradient. PA Doppler recordings showed 2 distinct patterns of flow. Pattern I, observed in 9 patients, showed biphasic forward flow with peak velocities in mid to late systole and middiastole. Pattern II, observed in the remaining 6 patients, showed decreased systolic forward flow, a late systolic to early diastolic flow reversal, and delayed onset of diastolic forward flow. Compared with pattern I patients, pattern II patients had no significant differences in any of the Doppler indexes of diastolic function; however, pattern II patients had a significantly tower ejection fraction (43 +/- 9 vs 57 +/- 5%). Thus, many patients undergoing the Fontan procedure have impaired ventricular relaxation, but, in the presence of a normal ejection fraction, biphasic forward PA flow is maintained. With the development of decreased ejection fraction, atrial systolic filling pressures are likely increased, the ventricular suction effect is decreased, and PA flow is diminished or absent in systole and early diastole.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29071/1/0000106.pd

Long-term assessment of right ventricular diastolic filling in patients with pulmonic valve stenosis successfully treated in childhood

Patients with severe pulmonic stenosis (PS) have right ventricular (RV) diastolic filling abnormalities detectable by tricuspid valve pulsed Doppler examination. To determine if these abnormalities persist long term after successful therapy of PS, 19 patients were examined 8 +/- 3 years after PS therapy. At the time of follow-up Doppler examination, the PS gradient was 15 +/- 8 mm Hg. From the tricuspid valve inflow Doppler study, the following measurements were obtained at peak inspiration: peak velocities at rapid filling (peak E) and during atrial contraction (peak A), ratio of peak E to peak A velocities, RV peak filling rate normalized for stroke volume, deceleration time, the fraction of filling in the first 0.33 of diastole as well as under the E and A waves, and the ratio of E to A area. Data from PS follow-up patients were compared with our previously reported data from 12 age-related control subjects and 14 untreated patients with PS. Patients with PS who were followed up had higher peak E velocity (0.75 +/- 0.14 vs 0.59 +/- 0.21 m/s), lower peak A velocity (0.47 +/- 0.09 vs 0.64 +/- 0.28 m/s), higher E/A velocity ratio (1.65 +/- 0.33 vs 1.11 +/- 0.52), higher 0.33 area fraction (0.52 +/- 0.08 vs 0.34 +/- 0.14), lower A area fraction (0.29 +/- 0.06 vs 0.45 +/- 0.21) and higher E/A area ratio (2.48 +/- 0.82 vs 1.73 +/- 1.05) than PS patients without treatment (p &lt; 0.03). All Doppler indexes of the patients with PS who were followed up were the same as those of the control subjects except for the peak E velocity that was slightly higher (0.75 +/- 0.14 vs 0.63 +/- 0.11 m/s), the peak A velocity that was slightly higher (0.47 +/- 0.09 vs 0.38 +/- 0.09 m/s) and the E/A area ratio that was slightly lower (2.48 +/- 0.82 vs 3.50 +/- 1.25) (p &lt; 0.03). Thus, at long-term follow-up, all RV diastolic filling indexes in successfully treated patients with PS improved compared with the untreated patients and approached values found in normal subjects. These data suggest that RV diastolic filling abnormalities in patients with PS are reversible over the long term and are therefore probably related to hypertrophy rather than fibrosis and scarring.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29164/1/0000209.pd

Echocardiographic detection of pericardiocentesis-induced subepicardial and intramyocardial hematoma

Pericardiocentesis has been widely used to relieve significant pericardial effusion and, in most cases, can be performed safely and without complications. We describe a rare complication of pericardiocentesis not previously reported in a pediatric patient. The crucial role of 2-dimensional echocardiography in the detection of this rare complication is illustrated.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27750/1/0000143.pd

Inhaled nitric oxide, right ventricular efficiency, and pulmonary vascular mechanics: Selective vasodilation of small pulmonary vessels during hypoxic pulmonary vasoconstriction

AbstractObjective: In the setting of acute pulmonary artery hypertension, techniques to reduce right ventricular energy requirements may ameliorate cardiac failure and reduce morbidity and mortality. Inhaled nitric oxide, a selective pulmonary vasodilator, may be effective in the treatment of pulmonary artery hypertension, but its effects on cardiopulmonary interactions are poorly understood. Methods: We therefore developed a model of hypoxic pulmonary vasoconstriction that mimics the clinical syndrome of acute pulmonary hypertension. Inhaled nitric oxide was administered in concentrations of 20, 40, and 80 ppm. Results: During hypoxic pulmonary vasoconstriction, the administration of nitric oxide resulted in a significant improvement in pulmonary vascular mechanics and a reduction in right ventricular afterload. These improvements were a result of selective vasodilation of small pulmonary vessels and more efficient blood flow through the pulmonary vascular bed (improved transpulmonary vascular efficiency). The right ventricular total power output diminished during the inhalation of nitric oxide, indicating a reduction in right ventricular energy requirements. The net result of nitric oxide administration was an increase in right ventricular efficiency. Conclusion: These data suggest that nitric oxide may be beneficial to the failing right ventricle by improving pulmonary vascular mechanics and right ventricular efficiency. (J Thorac Cardiovasc Surg 1997;113:1006-13

Pulsed Doppler assessment of left ventricular diastolic filling in children with left ventricular outflow obstruction before and after balloon angioplasty

To assess left ventricular (LV) diastolic filling in children with pressure overload hypertrophy, 12 patients with LV outflow obstruction (7 with aortic valve stenosis and 5 with aortic coarctation) and 12 healthy, age-matched control subjects were examined. Each child underwent M-mode echocardiography and pulsed Doppler examination of the LV inflow. The patients with LV outflow obstruction had cardiac catheterization and balloon angioplasty. Their echo/Doppler examinations were performed in the catheterization laboratory before and immediately after balloon angioplasty. From the M-mode echocardiogram, the LV cavity dimensions and wall thicknesses, LV mass and shortening fraction were measured. The following measurements were made from the Doppler recording: peak velocities at rapid ventricular filling (peak E) and during atrial contraction (peak A), ratio of peak E to peak A velocities, total area under the Doppler curve, percent of the total Doppler area occurring in the first one-third of diastole (0.33 area fraction), percent of the total area occurring under the E wave (E area fraction), percent of the total area occurring under the A wave (A area fraction) and the ratio of E area to A area.Before balloon angioplasty, the patients with LV outflow obstruction had higher peak E velocity (1.06 +/- 0.18 vs 0.88 +/- 0.11 m/s, p &lt; 0.01), higher peak A velocity (0.86 +/- 0.22 vs 0.47 +/- 0.08 m/s, p &lt; 0.01) and lower E/A velocity ratio (1.29 +/- 0.27 vs 1.93 +/- 0.34, p &lt; 0.01) than the normal subjects. In the patient group, 0.33 area fraction was significantly lower (0.38 +/- 0.07 vs 0.57 +/- 0.09, p &lt; 0.01) and A area fraction was significantly higher (0.44 +/- 0.14 vs 0.23 +/- 0.07, p &lt; 0.01) than in the normal subjects. Also, patients with LV outflow obstruction had greater LV wall thickness, smaller LV cavity dimensions and greater LV mass compared with normal subjects. In patients before and after balloon angioplasty, there was a significant decrease in LV outflow gradient (64 +/- 23 vs 33 +/- 22 mm Hg, p &lt; 0.01), but there was no change in any echo/Doppler measurement. Thus, children with LV outflow obstruction have abnormal LV early diastolic relaxation with a shift in filling toward late diastole. Immediately after successful relief of the systolic pressure overload, diastolic filling patterns are unchanged, suggesting that hypertrophy rather than afterload mismatch is the primary determinant of the impaired relaxation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/28087/1/0000533.pd