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Nitric Oxide

MARK FORREST trauma-list@trauma.org
Thu, 18 Jul 2002 01:08:09 +0100 

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Dear Keith,
These cardiac shunts can be significant in raised intrathoracic =
pressures, pulmonary hypertension and raised right heart pressures. I =
have seen PFOs demonstrated on ECHO  with agitated saline, by use of =
valsalva, in divers who have developed decompression illnessand signs of =
gas embolisation without any provocative dive profile but obviously =
breathing compressed gas and exerting themselves. Remember that such =
defects can occur in 25-30% of the population.=20

I often wish that we could ECHO 'at risk' patients on the ITU for =
shunts, but they are usually too critical to be introducing 'agitated =
saline' and the cardiologists are never keen to lend us their TOE!

How significant these shunts can be I do not know and have never read =
any relevant publications, but acute treatment must be to reduce right =
sided pressures and possible raise left sided (keep afterload high) =
which may be difficult in septic patients with low SVRI. As Dr Segal =
suggests, NO should help but we have never monitored it's use this way.

Regards
Mark F=20
  ----- Original Message -----=20
  From: Keith D. Lamb=20
  To: Dr segal eran ; trauma-list@trauma.org ; =
RC_WORLD@LISTSERV.IUPUI.EDU ; ccm-l@list.pitt.edu=20
  Sent: Wednesday, July 17, 2002 10:25 PM
  Subject: Re: Nitric Oxide


  Are there any treatments for this other than reducing right heart =
pressures? Is the resultant effect of this shunt on oxygenation worth =
worrying about?

  Keith

  Keith D. Lamb RCP, RRT
  Charge Respiratory Therapist
  Christiana Care Hospital
  Newark, Delaware
    ----- Original Message -----=20
    From: Dr segal eran=20
    To: 'Keith D. Lamb' ; trauma-list@trauma.org ; =
RC_WORLD@LISTSERV.IUPUI.EDU ; ccm-l@list.pitt.edu=20
    Sent: Wednesday, July 17, 2002 5:23 AM
    Subject: RE: Nitric Oxide


    Keith,

    Patients who develop pulmonary hypertension and a  shift in atrial =
pressures will  develop a shunt. This is to be expected in some 20% of =
those patients with severe lung injury who develop increased PAP =
(probably 20% of the 30% with elevated PAP) . Thus it is not very often. =


    Its very easy to demonstrate even with a TTE if you can get a =
reasonable 4 chamber view. We inject echo contrast (20 ml of vigorously =
shaken (not stirred) colloid) and see whether the bubbles can be =
observed in the left side.

    There is a fantastic image in one of the Vincent meeting books in a =
chapter written by JJ Rouby which shows the shunt and how it disappears =
when NO is given to the patient. =20

    Eran

    =20

    =20

    Eran Segal, MD

    Director

    General ICU

    Sheba Medical Center

    Israel

    Phone: 972-3-5302793

    Fax: 972-3-5354293

    =20



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<DIV><FONT face=3DArial size=3D2>Dear Keith,</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>These cardiac shunts can be significant =
in raised=20
intrathoracic pressures, pulmonary hypertension&nbsp;and raised right =
heart=20
pressures. I have seen PFOs demonstrated on ECHO&nbsp; with agitated=20
saline</FONT><FONT face=3DArial size=3D2>,&nbsp;by use of =
valsalva,&nbsp;in divers=20
who have developed decompression illnessand signs of gas=20
embolisation&nbsp;without any provocative dive profile&nbsp;but=20
obviously&nbsp;breathing compressed gas and exerting themselves. =
Remember that=20
such defects can occur in 25-30% of the population. </FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>I often wish that we could ECHO 'at =
risk' patients=20
on the ITU for shunts, but they are usually too critical to be =
introducing=20
'agitated saline' and the cardiologists are never keen to lend us their=20
TOE!</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>How significant these shunts can be I =
do not know=20
and have never read any relevant publications, but acute treatment must =
be to=20
reduce right sided pressures and possible raise left sided (keep =
afterload high)=20
which may be difficult in septic patients with low SVRI.&nbsp;As Dr =
Segal=20
suggests, NO should help but we have never monitored it's use&nbsp;this=20
way.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Regards</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Mark&nbsp;F</FONT>&nbsp;</DIV>
<BLOCKQUOTE dir=3Dltr=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Dkdlamb@prodigy.net href=3D"mailto:kdlamb@prodigy.net">Keith =
D. Lamb</A>=20
  </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3De_segal@sheba.health.gov.il=20
  href=3D"mailto:e_segal@sheba.health.gov.il">Dr segal eran</A> ; <A=20
  title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> ; <A =

  title=3DRC_WORLD@LISTSERV.IUPUI.EDU=20
  =
href=3D"mailto:RC_WORLD@LISTSERV.IUPUI.EDU">RC_WORLD@LISTSERV.IUPUI.EDU</=
A> ; <A=20
  title=3Dccm-l@list.pitt.edu=20
  href=3D"mailto:ccm-l@list.pitt.edu">ccm-l@list.pitt.edu</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, July 17, 2002 =
10:25=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: Nitric Oxide</DIV>
  <DIV><BR></DIV>
  <DIV><FONT face=3DArial>Are there any treatments for this other than =
reducing=20
  right heart pressures? Is the resultant effect of this shunt on =
oxygenation=20
  worth worrying about?</FONT></DIV>
  <DIV><FONT face=3DArial></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial>Keith</FONT></DIV>
  <DIV><FONT face=3DArial></FONT>&nbsp;</DIV>
  <DIV>Keith D. Lamb RCP, RRT<BR>Charge Respiratory =
Therapist<BR>Christiana Care=20
  Hospital<BR>Newark, Delaware</DIV>
  <BLOCKQUOTE dir=3Dltr=20
  style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
    <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
    <DIV=20
    style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
    <A title=3De_segal@sheba.health.gov.il=20
    href=3D"mailto:e_segal@sheba.health.gov.il">Dr segal eran</A> </DIV>
    <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dkdlamb@prodigy.net=20
    href=3D"mailto:kdlamb@prodigy.net">'Keith D. Lamb'</A> ; <A=20
    title=3Dtrauma-list@trauma.org=20
    href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> ; =
<A=20
    title=3DRC_WORLD@LISTSERV.IUPUI.EDU=20
    =
href=3D"mailto:RC_WORLD@LISTSERV.IUPUI.EDU">RC_WORLD@LISTSERV.IUPUI.EDU</=
A> ;=20
    <A title=3Dccm-l@list.pitt.edu=20
    href=3D"mailto:ccm-l@list.pitt.edu">ccm-l@list.pitt.edu</A> </DIV>
    <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, July 17, =
2002 5:23=20
    AM</DIV>
    <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> RE: Nitric =
Oxide</DIV>
    <DIV><BR></DIV>
    <DIV class=3DSection1>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: =
Arial">Keith,<o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">Patients =
who=20
    develop pulmonary hypertension and <SPAN class=3DGramE>a <SPAN=20
    style=3D"mso-spacerun: yes">&nbsp;</SPAN>shift</SPAN> in atrial =
pressures will=20
    <SPAN style=3D"mso-spacerun: yes">&nbsp;</SPAN>develop a shunt. This =
is to be=20
    expected in some 20% of those patients with severe lung injury who =
develop=20
    increased PAP (probably 20% of the 30% with elevated PAP<SPAN =
class=3DGramE>)=20
    .</SPAN> Thus it is not very often. <o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><SPAN class=3DGramE><FONT face=3DArial =
color=3Dnavy=20
    size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: =
Arial">Its</SPAN></FONT></SPAN><FONT=20
    face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial"> very =
easy to=20
    demonstrate even with a TTE if you can get a reasonable 4 chamber =
view. We=20
    inject echo contrast (20 ml of vigorously shaken (not stirred) =
colloid) and=20
    see whether the bubbles can be observed in the left=20
    side.<o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: Arial">There is =
a=20
    fantastic image in one of the Vincent meeting books in a chapter =
written by=20
    JJ Rouby which shows the shunt and how it disappears when NO is =
given to the=20
    patient. <SPAN=20
    style=3D"mso-spacerun: =
yes">&nbsp;</SPAN><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: =
Arial">Eran<o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: =
Arial"><o:p>&nbsp;</o:p></SPAN></FONT></P>
    <P class=3DMsoNormal><FONT face=3DArial color=3Dnavy size=3D2><SPAN=20
    style=3D"FONT-SIZE: 10pt; COLOR: navy; FONT-FAMILY: =
Arial"><o:p>&nbsp;</o:p></SPAN></FONT></P>
    <DIV>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><FONT face=3D"Times New Roman" color=3Dnavy =
size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: yes">Eran=20
    </SPAN></FONT><st1:place><st1:City><FONT color=3Dnavy><SPAN =
dir=3Dltr=20
    style=3D"COLOR: navy; mso-no-proof: =
yes">Segal</SPAN></FONT></st1:City><FONT=20
    color=3Dnavy><SPAN dir=3Dltr style=3D"COLOR: navy; mso-no-proof: =
yes">,=20
    </SPAN></FONT><st1:State><FONT color=3Dnavy><SPAN dir=3Dltr=20
    style=3D"COLOR: navy; mso-no-proof: =
yes">MD</SPAN></FONT></st1:State></st1:place><FONT=20
    color=3Dnavy><SPAN dir=3Dltr=20
    style=3D"COLOR: navy; mso-no-proof: =
yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><FONT face=3D"Times New Roman" color=3Dnavy =
size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: =
yes">Director</SPAN><SPAN=20
    lang=3DHE style=3D"mso-no-proof: yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><FONT face=3D"Times New Roman" color=3Dnavy =
size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: yes">General=20
    ICU</SPAN><SPAN lang=3DHE=20
    style=3D"mso-no-proof: yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><st1:place><st1:PlaceName><FONT face=3D"Times New =
Roman"=20
    color=3Dnavy size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: =
yes">Sheba</SPAN></FONT></st1:PlaceName><FONT=20
    color=3Dnavy><SPAN dir=3Dltr style=3D"COLOR: navy; mso-no-proof: =
yes">=20
    </SPAN></FONT><st1:PlaceName><FONT color=3Dnavy><SPAN dir=3Dltr=20
    style=3D"COLOR: navy; mso-no-proof: =
yes">Medical</SPAN></FONT></st1:PlaceName><FONT=20
    color=3Dnavy><SPAN dir=3Dltr style=3D"COLOR: navy; mso-no-proof: =
yes">=20
    </SPAN></FONT><st1:PlaceType><FONT color=3Dnavy><SPAN dir=3Dltr=20
    style=3D"COLOR: navy; mso-no-proof: =
yes">Center</SPAN></FONT></st1:PlaceType></st1:place><FONT=20
    color=3Dnavy><SPAN lang=3DHE=20
    style=3D"COLOR: navy; mso-no-proof: =
yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><st1:country-region><st1:place><FONT face=3D"Times New =
Roman"=20
    color=3Dnavy size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: =
yes">Israel</SPAN></FONT></st1:place></st1:country-region><FONT=20
    color=3Dnavy><SPAN lang=3DHE=20
    style=3D"COLOR: navy; mso-no-proof: =
yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><FONT face=3D"Times New Roman" color=3Dnavy =
size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: yes">Phone:=20
    972-3-5302793</SPAN><SPAN lang=3DHE=20
    style=3D"mso-no-proof: yes"><o:p></o:p></SPAN></FONT></P>
    <P class=3DMsoAutoSig dir=3Drtl=20
    style=3D"DIRECTION: rtl; unicode-bidi: embed; TEXT-ALIGN: left"=20
    align=3Dright><FONT face=3D"Times New Roman" color=3Dnavy =
size=3D3><SPAN dir=3Dltr=20
    style=3D"FONT-SIZE: 12pt; COLOR: navy; mso-no-proof: yes">Fax:=20
    972-3-5354293</SPAN><SPAN lang=3DHE=20
    style=3D"mso-no-proof: yes"><o:p></o:p></SPAN></FONT></P></DIV>
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