J.Jpn. Surg. Soc.. 61(7): 915-922, 1960
宿題報告
PREVENTION AND TREATMENT OF THE POSTOPERATIVE ACUTE PULMONALY EDEMA
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Department of Surgery, Keio University School of Medicine Shichiro ISHIKAWA |
Based on the referring statistical and clinical observations, and on the animal experiments done in the resent 6 years, pathophysiology, methods of the early diagnosis and practical treatment were discussed from the clinical standpoints.
The most important pathophysiology is the disturbances in the cardiopulmonary functions. The impaired cardiorespiratory functions in the early stages may be summarized into the following 3 points, such as (1) decreased effective ventilation, (2) anoxemia, and (3) precapillary pulmonary hypertension. The cardiac index decreases after its temporarily increase in the early stages. Decrease in cardiac index, increase in total pulmonary vascular resistance, and in pulmonary arteriolar resistance may develop into the overloading on the right side of the heart, which may lead the right heart failure.
The early diagnosis of the pulmonary edema is life-saving. X-ray examination and electric stethoscope may be available for the purpose. The most reliable method is the observation of the dye dilution curves. The electrophotometric methods and oxymetric methods may also be helpful to detect the impaired cardiopulmonary dynamics in every stages of the pulmonary edema.
The treatment should be concentrated on the improvement of the anoxemia and of the pulmonary hypertension. IPPB/I with oxygen inhalation, positive negative pressure breathing, administration of the steloid hormones, PAM(2-pyridine aldoxime methiodide), various pressure-controlling agents or ganglion-blocking agents, and the extracorporeal circulation were performed for the purpose of the treatment clinicaly or experimentally. Steroid hormones, PAM, and hesperidin were administered to depress the hyperosmobility in the pulmonary capillary bed. The combined administration of those referring 3 medicine may be effective, but the complete effects of the treatment could not be expected.
Remarkable effects were observed in IPPB/I with oxygen inhalation. But the effect of this treatment was uncertain in cases with pulmonary edema accompanying the cardiac decompensation. Significant effects of the positive negative pressure breathing were observed. Mechanical breathing was performed by the Stephenson type respirator after the intravenous administration of SCC. Those mechanical breathing therapy may depress the pulmonary hypertension and imporve the anoxemia as well as the impaired alveolar ventilation.
The extracorporeal circulation was applied on the experimentally induced postoperative acute pulmonary edema of Jordan's grade IV. The speaker will only to the cardiopulmonary by-pass method, as the best one of 4 types of the extracorporeal circulation studied. In this method the venesected blood from the superior- and inferior vena cava was infused, using the Sigma-motor pump, into the bilateral femoral arteries after oxygenated by the bubble oxygenator of Lillehei-DeWall type. Under the optimum rate of infusion (60 cc/kg/min) elevation of the arteaial oxygen saturation, depression of the abnormally elevated pulmonary arterial pressure were observed. The vicious cycle was effectively cut down to maintain the well-balanced circulatory dynamics even after the cessation of the circulation. Among 19 dogs treated by the referring cardiopulmonary by-pass method, 11 dogs were recovered, 6 were improved, and only 2 dog were not improved.
For the complete treatment of the postoperative acute pulmonary edema, considerations should be given to the pathophysiological specificity of the original pulmonary disorders and to some characteristics of the surgical procedures, which may act as the direct trigger, as well as the pathophysiological pictures of the acute pulmonary edema itself. The speaker will refer to these dispositions in the last part of the speach.
The dispositions in the acute pulmonary edema after any surgical procedures of pulmonary tuberculosis are the pre-existing ventilatory impairment and the overloading of the right heart. The dispositions in the acute pulmonary edema after the surgical procedures of lung cancer may be significant when the pneumonectomy is done. If the preoperative unilateral occlusion testing of the pulmonary arteries revealed any signs of the overloading of the right heart, the complete precausions should be paid for the pulmonary edema. The dispositions in the cardiac surgeries may be taken into consideration if any long-standing pulmonary hypertention be existed. In such cases with significant pulmonary hypertension the fibrotic thickening of the alveolar wall, the appearance of the "cardiac failure cell" in the alveolar spaces, the disturbances of the extracellular lymphatic passages, and the intimal thickening of the pulmonary arteriolar vessels may be seen. It is very scarce to arise the postoperative acute pulmonary edema after the surgical procedures of any cardiac diseases which do not accompany such as disorders in their lungs. Any specific dispositions in any oesophageal or abdominal surgeries could not be revealed.
It is important to understand the facts that the postoperative acute pulmonary edema may easily developed if any causual factors of the pulmonary edema be existed in addition to the referred specific disposition of the original disorders and of the surgical procedures.
(Author's abstract)
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