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					                                           TO THE EDITOR

                                           together with rhinorrhea, otorrhea,                esting recent article by Gabel et al (1).
                                           and conjunctival edema. The patient                This work is similar to the report by
 Facial Paleness                           developed neurologic, renal, and car-              Jalowayski et a1 ( 2 ) ,published in 1968.
                                           diovascular complications after sur-               The older program is also written in
 To the Editor:
                                           gery and died on the 5th postopera-                “Fortran IV” and also has the advan-
    We recently encountered an unu-        tive day. Dalal and Patel (3) reported             tages of the “table-driven” technique
 sual complication in a 58-year-old        two cases of right-sided paleness with             described by Gabel et al. However,
 man having a coronary artery bypass       cardiopulmonary bypass attributed to               the older system will accept direct
 procedure during which a bloodless        carotid artery cannulation.                        PO, input data and corrects for fetal
 pump prime was used. As cardiopul-           Our report indicates an unusual                 hemoglobin oxygen saturation char-
 monary bypass was initiated, a right-     complication of open heart opera-                  acteristics. It appears that most of the
 sided unilateral facial paleness, last-   tions. It also emphasizes the necessity            basic physiologic references in the
 ing approximately 60 seconds, was         for continual observation of the pa-               older program are identical with those
 observed. The surgeons were notified      tient and the operative field by the               of the newer program. The older pro-
 and they thought the Sarns aortic can-    anesthesia team. Observation of the                gram also has the advantage of a tab-
 nula might be the cause. A thrill felt    paleness in the case we have de-                   ular output for large groups of results
 over the innominate artery disap-         scribed and subsequent repositioning               in addition to the individual patient
 peared when the cannula was reposi-       of the cannula by the surgeon, possi-              report format.
tioned. The patient had a left ho-         bly adverted further neurologic dam-                  Having used the older program for
monomous hemianopsia after surgery         age in the patient.                                a period of approximately 3 years
with no other neurologic problems.                                                            with large numbers of samples, I can
                                                 James W. Chapin, MD*
    It was felt that the aortic cannula                                                       attest to its accuracy, simplicity, and
had been placed in such a position               Patrick Nance, M D
                                                  Department of Anesthesiology                usefulness. I can provide copies of the
that the pump flow was preferentially                                                         program to interested readers free of
perfusing the right side of the head            John W. Yarbrough, M D
                                                  Department of Surgery                       charge.
through the innominate artery and
                                                  University of Nebraska Medical                     Bradley E. Smith, M D
that the clear pump prime caused the
transient paleness. This paleness                    Center                                           Department of Anesthesiology
cleared as the pump prime was then               Omaha, NE 68105                                     Vanderbilt University
mixed with the patient’s blood. Other                                                                   Medical Center
                                                           REFERENCES
possible causes of the neurologic se-                                                                Nashville, TN 37232
                                              Gutman FA, Zeggra H. Ocular complications
quelae could be emboli, hypoxia, or           in cardiac surgery. Surg Clin North Am                           REFERENCES
hypotension.                                  1971;51:1095-1103.                               1. Gabel RA, Hooper A, Marseglia    JJ Jr, Farese
                                              Ross WT, Lake CL, Wellons HA. Cardio-               G. Calculation and correction of blood-gas
   Gutman and Zeggra (1) at the               pulmonary bypass complicated by inadvert-           and acid-base variables with a versatile com-
Cleveland Clinic reviewed the ocular          ent carotid cannulation. Anesthesiology             puter program. Anesth Analg 1981;60:889-
complications of cardiac surgery for          1981;54:85-86.                                      96.
both myocardial revascularization             Dalal FY, Patel KO. Another sign of inad-        2. Jalowayski A, Lauterbach R, Smith BE, Mo-
                                              vertent carotid cannulation. Anesthesiology         dell JH. A computer method for determina-
and valve replacement. In the 100 pa-         1981;55:487.                                        tionof acid-base and oxygenation variables
tients having myocardial revasculari-                                                             in adult and infant blood samples. J Lab Clin
zation, five developed ocular compli-                                                             Med 1966;71:328-32.
cations: three had homonomous hem-
                                             * Reprint requests to Dr. Chapin
ianopsia and two had retinal infarcts.
All five patients had an episode of
either hypoxia, hypotension, or atrial                                                        To the Editor:
fibrillation.                                                                                    W e are grateful to Dr. Smith for
   Ross et a1 (2) reported a case in                                                          calling our attention to and sending
which the left carotid artery was in-      Computer Programs                                  us a copy of the program reported by
advertently cannulated during cardi-       for Acid-Base                                      Jalowayski et a1 in 1968 (1). Their
opulmonary bypass for aortic valve
replacement. There was low perfu-
                                           Variables                                          program helps to illustrate the many
                                                                                              advances in both blood-gas analysis
sion pressure during bypass and            To the Editor:                                     and computer science that have oc-
edema of the left side of the face           I draw your attention to the intei-              curred over the past 13 years. In the
                                                                                            ANESTHESIA AND ANALGESIA
                                                                                            V o l 6 1 , No 5, May 1982                475
                                                      LETTERS TO THE EDITOR

late 1960s direct measurement of                      tion of acid-base and oxygenation variables     closed and pressure in the cuff exists.
Pco2 with the Severinghaus electrode                  in adult and infant blood samples. J Lab Clin   In addition, an alarm sounds if the
                                                      Med 1968;71:328-32.
was just replacing the Astrup tech-              2    Kelman GR. Digital computer subroutine for
                                                                                                      cuff is inflated longer than 300 sec-
nique, in which PCO, was estimated                    the conversion of oxygen tension into satu-     onds. However, there is no provision
from three measurements of pH. PO?                    ration. J Appl Physiol 1966;21:1375-6.          for continuously reading cuff pres-
was still sometimes read from a pH               3    Dell RB, Engel K, Winters RW. A computer        sures during or between blood pres-
                                                      program for the blood pH-log Pco, nomo-
meter (sic), requiring mathematical                   gram. %and J Clin Lab Invest 1967;19:29-
                                                                                                      sure determinations. Such a provision
conversion to proper units. The pro-                  37.                                             might aid in prevention of the com-
gram of Jalowayski et a1 (1)satisfied            4    Vallbona C, Pevay E, McMath F. Computer         plications noted with the use of the
requirements of both the older and                    analysis of blood gases and of acid-base        automatic cuff.
                                                      status. Comput Biomed Res 1971;4:623-33.
newer techniques of blood-gas anal-              5    Maas AHJ, Kreuger JA, Hoelen AJ, Visser
                                                                                                         In order to observe cuff inflation
ysis that were used in 1968.                          BF. A computer program for calculating the      pressures and to ensure deflation to
   Likewise, their program reflected                  acid-base parameters in samples of blood        zero pressure between determina-
conventional computer technology of                   using a mini-computer. Pfluegers Arch           tions, we have devised a simple mod-
                                                      1972;334364-75.
the day. Data were punched onto                  6    Hardt J. A computer program for calculating
                                                                                                      ification of the apparatus. A Y-piece
cards and entered into the computer                   blood acid-base parameters on an Olivetti       is inserted into the tubing near the
in batches, thus precluding interac-                  “Programma 101’’ desk computer. Clin            cuff. Two arms of the Y serve to
tion between the user and the com-                    Chem 1972;18:658-61                             pressurize the cuff and the third arm
puter. Only after peripheral terminals            7   Grogono W . Assessment of acid-base dis-
                                                      turbances employing a desk-top computer.
                                                                                                      is connected by rubber tubing directly
came into common use and after ta-                    Br Med J 1973;1:381-6.                          to the manometer on the anesthesia
ble-driven programming was devel-                8    Gershwin R, Smith NT, Suwa K. An equa-          machine. This modification provides
oped in the early 1970s could users                   tion system and programs for obtaining base     a continuous display of cuff pressure
begin fashioning their own unique                     excess using a programmable calculator.
                                                                                                      and, we feel, contributes to the safe
                                                      Anesthesiology 1974;40:89-92.
versions of generalized table-driven             9    Ruiz BC, Tucker WK, Kirby RR. A program         use of this machine.
programs by interacting with the                      for calculation of intrapulmonary shunts,                Peter M. Glass, M D
computer.                                             blood-gas and acid-base values with a                    Robert R. Bezzo, RN
                                                      programmable calculator. Anesthesiology
   Our program, founded on innova-                                                                              Department of Anesthesia
                                                      1975;42:88-95.
tive programming techniques, is de-              10   Gabel RA, Hooper A, Marseglia JJ Jr, Farese               Sacred Heart Medical Center
signed to accommodate recent devel-                   G. Calculation and correction of blood-gas                Spokane, WA 99204
opments in measurement and inter-                     and acid-base variables with a versatile com-
                                                      puter program Anesth Analg 1981;60:889-                         REFERENCES
pretation of blood gases and pH. Be-
                                                      96.                                              1. Sy WP. Ulna nerve palsy possibly related to
cause the science and technology of                                                                      use of automatically cycled blood pressure
computers and of blood-gas analysis                                                                      cuff. Anesth Analg 1981;60:687-8.
have changed so drastically since                                                                     2. Showman A, Betts EK. Hazard of automatic
1968, our program actually bears little                                                                  noninvasive blood pressure monitoring.
                                                                                                         Anesthesiology 1981;55:717-8.
resemblance to that of Jalowayski et
a1 (1).
   Many computer and calculator
                                                 Modification of                                         * Reprint requests to Dr. Glass.
programs have been developed to as-              Dinamap 845
sist in blood-gas analysis, some pub-            Automatic Blood
lished before (2, 3) and others after
(4-9) the work of Jalowayski et al. In           Pressure Cuff to                                     Further Studies on
our paper (10) referred to the three
                we                               Permit Continuous                                    the Myocardial
programs that contributed most di-
rectly to our work (2,8,9). W e enthu-
                                                 Display of Cuff                                      Metabolic Effects of
siastically acknowledge the substan-             Pressure                                             Protamine Sulfate
tial contributions of others to the
                                                 To the Editor:                                       following
field.
         Ronald A. Gabel, M D
                                                    Use of the Dinamap 845 automatic                  Cardiopulmonary
                                                 blood pressure cuff in the operating
         Department of Anesthesia                room has become increasingly popu-
                                                                                                      Bypass
         Harvard Medical School                  lar. A recent article (1) reported the               To the Editor:
         Boston, MA 02115                        possibility of barotrauma to the ulna                   The cardiovascular effects of rapid
         John J. Marseglia, Jr., MAS             nerve produced by malposition or                     infusions of protamine have been de-
         Genevieve Farese, BA                    prolonged inflation of the cuff. Ven-                scribed in man and appear to be be-
          United States Army Research            ostasis manifested by petechiae,                     nign (1). Recently, we described the
         Institute of Environmental              bluish discoloration, and edema of                   effects of protamine on myocardial
            Medicine                             the extremity has also been observed                 oxygen supply and demand in nine
         Natick. MA 01760                        (2).                                                 patients following cardiopulmonary
                                                    Internal alarms to increase patient               bypass (2). Our results showed that
                  REFERENCES                     safety are a feature of the Dinamap.                 there was no adverse alteration in the
 1 . Jalowayski A, Lauterbach R, Smith BF, Mo-   A red dot on the face of the device is               global myocardial metabolic state
     dell JH. A computer method for determina-   illuminated when the exit valve is                   after rapid protamine infusion in

               ANESTHESIA AND ANALGESIA
4 76           Vol61, No 5, May 1982

				
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