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Anesth Analg 2004;99:1018-1023
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000132551.92524.E7

CARDIOVASCULAR ANESTHESIA

Angiotensin-Converting Enzyme Activity: A Novel Way of Assessing Pulmonary Changes During Total Knee Arthroplasty

Kethy Jules-Elysee, MD, Thomas J. J. Blanck, MD, John D. Catravas, PhD, George Chimento, MD, Alexander Miric, MD, Richard Kahn, MD, Leonardo Paroli, MD, and Thomas Sculco, MD

Department of Anesthesiology, Hospital for Special Surgery, New York, New York

Address correspondence and reprint requests to Kethy Jules-Elysee, MD, Department of Anesthesiology, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021. Address e-mail to flynne{at}hss.edu

Emboli after tourniquet release (TR) during total knee arthroplasty (TKA) occur in all patients. This may lead to fat embolism syndrome with lung injury. Angiotensin-converting enzyme (ACE) lines the pulmonary endothelium, and a decrease in ACE metabolism or hydrolysis of 3HBPAP (3H-benzoyl-Phe-Ala-Pro; a substrate specific for ACE) has been associated with lung injury. We evaluated the association of this assay with pulmonary changes during TKA. Eleven consecutive patients undergoing bilateral TKA had the ACE assay performed perioperatively. We determined substrate hydrolysis and pulmonary capillary surface area (capillary perfusion index; CPI) and correlated it with pulmonary vascular resistance (PVR) and clinical outcome. Ten of the 11 patients demonstrated an increase in substrate hydrolysis and CPI along with a decrease in PVR after first or second TR when compared with baseline values (P < 0.05). In the other patient, PVR continued to increase even after TR, whereas CPI and substrate hydrolysis decreased after surgery. Whereas all others did well clinically, this patient developed confusion and hypoxemia. In previous studies, a decrease in PVR with an increase in CPI, as exhibited by the 10 patients, has been associated with pulmonary capillary recruitment. We believe this to be an important mechanism by which the lungs are able to accommodate the burden of emboli at the time of TR.

IMPLICATIONS: The embolic phenomenon to the heart and lungs occurs in all patients undergoing total knee arthroplasty at the time of tourniquet release. This study investigates possible mechanisms that allow most patients to tolerate such insults to their lungs without clinical complications.






Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press
Copyright © 2004 by the International Anesthesia Research Society.