1137
of symptoms he had been fitting shop windows, working on the inside of the glass in direct sunlight, wearing a singlet. That day was the hottest in the UK since meteorological records began, the outside temperature in Leeds rising to 34-4°C. We suggest that this man’s rhabdomyolysis and the consequent acute renal failure resulted from direct thermal trauma to exposed areas from direct sunlight on an unusually hot day, exacerbated by working under onset
glass. J.A.COOK J. M. HILL J. H. TURNEY
Regional Renal Unit, General Infirmary
at
Leeds,
Leeds LS1 3EX, UK
RA, Hamilton RW, Morse BM, Penn AS, Goldberg M. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974; 291: 807-11. 2. Dubrow A, Flamenbaum W. Acute renal failure associated with myoglobmuria and haemoglobinuria. In: Brenner BM, Lazarus JM, eds. Acute renal failure, 2nd ed. Edinburgh: Churchill Livingstone, 1988: 279-93. 3. Frimoyer PA, Giammarco R, Farrar FM, Schroeder ET. Technetium Tc99m medronate bone scanning in rhabdomyolysis. Arch Intern Med 1985; 145: 1991-95. 1 Grossman
Radiation exposure and cardiac catheterisation SIR,-Dr Pipilis and colleagues report (Sept 1,
2-3-fold increase in radiation exposure of staff when cardiac catheterisation is done via the brachial rather than femoral approach. It should be a matter of considerable concern that staff may be subjected to even greater variations in radiation exposure when performing comparable procedures with similar equipment at two different cardiac centres. This hospital uses Siemens X-ray equipment similar to that used by Pipilis and colleagues in Oxford, including a ’Pandoros Optimatic 12’ pulse DC generator, as part of a ’Cardoskop U’ system. Angiography is usually done with 35 mm cinefilm at 25 &ames/s. However, our equipment does not include either a mobile waist-high screen or the swivelling leaded glass and leaded rubber screen used by Pipilis et al. For two years I have monitored the radiation dose received at various parts of my body during cardiac catheterisation. I used a ’Pendix’ personal dosimeter (GST, Eppelheim/Heidelberg) to record exposure when acting as operator and when assisting a junior doctor under training. One site was identical to that studied by Pipilis and colleagues (ie, at the level of the neck above the lead apron). Other sites were the left axilla and left thigh beneath the lead apron. The left side is nearest the radiation source when the femoral approach is used. Only data from diagnostic left-heart catheterisations via the femoral approach are reported here and data are restricted to those procedures when operator and assistant did not change places during the catheterisation. At St Thomas’ Hospital operators and assistants receive doses of radiation at the neck (above the lead apron) 8-10 times higher than those received by staff doing procedures with longer screening times in Oxford (table). This difference is at least partly the result of lack of additional radiation screening measures at St Thomas’. p
567)
a
RADIATION DOSES TO STAFF DURING CARDIAC CATHETERISATION
Data
as mean
(SD). 0=operator, A=assistant
The split-sided, wrap-around lead aprons used at St Thomas’ allow radiation exposures to the left axilla and thigh comparable with those detected above the apron at the neck. Most staff here carry just one film badge, which is worn on the front of the abdomen beneath the lead apron. The highest dose I have ever recorded at that site during cardiac catheterisation was 13 }iSv but doses over 800 Sv have been recorded at other sites during complex cases. In some hospitals the monitoring of radiation exposure seems to be too insensitive to reflect the exposure. Furthermore algorithms to calculate how many cardiac catheterisations, pacemaker implantations, and angioplasties may be done in a year before a cardiologist need be classified under UK radiological protection legislation’ are worthless since they take no account of variations in radiation exposure during orocedures at different cardiac centres. Department of Cardiology, St Thomas’ Hospital, London SE1 7EH, UK
PETER WILMSHURST
HG, Faulkner K. Comparison of radiation risks with other nsks in cardiac radiological procedures. In: Faulkner K, Wall BF, eds. Are X-rays safe enough? Patient doses and nsks in diagnostic radiology. (IPSM Rep no 55). York. Institute of Physical Sciences in Medicine, 1988: 64-71.
1. Love
in a blood donor after administration of desmopressin
Myocardial infarction
SIR,- The capacity of desmopressin to raise plasma levels of coagulation factors has led to its use in patients with congenital and acquired bleeding tendencies,1 and in blood donors to augment yields of factor VIII and von Willebrand factor.2-4 Although desmopressin had an excellent safety record,s there have been reports of myocardial and cerebral infarctions after its administration to patients 6 I report an acute myocardial infarction in a blood donor shortly after infusion of this agent. A 47-year-old man in a plasma exchange donation programme to provide cryoprecipitate for his haemophilic son had donated 143 times (88 with desmopressin stimulation) since 19837 He met all medical criteria for blood donation and seemed in excellent health; however, he had risk factors for coronary artery disease, including a family history of premature heart disease, a 52 pack-year history of cigarette smoking before 1984, and raised cholesterol (300-340 mg/dl) and triglyceride (475 mg/dl) levels. On Jan 6, 1990, he received desmopressin 0-3 p.g/kg intravenously over 30 min, as usual. Donation then began, but after another 30 min he complained of chest pain. An electrocardiogram indicated subtle ST segment changes in the inferior leads. Creatine kinase was initially 103 IU/1 (normal below 145), but 6 h later it had risen to 549 lUll with 14% in the MB fraction. The patient recovered uneventfully without thrombolytic therapy. For the preceding 75 donations, his factor VIII level immediately after demospressin infusion had averaged 331% (range 100-690%); on Jan 6 it was 1040%. Angiography on day 5 showed a 10 mm hypokinetic area in the left ventricle. There were 50% narrowings in the left anterior descending and right coronary arteries, but no occlusion of even a small terminal branch could be identified. Previous reports of myocardial infarction associated with desmopressin have been confined to patients with antecedent vascular disease, and some investigators have suggested that the stimulation of coagulation causes thrombosis of a diseased coronary artery. This man’s factor VIII level was unusually high at the time of the incident, but angiography did not conclusively demonstrate a thrombotic occlusion. Paradoxical vasospasm might also account for these observations. Vascular events after desmopressin are uncommon. A recent survey found only ten reports for the years 1985-88, during which 433 000 doses were sold by the manufacturer. Such a low frequency in a population with independent risk factors might be labelled as fortuitous. Indeed, in controlled studies of patients undergoing open heart surgery, there was no significant difference between the frequencies of thromboembolism in desmopressin recipients and controls.6 The incident in the blood donor is more disturbing because he had been in excellent health and had no prior indication of vascular disease; furthermore angiography, though not
of symptoms he had been fitting shop windows, working on the inside of the glass in direct sunlight, wearing a singlet. That day was the hottest in the UK since meteorological records began, the outside temperature in Leeds rising to 34-4°C. We suggest that this man’s rhabdomyolysis and the consequent acute renal failure resulted from direct thermal trauma to exposed areas from direct sunlight on an unusually hot day, exacerbated by working under onset
glass. J.A.COOK J. M. HILL J. H. TURNEY
Regional Renal Unit, General Infirmary
at
Leeds,
Leeds LS1 3EX, UK
RA, Hamilton RW, Morse BM, Penn AS, Goldberg M. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974; 291: 807-11. 2. Dubrow A, Flamenbaum W. Acute renal failure associated with myoglobmuria and haemoglobinuria. In: Brenner BM, Lazarus JM, eds. Acute renal failure, 2nd ed. Edinburgh: Churchill Livingstone, 1988: 279-93. 3. Frimoyer PA, Giammarco R, Farrar FM, Schroeder ET. Technetium Tc99m medronate bone scanning in rhabdomyolysis. Arch Intern Med 1985; 145: 1991-95. 1 Grossman
Radiation exposure and cardiac catheterisation SIR,-Dr Pipilis and colleagues report (Sept 1,
2-3-fold increase in radiation exposure of staff when cardiac catheterisation is done via the brachial rather than femoral approach. It should be a matter of considerable concern that staff may be subjected to even greater variations in radiation exposure when performing comparable procedures with similar equipment at two different cardiac centres. This hospital uses Siemens X-ray equipment similar to that used by Pipilis and colleagues in Oxford, including a ’Pandoros Optimatic 12’ pulse DC generator, as part of a ’Cardoskop U’ system. Angiography is usually done with 35 mm cinefilm at 25 &ames/s. However, our equipment does not include either a mobile waist-high screen or the swivelling leaded glass and leaded rubber screen used by Pipilis et al. For two years I have monitored the radiation dose received at various parts of my body during cardiac catheterisation. I used a ’Pendix’ personal dosimeter (GST, Eppelheim/Heidelberg) to record exposure when acting as operator and when assisting a junior doctor under training. One site was identical to that studied by Pipilis and colleagues (ie, at the level of the neck above the lead apron). Other sites were the left axilla and left thigh beneath the lead apron. The left side is nearest the radiation source when the femoral approach is used. Only data from diagnostic left-heart catheterisations via the femoral approach are reported here and data are restricted to those procedures when operator and assistant did not change places during the catheterisation. At St Thomas’ Hospital operators and assistants receive doses of radiation at the neck (above the lead apron) 8-10 times higher than those received by staff doing procedures with longer screening times in Oxford (table). This difference is at least partly the result of lack of additional radiation screening measures at St Thomas’. p
567)
a
RADIATION DOSES TO STAFF DURING CARDIAC CATHETERISATION
Data
as mean
(SD). 0=operator, A=assistant
The split-sided, wrap-around lead aprons used at St Thomas’ allow radiation exposures to the left axilla and thigh comparable with those detected above the apron at the neck. Most staff here carry just one film badge, which is worn on the front of the abdomen beneath the lead apron. The highest dose I have ever recorded at that site during cardiac catheterisation was 13 }iSv but doses over 800 Sv have been recorded at other sites during complex cases. In some hospitals the monitoring of radiation exposure seems to be too insensitive to reflect the exposure. Furthermore algorithms to calculate how many cardiac catheterisations, pacemaker implantations, and angioplasties may be done in a year before a cardiologist need be classified under UK radiological protection legislation’ are worthless since they take no account of variations in radiation exposure during orocedures at different cardiac centres. Department of Cardiology, St Thomas’ Hospital, London SE1 7EH, UK
PETER WILMSHURST
HG, Faulkner K. Comparison of radiation risks with other nsks in cardiac radiological procedures. In: Faulkner K, Wall BF, eds. Are X-rays safe enough? Patient doses and nsks in diagnostic radiology. (IPSM Rep no 55). York. Institute of Physical Sciences in Medicine, 1988: 64-71.
1. Love
in a blood donor after administration of desmopressin
Myocardial infarction
SIR,- The capacity of desmopressin to raise plasma levels of coagulation factors has led to its use in patients with congenital and acquired bleeding tendencies,1 and in blood donors to augment yields of factor VIII and von Willebrand factor.2-4 Although desmopressin had an excellent safety record,s there have been reports of myocardial and cerebral infarctions after its administration to patients 6 I report an acute myocardial infarction in a blood donor shortly after infusion of this agent. A 47-year-old man in a plasma exchange donation programme to provide cryoprecipitate for his haemophilic son had donated 143 times (88 with desmopressin stimulation) since 19837 He met all medical criteria for blood donation and seemed in excellent health; however, he had risk factors for coronary artery disease, including a family history of premature heart disease, a 52 pack-year history of cigarette smoking before 1984, and raised cholesterol (300-340 mg/dl) and triglyceride (475 mg/dl) levels. On Jan 6, 1990, he received desmopressin 0-3 p.g/kg intravenously over 30 min, as usual. Donation then began, but after another 30 min he complained of chest pain. An electrocardiogram indicated subtle ST segment changes in the inferior leads. Creatine kinase was initially 103 IU/1 (normal below 145), but 6 h later it had risen to 549 lUll with 14% in the MB fraction. The patient recovered uneventfully without thrombolytic therapy. For the preceding 75 donations, his factor VIII level immediately after demospressin infusion had averaged 331% (range 100-690%); on Jan 6 it was 1040%. Angiography on day 5 showed a 10 mm hypokinetic area in the left ventricle. There were 50% narrowings in the left anterior descending and right coronary arteries, but no occlusion of even a small terminal branch could be identified. Previous reports of myocardial infarction associated with desmopressin have been confined to patients with antecedent vascular disease, and some investigators have suggested that the stimulation of coagulation causes thrombosis of a diseased coronary artery. This man’s factor VIII level was unusually high at the time of the incident, but angiography did not conclusively demonstrate a thrombotic occlusion. Paradoxical vasospasm might also account for these observations. Vascular events after desmopressin are uncommon. A recent survey found only ten reports for the years 1985-88, during which 433 000 doses were sold by the manufacturer. Such a low frequency in a population with independent risk factors might be labelled as fortuitous. Indeed, in controlled studies of patients undergoing open heart surgery, there was no significant difference between the frequencies of thromboembolism in desmopressin recipients and controls.6 The incident in the blood donor is more disturbing because he had been in excellent health and had no prior indication of vascular disease; furthermore angiography, though not
