In Reply:-We are grateful for the opportunity to respond to the thoughtful comments by Drs. Aya, Saissi, and Eledjam. The case they describe and the one we reported previously [1] may indicate that rt-PA can be used to treat life-threatening pulmonary embolism during and after cesarean section. We administered the dose of rt-PA as reported before in Japan, which was less than the doses reported in the United States or Europe. Because 10 mg rt-PA is equivalent to 5,800,000 units, we believe that the dose we used was not greater than that administered in the case reported by Aya et al. However, massive hemorrhage occurred in our case. It is imperative to try to reduce the dose of rt-PA in the future. Because we were resuscitating the patient and had no time to place the pulmonary artery catheter, rt-PA was administered via a right internal jugular vein in our case. But as Aya et al. demonstrated, when rt-PA was administered via the pulmonary artery catheter, the dose of rt-PA could be reduced. In the presence of severe complications, a further survey of the proper dose of rt-PA would be indicated.

Kenji Nishimura, M.D.

Visiting Researcher

Masahiko Kawaguchi, M.D.

Staff Anesthesiologist

Hitoshi Furuya, M.D.

Professor and Chairman; Department of Anesthesiology; Nara Medical University; Nara, Japan

(Accepted for publication February 5, 1999.)

Nishimura K, Kawaguchi M, Shimokawa M, Kitaguchi K, Furuya H: Treatment of pulmonary embolism during cesarean section with recombinant tissue plasminogen activator. Anesthesiology 1998; 89:1027-8