Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.

No abstract available.
Aneurysm, False ; Catheterization ; Catheters ; Humans ; Takayasu Arteritis

BACKGROUND: AVP (arginine vasopressin) shows unique hemodynamic characteristics, as a vasopressor. AVP has been tried in many cathecholamine refractory vasodilatory situations, and sometimes resulted in effective hemodynamic improvement. In this study, we hypothesized that low dose AVP infusion could recover the decreased SVR (systemic vascular resistance) induced by milrinone infusion with minimal effect on PVR (pulmonary vascular resistance). METHODS: Sixteen patients undergoing OPCAB participated in this study. After a loading dose milrinone was infused, low dose vasopressin infusion was started and titrated until the systemic blood pressure increased by 20%. During the study, hemodynamic factors including pulmonary capillary wedge pressure and cardiac output were measured using a continuous thermodilution technique with a Swan-Ganz catheter. RESULTS: Milrinone infusion reduced both SVR and PVR. And vasopression infusion increased SVR, but show relatively less effect on PVR. CONCLUSIONS: Low-dose vasopressin infusion could be used to recover the SVR decrease caused by milirinone infusion with little effect on PVR.
Blood Pressure ; Cardiac Output ; Catheters ; Hemodynamics* ; Humans ; Milrinone* ; Pulmonary Wedge Pressure ; Thermodilution ; Vasopressins*

Antiphospholipid syndrome (APS) is a rare disease in which patients display prolonged coagulation test results in vitro, but usually develop thrombotic symptoms in vivo. Patients with APS are at increased risk of valvular heart disease or coronary vascular disease, conditions that often necessitate cardiac surgery via bypass. The management of anticoagulation during cardiopulmonary bypass (CPB) is particularly challenging in these patients because of the unique features of APS. Patients with APS are constantly at risk of arterial and venous thrombotic events. Therefore it is very important to maintain proper anticoagulation perioperatively, especially during CPB. In this paper, we present three successful cases of APS patients who underwent cardiac surgery with CPB.
Antiphospholipid Syndrome* ; Cardiopulmonary Bypass ; Heart Valve Diseases ; Humans ; Rare Diseases ; Thoracic Surgery* ; Vascular Diseases

BACKGORUND: Echocardiography is usually performed for preoperative cardiac evaluation before coronary bypass graft surgery. if the variables detected by this noninvasive method could predict the outcome of the off-pump coronary bypass surgery (OPCAB), it would be very helpful. The purpose of this study is the evaluation of preoperative transthoracic echocardiographic findings as the predictor of OPCAB outcome. METHODS: We evaluated the relationships between preoperative variables identified by the transthoracic echocardiography and postoperative outcomes. RESULTS: Among the doppler findings trans-mitral flow shows no relationship with the postoperative outcome. But, left ventricular mass had the predictability of postoperative time of extubation, iCU stay, and hospital stay. CONCLUSiONS: Left ventricular mass can be used to predict the outcome after OPCAB and There are the need of further study to find out the reason the left ventricular mass show relationship with the postoperative outcome.
Atrial Fibrillation ; Coronary Artery Bypass, Off-Pump* ; Echocardiography* ; Length of Stay ; Prognosis* ; Transplants*

BACKGROUND: The aim of this study is to determine the effect of high dose fentanyl on the test dose containing 15microgram epinephrine during propofol anesthesia. METHODS: One hundred patients with ASA physical status 1 were randomized to receive 2 mg/kg propofol with or without 10microgram/kg fentanyl at the induction of anesthesia (n = 50 each). Anesthesia was maintained with propofol 8 mg/kg/h and 67% nitrous oxide in oxygen. Each group of patients were further divided into a test dose group receiving 1.5% lidocaine 3 ml plus epinephrine 15microgram or a saline group receiving 3 ml of isotonic saline (n = 25 each). Heart rate (HR) and systolic blood pressure (SBP) were monitored for 4 min after intravenous injection of the study drugs. RESULTS: In the propofol and the propofol-fentanyl group, the intravenous injection of the test dose produced a HR increase > or = 20 bpm (conventional HR criterion) in 25 and 23 out of the total 25 patients, respectively. Therefore, in the propofol-fentanyl group, sensitivity, specificity, positive predictive value, and negative predictive value were 82%, 100%, 100%, and 92.6%. According to the modified HR criterion (HR increase > or = 10 bpm), all the values were 100%. All patients receiving test dose developed SBP increase > or = 15 mmHg. CONCLUSIONS: Our results indicate that both HR increase > or = 10 bpm or SBP increase > or = 15 mmHg are clinically applicable during propofol-nitrous oxide anesthesia with 10microgram/kg fentanyl.
Anesthesia* ; Blood Pressure ; Epinephrine ; Fentanyl* ; Heart Rate ; Humans ; Injections, Intravenous ; Lidocaine ; Nitrous Oxide ; Oxygen ; Propofol ; Sensitivity and Specificity

Importance of accurate molecular diagnosis and quantification of particular disease-related pathogenic microorganisms is highlighted as an introductory step to prevent and care for diseases. In this study, we designed a primer/probe set for quantitative real-time polymerase chain reaction (qRT-PCR) targeting rgpA gene, known as the specific virulence factor of periodontitis-related pathogenic bacteria ‘Porphyromonas gingivalis’, and evaluated its diagnostic efficiency by detecting and quantifying relative bacterial load of P. gingivalis within saliva samples collected from clinical subjects. As a result of qRT-PCR, we confirmed that relative bacterial load of P. gingivalis was detected and quantified within all samples of positive control and periodontitis groups. On the contrary, negative results were confirmed in both negative control and healthy groups. Additionally, as a result of comparison with next-generation sequencing (NGS)–based 16S metagenome profiling data, we confirmed relative bacterial load of P. gingivalis, which was not identified on bacterial classification table created through 16S microbiome analysis, in qRT-PCR results. It showed that an approach to quantifying specific microorganisms by applying qRT-PCR method could solve microbial misclassification issues at species level of an NGS-based 16S microbiome study. In this respect, we suggest that P. gingivalis–specific primer/probe set introduced in present study has efficient applicability in various oral healthcare industries, including periodontitis-related microbial molecular diagnosis field.

BACKGROUND: The purpose of this study was to measure lumbar epidural pressure (EP) during the insertion of a Tuohy needle under general anesthesia and to evaluate the influence of airway pressure on EP. METHODS: Lumbar EP was measured directly through a Tuohy needle during intermittent positive pressure ventilation in fifteen patients. Mean and peak EP were recorded after peak inspiratory pressures (PIP) of 0, 15, and 25 cmH2O. RESULTS: All measured lumbar EPs were positive, with the pressure increasing during inspiration and decreasing during expiration. Median EP was 6.0 mmHg (interquartile range, 4.0-8.0) at 0 cmH2O of PIP, 6.5 mmHg (4.5-8.5) at 15 cmH2O, and 8.5 mmHg (6.0-10.5) at 25 cmH2O, increasing significantly at 15 cm H2O PIP, and further increasing at 25 cmH2O (P < 0.001). CONCLUSIONS: We demonstrate the influence of increased airway pressure on lumbar EP measured directly through a Tuohy needle. Lumbar EPs were positive, and increasing PIP levels significantly increased lumbar EP.
Anesthesia, General ; Humans ; Intermittent Positive-Pressure Ventilation ; Needles ; Positive-Pressure Respiration

BACKGROUND: Thromboelastogram (TEG) is regarded as a method by which coagulation can be measured during surgery. Off pump coronary artery bypass (OPCAB) surgical patients are routinely placed on aspirin. But conventional TEG could not detect platelet dysfunction by antiplatelet agent. We used modified TEG (addition of heparin and platelet agonists) to determine whether this modified TEG could assess the platelet dysfunction by aspirin in OPCAB surgical patients and healthy volunteers. METHODS: After institutional review board approval and consent, platelet function of 10 OPCAB patients (group 1) and 10 healthy subjects (group 2: before aspirin, group 3: after aspirin) were measured using modified TEG. In each group, TEG parameters (R, K time and MA) were analyzed using paired t-test and one way ANOVA was used to determine the difference between groups. RESULTS: In group 1 (OPCAB patients) and group 2 (healthy subjects, before aspirin), the R and K time were increased significantly with the addition of heparin and then decreased subsequently with the platelet agonists (ADP or collagen) in the presence of anticoagulation (heparin). MA showed a decrease in both groups. This compares with no significant difference in all parameters in group 3 (healthy subjects, after aspirin) with the addition of heparin, ADP and collagen. There were no significant differences in each TEG parameter between groups. CONCLUSIONS: This study suggested that aspirin medication obliterated the effect of anticoagulation and platelet agonists in modified TEG. However modified TEG does not provide a comprehensive and sensitive reflection of platelet inhibition by aspirin. TEG should be supplemented by other methods of platelet function assessment.
Adenosine Diphosphate ; Aspirin* ; Blood Platelets* ; Collagen ; Coronary Artery Bypass, Off-Pump* ; Ethics Committees, Research ; Healthy Volunteers* ; Heparin ; Humans

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.
Airway Management ; Anesthesia, General ; Atrophy ; Bronchi ; Coronary Artery Bypass, Off-Pump ; Elastic Tissue ; Emergencies ; Extracorporeal Membrane Oxygenation ; Humans ; Muscle, Smooth ; Trachea ; Tracheobronchomegaly ; Transplants ; Ventilation ; Vocal Cords