BACKGROUND/AIMS: The mortality of hospitalized patients undergoing treatment with an intra-aortic balloon pump (IABP) due to cardiogenic shock is well known as quite high. The aim of this study was to evaluate the outcome of percutaneous coronary intervention (PCI) with an IABP in patients with acute coronary syndrome (ACS) and cardiogenic shock and identify the predictors of in-hospital mortality. METHODS: 134 patients who underwent PCI with IABP due to ACS complicated by cardiogenic shock were consecutively enrolled. Outcomes were obtained and analyzed during hospitalization and after 1 year. RESULTS: The incidence of all-cause mortality was 35.8% (in-hospital mortality, 34.3%; 1-year mortality, 1.5%). The nonsurvival group exhibited higher peak levels of creatine kinase MB; lower ejection fractions; and higher incidences of ST elevation myocardial infarction, ventricular arrhythmia, and use of an assistive device than did the survival group. Aging (hazard ratio 2.839; 95% confidence interval 1.408-5.723; p = 0.004), the use of a temporary pacemaker (2.035; 1.114-3.720; 0.021), the use of a mechanical ventilator (4.376; 1.852-10.341; 0.001), and the performance of cardiopulmonary resuscitation (CPR) (2.219; 1.017-4.839; 0.045) were independent predictors for in-hospital mortality. However, out-of-hospital mortality among in-hospital survivors was not affected by predictors of in-hospital mortality. CONCLUSIONS: The incidence of in-hospital mortality was high, as expected in patients undergoing PCI with IABP due to ACS with cardiogenic shock. Aging, CPR, and additional procedures such as pacemaker use and mechanical ventilation were predictors of in-hospital mortality. However, the patients who were successfully discharged after the complex procedure showed acceptable 1-year outcomes.
Acute Coronary Syndrome ; Aging ; Arrhythmias, Cardiac ; Cardiopulmonary Resuscitation ; Creatine Kinase ; Hospital Mortality ; Hospitalization ; Humans ; Incidence ; Intra-Aortic Balloon Pumping ; Mortality ; Myocardial Infarction ; Percutaneous Coronary Intervention* ; Respiration, Artificial ; Self-Help Devices ; Shock, Cardiogenic* ; Survivors ; Ventilators, Mechanical

BACKGROUND: For patients in the intensive care unit (ICU) or under monitored anesthetic care (MAC), the precise monitoring of sedation depth facilitates the optimization of dosage and prevents adverse complications from underor over-sedation. For this purpose, conventional subjective sedation scales, such as the Observer's Assessment of Alertness/Sedation (OAA/S) or the Ramsay scale, have been widely utilized. Current procedures frequently disturb the patient's comfort and compromise the already well-established sedation. Therefore, reliable objective sedation scales that do not cause disturbances would be beneficial. We aimed to determine whether spectral entropy can be used as a sedation monitor as well as determine its ability to discriminate all levels of propofol-induced sedation during gradual increments of propofol dosage. METHODS: In 25 healthy volunteers undergoing general anesthesia, the values of response entropy (RE) and state entropy (SE) corresponding to each OAA/S (5 to 1) were determined. The scores were then analyzed during each 0.5 mcg/ml- incremental increase of a propofol dose. RESULTS: We observed a reduction of both RE and SE values that correlated with the OAA/S (correlation coefficient of 0.819 in RE-OAA/S and 0.753 in SE-OAA/S). The RE and SE values corresponding to awake (OAA/S score 5), light sedation (OAA/S 3-4) and deep sedation (OAA/S 1-2) displayed differences (P < 0.05). CONCLUSIONS: The results indicate that spectral entropy can be utilized as a reliable objective monitor to determine the depth of propofol-induced sedation.
Anesthesia, General ; Deep Sedation ; Entropy ; Humans ; Intensive Care Units ; Light ; Organothiophosphorus Compounds ; Propofol ; Weights and Measures

Adult-onset Still's disease is an uncommon systemic inflammatory disease of unknown etiology and pathogenesis. It is characterized by an evanescent rash, spiking fever (>39degrees), arthralgia, sore throat, abnormal liver function tests and leukocytosis (>10,000/mm3). We report a case involving a 41-year-old male with initial symptoms suggestive of anaphylactic and septic shock. Steroid therapy led to recovery. Adult-onset Still's disease was ultimately confirmed.
Acute Kidney Injury ; Adult ; Anaphylaxis ; Arthralgia ; Exanthema ; Fever ; Humans ; Leukocytosis ; Liver Function Tests ; Male ; Pharyngitis ; Renal Insufficiency ; Shock ; Shock, Septic ; Still's Disease, Adult-Onset

Adult-onset Still's disease is an uncommon systemic inflammatory disease of unknown etiology and pathogenesis. It is characterized by an evanescent rash, spiking fever (>39degrees), arthralgia, sore throat, abnormal liver function tests and leukocytosis (>10,000/mm3). We report a case involving a 41-year-old male with initial symptoms suggestive of anaphylactic and septic shock. Steroid therapy led to recovery. Adult-onset Still's disease was ultimately confirmed.
Acute Kidney Injury ; Adult ; Anaphylaxis ; Arthralgia ; Exanthema ; Fever ; Humans ; Leukocytosis ; Liver Function Tests ; Male ; Pharyngitis ; Renal Insufficiency ; Shock ; Shock, Septic ; Still's Disease, Adult-Onset

Recent changes in healthcare systems have changed the epidemiologic paradigms in many infectious fields including bloodstream infection (BSI). We compared clinical characteristics of community-acquired (CA), hospital-acquired (HA), and healthcare-associated (HCA) BSI. We performed a prospective nationwide multicenter surveillance study from 9 university hospitals in Korea. Total 1,605 blood isolates were collected from 2006 to 2007, and 1,144 isolates were considered true pathogens. HA-BSI accounted for 48.8%, CA-BSI for 33.2%, and HCA-BSI for 18.0%. HA-BSI and HCA-BSI were more likely to have severe comorbidities. Escherichia coli was the most common isolate in CA-BSI (47.1%) and HCA-BSI (27.2%). In contrast, Staphylococcus aureus (15.2%), coagulase-negative Staphylococcus (15.1%) were the common isolates in HA-BSI. The rate of appropriate empiric antimicrobial therapy was the highest in CA-BSI (89.0%) followed by HCA-BSI (76.4%), and HA-BSI (75.0%). The 30-day mortality rate was the highest in HA-BSI (23.0%) followed by HCA-BSI (18.4%), and CA-BSI (10.2%). High Pitt score and inappropriate empirical antibiotic therapy were the independent risk factors for mortality by multivariate analysis. In conclusion, the present data suggest that clinical features, outcome, and microbiologic features of causative pathogens vary by origin of BSI. Especially, HCA-BSI shows unique clinical characteristics, which should be considered a distinct category for more appropriate antibiotic treatment.
Adult ; Aged ; Anti-Bacterial Agents/therapeutic use ; Bacteremia/drug therapy/*epidemiology/microbiology/mortality ; Community-Acquired Infections/drug therapy/*epidemiology/microbiology/mortality ; Cross Infection/drug therapy/*epidemiology/microbiology/mortality ; Humans ; Korea/epidemiology ; Male ; Middle Aged ; Prospective Studies ; Risk Factors ; Treatment Outcome ; Young Adult

We experienced an extremely rare complication during performance of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair for a 57-year-old healthy man. About 50 minutes after CO2 insufflation, the patient developed tachycardia, hypoxemia, hypercapnia and an increased airway pressure. Right pneumothorax with subcutaneous emphysema was recognized on the emergency chest X-ray and this was successfully treated by chest tube insertion. Anesthesiologists should be aware of the possible occurrence of pneumothorax during laparoscopic TEP hernia repair.
Anoxia ; Chest Tubes ; Emergencies ; Hernia, Inguinal ; Herniorrhaphy ; Humans ; Hypercapnia ; Insufflation ; Laparoscopy ; Middle Aged ; Pneumothorax ; Pyrazines ; Subcutaneous Emphysema ; Tachycardia ; Thorax

BACKGROUND: Discrepancy of central-peripheral arterial pressure after cardiopulmonary bypass may affect the reliability of arterial pressure waveform derived cardiac index (APCI) monitoring. METHODS: In 15 elective cardiac surgeries employing moderate hypothermic cardiopulmonary bypass (CPB), APCI from radial arterial cannula and pulmonary artery catheter derived cardiac index from thermodilution method (PACI) were measured 1) after anesthesia induction (T1), 2) before CPB (T2), 3) immediately after CPB (T3) and 4) 1 hour after CPB (T4). APCI and PACI were analyzed by using the Bland-Altman analysis. RESULTS: Biases of APCI and PACI at T1, T2, T3 and T4 were 0.093 L/min/m2, -0.053 L/min/m2, 0.485 L/min/m2 and -0.09 L/min/m2, respectively. The limits of agreement (2 SD) at T1, T2, T3 and T4 were from -2.285 to 2.471 L/min/m2, -2.475 to 2.369 L/min/m2, -2.255 to 3.225 L/min/m2 and -2.609 to 2.423 L/min/m2, respectively. Bias of APCI and PACI during entire period (T1-T4) was 0.095 L/min/m2 and 2 SD was from -2.387 to 2.557 L/min/m2. However, mean error % (2 SD/mean) of APCI at T1, T2, T3, and T4 were greater than 30%. CONCLUSIONS: Our results were not able to show that APCI measured from radial artery is comparable to PACI for hemodynamic monitoring during cardiac surgery employing moderate hypothermic CPB. Considering the limitations of PACI as a gold standard of hemodynamic monitoring in a certain clinical circumstance, further investigation employing other monitoring method than PACI may be followed to get more definitive conclusion.
Anesthesia ; Arterial Pressure ; Bias (Epidemiology) ; Cardiopulmonary Bypass ; Catheters ; Hemodynamics ; Pulmonary Artery ; Radial Artery ; Thermodilution ; Thoracic Surgery

We report a case of intrasellar arachonoid cyst with extension to the sphenoid sinus, which is a very uncommon lesion. Preoperatively, we studied the PNS CT & Brain MRI and these images showed a large cyst in the widened sellar turcica with extension to the sphenoid anterior wall. We planned endoscopic surgery via transnasal-transphenidal approach. The endoscopic surgery was performed with no complication. We reviewed the literature and discussed the treatment of the intrasellar arachnoid cyst.
Arachnoid ; Brain ; Sphenoid Sinus

During off-pump coronary artery bypass graft surgery (OPCAB), vigorous displacement and compression of the heart producing significant hemodynamic change are essential for optimal exposure of graft anastomoses. Intraoperative transesophageal echocardiography (TEE) is useful in determining hemodynamic compromise and prompting medical and mechanical support. However, in addition to the loss of contact between the heart and diaphragm during the displacement, swabs or snears underneath the heart interrupt the TEE signal transmission, resulting in a compromised transgastric (TG) TEE view. Therefore, TEE monitoring during OPCAB is usually limited to the mid-esophageal view. The authors placed a saline bag (a surgical glove filled with saline) underneath the heart to facilitate this anterior displacement of the heart, as well as avoid the signal interruption of the TG echocardiographic window. As a result, the optimal heart position with the minimal changes in LV regional wall motion, LV function and mitral regurgitation were found using the TG and other TEE views. The series of velocity-time integral of aortic valvular flow (VTI-Ao) in TG long axis view, in addition to SvO2, were then monitored as a surrogate marker of the cardiac output during a graft construction of the left circumflex artery. It was concluded that the use of a saline bag may be useful in avoiding compromise of the TG TEE view and determine the hemodynamic change using VTI-Ao during cardiac displacement for OPCAB.
Arteries ; Axis, Cervical Vertebra ; Biomarkers ; Cardiac Output ; Coronary Artery Bypass, Off-Pump* ; Diaphragm ; Echocardiography* ; Echocardiography, Transesophageal ; Gloves, Surgical ; Heart ; Hemodynamics ; Mitral Valve Insufficiency ; Transplants*

The determination of arterial pressure wave-derived cardiac output (APCO) and central venous O2 saturation (ScvO2) has been introduced as a less invasive procedure for monitoring cardiac function and oxygen delivery. We have used an APCO sensor (FloTracTM) and a monitor for ScvO2 (Vigileo(TM)) in two cases of cardiac valve surgery, where placement of pulmonary artery catheter (PAC) was not applicable due to unfavorable cardiac structure (case 1) and was contraindicated due to an unstable cardiac conduction disorder and arrhythmia (case 2). In case 1, monitoring of APCO was started from the beginning of anesthesia induction and a ScvO2 monitoring central venous catheter was inserted just after anesthesia induction. APCO, ScvO2 and other hemodyanamic information such as arterial BP, CVP, and data obtained from transesophageal echocardiography (TEE) during the pre- cardiopulmonary bypass (CPB) period were measured. APCO and ScvO2 during the post-CPB period showed a reliable correspondence with continuous cardiac output (CCO) and mixed venous O2 saturation (SvO2) as measured by PAC at the end of CPB. In case 2, APCO and ScvO2 were monitored instead of CCO and SvO2. The values of APCO showed a good correlation to intraoperative COs indirectly calculated by the velocity-time integral of the aortic outflow determined in the TEE examination. We experienced that monitoring APCO and ScvO2 is useful for anesthesia management in cardiac valve surgery and can be an alternative to CCO and SvO2 if the placement of PAC and the thermodilution method are not applicable.
Anesthesia ; Arrhythmias, Cardiac ; Arterial Pressure* ; Cardiac Output* ; Cardiopulmonary Bypass ; Catheters ; Central Venous Catheters ; Echocardiography, Transesophageal ; Heart Valves ; Oxygen* ; Pulmonary Artery ; Thermodilution ; Thoracic Surgery*