Background: Ultrafiltration (UF) would enhance coagulation profiles by concentrating coagulation elements during cardiopulmonary bypass (CPB) for cardiac surgery. Methods: We retrospectively reviewed electronic medical records of 75 patients who had undergone cardiac surgery with rotational thromboelastometry-based coagulation management in a university hospital and analyzed the UF-induced changes in the maximum clot firmness (MCF) of extrinsically activated test with tissue factor (EXTEM) during CPB in 30 patients. Results: The median volume of filtered-free water was 1,350 ml, and median hematocrit was significantly increased from 22.5% to 25.5%. As the primary measure, UF significantly increased the median MCF-EXTEM from 48.0 mm to 50.5 mm (P = 0.015, effect size r = 0.44). The area under the receiver operating characteristic curve pre-UF MCF-EXTEM for discrimination of any increase of MCF-EXTEM after applying UF was 0.89 (95% CI [0.77, 1.00], P < 0.001), and its cut-off value was 50.5 mm (specificity of 81.8% and sensitivity of 84.2% in Youden’s J statistic). In the secondary analyses using the cut-off value, UF significantly increased the median MCF-EXTEM from 40.5 mm to 42.5 mm in 18 patients with pre-UF MCF-EXTEM ≤ 50.5 mm. However, it did not increase MCF-EXTEM in 12 patients with pre-UF MCF-EXTEM > 50.5 mm. There was a significant interaction between pre-UF MCF-EXTEM values and applying UF (P < 0.001 for the subgroup, P = 0.046 for UF, P = 0.003 for interaction). Conclusions Applying UF improved clot firmness, and the improvement was more pronounced when pre-UF MCF-EXTEM had been reduced during CPB.

BACKGROUND: Isoflurane, a common anesthetic for cardiac surgery, reduced myocardial contractility in many experimental studies, few studies have determined isoflurane's direct impact on the left ventricular (LV) contractile function during cardiac surgery. We determined whether isoflurane dose-dependently reduces the peak systolic velocity of the lateral mitral annulus in tissue Doppler imaging (S′) in patients undergoing cardiac surgery. METHODS: During isoflurane-supplemented remifentanil-based anesthesia for patients undergoing cardiac surgery with preoperative LV ejection fraction greater than 50% (n = 20), we analyzed the changes of S′ at each isoflurane dose increment (1.0, 1.5, and 2.0 minimum alveolar concentration [MAC]: T1, T2, and T3, respectively) with a fixed remifentanil dosage (1.0 μg/min/kg) by using transesophageal echocardiography. RESULTS: Mean S′ values (95% confidence interval [CI]) at T1, T2, and T3 were 10.5 (8.8–12.2), 9.5 (8.3–10.8), and 8.4 (7.3–9.5) cm/s, respectively (P < 0.001 in multivariate analysis of variance test). Their mean differences at T1 vs. T2, T2 vs. T3, and T1 vs. T3 were −1.0 (−1.6, −0.3), −1.1 (−1.7, −0.6), and −2.1 (−3.1, −1.1) cm/s, respectively. Phenylephrine infusion rates were significantly increased (0.26, 0.22, and 0.47 μg/kg/min at T1, T2, and T3, respectively, P < 0.001). CONCLUSION: Isoflurane increments (1.0–2.0 MAC) dose-dependently reduced LV systolic long-axis performance during cardiac surgeries with a preserved preoperative systolic function.
Anesthesia ; Echocardiography ; Echocardiography, Transesophageal ; Heart Function Tests ; Heart Valves ; Humans ; Isoflurane ; Multivariate Analysis ; Phenylephrine ; Thoracic Surgery

The aged population is increasing rapidly, and the range of subjects undergoing surgery under general anesthesia is also expanding. Organ dysfunction reduces physiologic reserve, and comorbidity and polypragmasy increase the risk of postoperative complications. All anesthetic agents and techniques can be employed, if individualized to each patient's condition. Careful intraoperative monitoring and proper management to maintain homeostasis can reduce the risk of complications. Experienced anesthesiologists must choose the appropriate drug and adjust the dose individually, considering the physiologic changes that take place in the elderly. Goal-directed fluid replacement is mandatory. Anesthesiologists and surgeons should understand the risks experienced by the elderly and their fragility, and will achieve optimal outcomes if they communicate and cooperate closely.
Aged* ; Anesthesia, General* ; Anesthetics ; Comorbidity ; Frail Elderly ; Homeostasis ; Humans ; Monitoring, Intraoperative ; Postoperative Complications ; Surgeons

Intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) facilitates an understanding of the complex cardiac pathology that is not fully delineated in a two-dimensional (2D) echocardiographic evaluation, and it suggests earlier and more precise surgical planning and intraoperative decision making. In the present case, the intraoperative 2D-TEE midesophageal long-axis view indicated a significant narrowing of the left ventricular outflow tract (LVOT) area by a band-like structure that vertically traversed the middle of the LVOT and connected to the anterior mitral leaflet base and the interventricular septum. However, additional 3D-TEE images of the LVOT and their cropped and rendered 2D images showed that web-like tissue, which presumably had grown around the patch closure from a previous atrioventricular septal defect, was obstructing the LVOT partially.
Decision Making ; Echocardiography ; Echocardiography, Three-Dimensional ; Echocardiography, Transesophageal* ; Pathology

BACKGROUND: This study evaluated the efficacy of ulinastatin for attenuating organ injury and the release of proinflammatory cytokines due to cardiopulmonary bypass (CPB) during cardiac surgery. METHODS: Patients undergoing valvular heart surgery employing CPB were assigned to receive either ulinastatin (group U, n = 13) or a placebo (group C, n = 11) before the commencement of CPB. Hemodynamic data, parameters of major organ injury and function, and proinflammatory cytokines were measured after the induction of anesthesia (T1), after CPB (T2), at the end of anesthesia (T3), and at 24 hours after surgery (POD). RESULTS: The demographic data, CPB duration, and perioperative transfusions were not different between the groups. PaO2/FiO2 in group U was significantly higher than that in group C at T3 (3.8 +/- 0.8 vs. 2.8 +/- 0.7, P = 0.005) and at POD (4.0 +/- 0.7 vs. 2.8 +/- 0.7, P < 0.001). Creatine kinase-MB at POD in group U was significantly lower than that in group C (17.7 +/- 8.3 vs. 33.7 +/- 22.1, P = 0.03), whereas troponin I at POD was not different between the groups. Creatinine clearance and the extubation time were not different between the groups at POD. The dopamine infusion rate during the post-CPB period in group U was significantly lower than that in group C (1.6 +/- 1.6 vs. 5.5 +/- 3.3 microg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-alpha concentrations at T1, T2, and T3 as well as the incidences of postoperative cardiac, pulmonary and kidney injuries were not different between the groups. CONCLUSIONS: Ulinastatin pretreatment resulted in an improved oxygenation profile and reduced inotropic support, probably by attenuating the degree of cardiopulmonary injury; however, it did not reduce the levels of proinflammatory cytokines.
Anesthesia ; Cardiopulmonary Bypass ; Creatine ; Creatinine ; Cytokines ; Dopamine ; Glycoproteins ; Hemodynamics ; Humans ; Incidence ; Interleukin-6 ; Kidney ; Oxygen ; Thoracic Surgery ; Troponin I ; Tumor Necrosis Factor-alpha

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

We describe a patient with infective endocarditis (IE) complicated by mycotic cerebral aneurysms (MCAs). Transarterial embolization of a larger MCA was attempted but failed. Aneurysmal clipping through craniotomy was followed by mitral valvuloplasty. During mitral valvuloplasty for IE, the low values of cerebral oxygen saturation after aneurysmal clipping were improved by continuous nimodipine infusion. We also review anesthetic management of patients with IE complicated by MCAs.
Aneurysm ; Craniotomy ; Endocarditis ; Humans ; Intracranial Aneurysm ; Nimodipine ; Oxygen

The incidence of imported malaria has been increasing in Korea. We reviewed data retrospectively to evaluate the epidemiology, clinical features, and outcomes of imported malaria from 1995 to 2007 in a university hospital. All patients diagnosed with imported malaria were included. Imported malaria was defined as a positive smear for malaria that was acquired in a foreign country. A total of 49 patients (mean age, 35.7 year; M : F = 38 : 11) were enrolled. The predominant malarial species was Plasmodium falciparum (73.5%), and the most frequent area of acquisition was Africa (55.1%), followed by Southeast Asia (22.4%) and South Asia (18.4%). Fourteen-patients (30.6%) suffered from severe malaria caused by P. falciparum and 1 patient (2.0%) died of multiorgan failure. Most of the patients were treated with mefloquine (79.2%) or quinine (10.2%); other antimalarial agents had to be given in 13.2% treated with mefloquine and 44.4% with quinine due to adverse drug events (ADEs). P. falciparum was the most common cause of imported malaria, with the majority of cases acquired from Africa, and a significant number of patients had severe malaria. Alternative antimalarial agents with lower rates of ADEs might be considered for effective treatment instead of mefloquine and quinine.
Adult ; Animals ; Antimalarials/adverse effects/therapeutic use ; Female ; Humans ; Korea/epidemiology ; Malaria, Falciparum/drug therapy/epidemiology/*parasitology ; Male ; Middle Aged ; Plasmodium falciparum/drug effects/isolation & purification ; Retrospective Studies ; *Travel

Loeys-Dietz Syndrome (LDS) is a recently described autosomal dominant aortic aneurysm syndrome with widespread systemic involvement. It is characterized by the triad of 1) arterial tortuosity and aneurysms, 2) hypertelorism, and 3) bifid uvula or cleft palate. A 12-year-old boy with LDS was scheduled to undergo correction of aortic valve regurgitation due to aortic annuloectasia. We report our clinical experiences of a case of LDS patient with brief review of related literatures and relevant anesthetic problems.
Aneurysm ; Aortic Aneurysm ; Aortic Valve ; Arteries ; Child ; Cleft Palate ; Humans ; Hypertelorism ; Joint Instability ; Loeys-Dietz Syndrome ; Skin Diseases, Genetic ; Uvula ; Vascular Malformations

BACKGROUND/AIMS: Tuberculous meningitis is a common, occasionally fatal infectious disease of the central nervous system. We evaluated the diagnostic validity of weighted diagnostic index scores (WDIS), which have been suggested to aid in the diagnosis of adult patients with tuberculous meningitis, on the basis of simple clinical and laboratory findings. METHODS: The microbiological and clinical data of adult patients with either tuberculous or bacterial meningitis were reviewed retrospectively. Diagnostic validity and WDIS cut-off values were evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 77 cases were included: 47 with tuberculous meningitis and 30 with bacterial meningitis. For the diagnosis of tuberculous meningitis, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of WDIS suggested by Thwaites (cut-off value of < or =4) were 100, 90, 94 and 100%, respectively. Based on ROC curve analysis (area under ROC curve=0.993), a cut-off value of < or =3 was most appropriate for the diagnosis of tuberculous meningitis. The sensitivity and specificity of WDIS with a cut-off value of < or =3 were 100 and 93.3%, respectively. CONCLUSIONS: Our study demonstrated that WDIS are highly predictable and acceptable for the early diagnosis of tuberculous meningitis in Korea, based on our analysis of clinical and laboratory findings. A cut-off value of < or =3 showed the best diagnostic validity.
Adult ; Central Nervous System ; Communicable Diseases ; Early Diagnosis ; Humans ; Korea ; Meningitis, Bacterial ; Retrospective Studies ; ROC Curve ; Sensitivity and Specificity ; Tuberculosis, Meningeal