Tae Gyoon Yoon

Effect of ulinastatin on perioperative organ function and systemic inflammatory reaction during cardiac surgery: a randomized double-blinded study.

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 µg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-α 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.

Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation

BACKGROUNDnRisk for injuries resulting from overinflated or underinflated endotracheal tube cuff warrants adequate cuff inflation technique. Thus, this study was designed to measure the actual intracuff pressures obtained by new estimation techniques.nnnMETHODSn95 adult surgical patients requiring tracheal intubation were randomized to two groups with respect to the endotracheal tube model: Portex(R) (n = 55) and Euromedical(R) (n = 40). After induction of anesthesia, the cuff was inflated using new estimation techniques with two different syringes: PR10 or PR20 (passive release technique using a 10-ml or 20-ml syringe, respectively). Subsequently, an aneroid manometer was used to measure the actual intracuff pressures. These inflation techniques were repeated two times. A direct cuff measurement range of 25 to 40 cmH2O was used as a reference for optimal intracuff pressure. Size 7.0 mm internal diameter (ID) tubes were used for women and size 7.5 mm ID for men.nnnRESULTSn88 eligible patients were studied: Portex group (n = 50) and Euromedical group (n = 38). With respect to the rate of optimal cuff inflation, PR10 was significantly higher than PR20 in both groups (56% vs. 10% in Portex group; 63.2% vs. 0% in Euromedical group, respectively) (P < 0.05).nnnCONCLUSIONSnWhen direct intracuff measurement is not available, a new method, named passive release technique using a 10-ml syringe, is a useful alternative cuff inflation method.

The influence of different mechanical ventilator settings of peak inspiratory pressure on stroke volume variation in pediatric cardiac surgery patients

Background The usefulness of dynamic parameters derived by heart-lung interaction for fluid responsiveness in pediatric patients has been revealed. However, the effects of peak inspiratory pressure (PIP) that could affect the absolute values and the accuracy in pediatric patients have not been well established. Methods Participants were 30 pediatric patients who underwent ventricular septal defect repair. After completion of surgical procedure and sternum closure, mean arterial blood pressure, heart rate, central venous pressure, cardiac output, cardiac index and stroke volume variation (SVV) were measured at PIP 10 cmH2O (PIP10), at PIP 15 cmH2O (PIP15), at PIP 20 cmH2O (PIP20) and at PIP 25 cmH2O (PIP25). Results SVV at PIP15 was larger than that at PIP10 (13.7 ± 2.9% at PIP10 vs 14.7 ± 2.5% at PIP15, P < 0.001) and SVV at PIP20 was larger than that at PIP10 and PIP15 (13.7 ± 2.9% at PIP10 vs 15.4 ± 2.5% at PIP20, P < 0.001; 14.7 ± 2.5% at PIP15 vs 15.4 ± 2.5% at PIP20, P < 0.001) and SVV at PIP25 was larger than that at PIP10 and PIP15 and PIP20 (13.7 ± 2.9% at PIP10 vs 17.4 ± 2.4% at PIP25, P < 0.001; 14.7 ± 2.5% at PIP15 vs 17.4 ± 2.4% at PIP25, P < 0.001; 15.4 ± 2.5% at PIP20 vs 17.4 ± 2.4% at PIP25, P < 0.001). Conclusions SVV is affected by different levels of PIP in same patient and under same volume status. This finding must be taken into consideration when SVV is used to predict fluid responsiveness in mechanically ventilated pediatric patients.

Large left atrial myxoma causing mitral annular dilation, functional mitral stenosis with concealed atrial septal defects

Transthoracic echocardiography (TTE) is a relatively precise method of evaluating intracardiac myxoma. However, if the cardiac myxoma is combined with other pathology, it could be missed by TTE. We report a case of a left atrial (LA) myxoma with mechanical mitral annular dilation and functional mitral stenosis (MS) combined with unrevealed atrial septal defects (ASD). A 52-year-old woman was admitted to the stroke unit with aphagia and right hemiplegia. Brain magnetic resonance imaging revealed an acute infarction in the left frontotemporal area. A TTE for a stroke cardiac work-up showed a giant LA mobile mass attached to the fossa ovalis, and surgery was scheduled for removal. Anesthesia was induced and maintained using targetcontrolled infusions (Orchestra Base Primea, Fresenius Vial, Brezins, France) of propofol (target concentration 1.2-1.3 mcg/ ml) and remifentanil (target concentration, 10-20 ng/ml). A preoperative TTE showed the disturbed left ventricle (LV) inflow myxoma during the diastole, with mild mitral regurgitation (MR). These findings suggested that the hemodynamic effect of the myxoma was severe MS, and we therefore carefully managed the ventricular preload and heart rate. Fluid was administered with monitoring of blood pressure, central venous pressure, pulmonary artery pressure and cardiac output, to maintain the preload, and phenylephrine was infused to prevent a decline in the systemic vascular resistance associated with remifentanil infusion. Dopamine was infused to preserve contractility. We used a transesophageal echocardiography (TEE) (X7-2t transducer and iE33; Phillips Healthcare, Andover, MA, USA) probe and evaluated the patient. An intraoperative TEE demonstrated that the mobile mass size was 54 × 29 mm in the LA, which was attached to the fossa ovalis (Fig. 1), and revealed a secondum type of ASD (Fig. 1) with a left to right shunt. The ASD was not identified on preoperative TTE. The LA mobile mass was prolapsed across the mitral valve into the LV during the diastolic phase, partially obstructed blood flow, and caused severe functional MS. MR was also found. However, the regurgitant flow was disturbed by the myxoma, and it was difficult to quantify with two-dimensional (2D) TEE. Real-time three-dimensional (3D) TEE using the en face surgical view from the LA demonstrated that the myxoma was located centrally over the mitral valve. In addition, 3D color doppler showed a central ellipsoidal MR almost reaching the LA superior wall. Three-dimensional imaging suggested more se vere regurgitation than appreciated by 2D imaging. An increased mitral valve annulus of 45 mm was observed. We noticed that the MR was significantly different from our preoperative expectations. The estimated pulmonary arterial systolic pressure was about 40 mmHg with plethora of the inferior vena cava. We reduced the phenylephrine infusion to lower the afterload so that the forward cardiac output was maximized. The LA mo bile mass was resected, including the atrial septum, resulting in enlargement of the ASD. The defect was repaired with a bovine pericardial patch. Mitral valve lifting annuloplasty via the appli cation of a flexible strip was also performed to reduce the dilated mitral valve annulus and correct the MR. After weaning from cardiopulmonary bypass, TEE confirmed complete resection of the LA mobile mass, closure of the ASD, and a well-functioning

Cerebral oxygen saturation monitoring for off-pump coronary bypass graft surgery with Moyamoya disease - A case report -

We report a case using cerebral oxygen saturation (rCbO2) for off-pump coronary artery bypass graft (OPCAB) surgery in a patient with co-existing Moyamoya disease. The rCbO2 with the routine monitoring for OPCAB surgery were monitored intraoperatively. In spite of infusing nimodipine (0.2 microgram/kg/min) and maintaining the end-tidal CO2 tension at 35-40 mmHg, a sudden reduction in the right-side rCbO2 from the base line value of 70-80%/78-83% (Left/Right) to 70-72%/65-70% was developed during the harvesting of the vascular graft. We increased the rate of phenylephrine infusion to increase systemic and cerebral perfusion pressure, and both rCbO2 values were elevated to 80%/70% within 3 minutes. However, the preferential reduction in the right-side rCbO2 compared with the left-side value was not corrected. While suspecting cerebral ischemia due to cerebral vascular spasm, we administered nimodipine 2 mg bolus and increased infusion rate to 0.5 microgram/kg/min. Finally, the preferential rCbO2 reduction in the right-side was corrected and both rCbO2 reached 84%/91%. We concluded rCbO2 monitoring is useful for detecting an intraoperative episode of cerebral ischemia and maintaining the optimal cerebral perfusion during OPCAB surgery with Moyamoya disease.

Anesthetic managements for repair of atrial septal defect in a patient with Young-Simpson Syndrome - A case report -

Young-Simpson Syndrome (YSS) is a rare malformation syndrome characterized by facial dysmorphism, congenital heart abnormalities, congenital hypothyroidism and severe growth retardation. A 5-month-old girl was scheduled to undergo patch closure of atrial septal defect. She had been diagnosed with YSS preoperatively. We report out clinical experience of a case of YSS patient with brief review of related literatures and relevant anesthetic problems.

Cardiac arrest that developed during anesthetic induction in a patient with abdominal gas gangrene - A case report -

We report here on a fatal case of abdominal gas gangrene. Two days after gastrectomy, a 56-year-old man presented with intractable abdominal pain and fever of a sudden onset, which quickly progressed over several hours to septic shock. Despite of the unexplained gas collections in the abdominal muscle, fascia, and subcutaneous layers on computed tomography scan, its clinical significance was overlooked. Emergency laparotomy was initially scheduled because of concern that there may have been a perforated viscus. At the time of monitoring for the anesthesia, we noticed marbled skin discoloration and the subcutaneous emphysema had spread on his flank. Shortly after the initial suspicion of gas gangrene, cardiac arrest developed during the arterial line cannulation. Despite prompt resuscitation measures, including the administration of catecholamines and the application of extracoporeal membrane oxygenation, he eventually died. Anesthesiologists need to understand this fulminant disease because extensive debridement under general anesthesia is essential for the treatment of abdominal gas gangrene.

Anesthetic managements for correction of aortic valve regurgitation in a patient with Loeys-Dietz Syndrome - A case report -

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.