Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery.

Background: There is no objective quantitative parameter for dysphagia, and the relationship between changes in maximum tongue pressure values and dysphagia is unknown. This study aimed to determine whether there is a difference in the change in maximal tongue pressure after extubating patients who were ventilated after cardiovascular surgery, with or without dysphagia. Materials and methods: Adult patients who underwent mechanical ventilation via endotracheal intubation following cardiovascular surgery were included. Tongue pressure was measured before cardiovascular surgery and at 6 hours; 3 and 7 days after extubation. Dysphagia was confirmed by the functional oral intake scale (FOIS) on day 7 after extubation; an FOIS level above or equal to 6 was considered "dysphagia-negative." Results: Of 68 patients, 15 (22.1%) were in the dysphagia-positive group, which significantly showed a history of diabetes mellitus, prolonged mechanical ventilation, and postextubation hospitalization. Additionally, the postoperative C-reactive protein level was significantly higher in the dysphagia-positive group than in the dysphagia-negative group. Maximum tongue pressure was significantly lower in the dysphagia-positive group at 3 and 7 days postextubation. Using a cutoff value of 27.6 kPa in a receiver operating characteristic (ROC) curve for maximum tongue pressure at 3 days after extubation, the area under the curve (AUC) was 0.82, sensitivity was 84.9%, and specificity was 84.2%. Conclusion: Tongue pressure at 3 days after extubation is significantly lower in patients with dysphagia after cardiovascular surgery than in patients without dysphagia. If the maximum tongue pressure value is below 27.6 kPa on the third day following extubation, oral intake should be performed with caution. How to cite this article: Yamada T, Ochiai R, Kotake Y. Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery. Indian J Crit Care Med 2022;26(12):1253-1258.

Impact of Left Heart Bypass on Arterial Oxygenation During One-Lung Ventilation for Thoracic Aortic Surgery.

OBJECTIVE: The aim of this study was to reveal the mechanism of improved arterial oxygenation by measuring the changes in oxygenation before and after initiation of left heart bypass (LHB) during one-lung ventilation (OLV) for thoracic aortic surgery. DESIGN: Prospective, observational study. SETTING: Single-institution, private hospital. PARTICIPANTS: The study comprised 50 patients who underwent aortic surgery via a left thoracotomy approach with LHB circulatory support. INTERVENTIONS: Patients were ventilated using pure oxygen during OLV, and the ventilator setting was left unchanged during the measurement period. MEASUREMENTS AND MAIN RESULTS: The measurement of partial pressure of arterial oxygen (PaO2) was made at the following 4 time points: 2 minutes after heparin infusion (point 1 [P1]), 2 minutes after inflow cannula insertion through the left pulmonary vein (P2), immediately before LHB initiation (P3), and 10 minutes after LHB initiation (P4). The mean±standard deviation (mmHg) of PaO2 measurements at the P1, P2, P3, and P4 time points were 244±121, 250±123, 419±122, and 430±109, respectively, with significant increases between P1 and P3, P1 and P4, P2 and P3, and P2 and P4 (p<0.0001, respectively). No significant increase in PaO2 was seen between P1 and P2 or between P3 and P4. CONCLUSIONS: The improved arterial oxygenation during OLV in patients who underwent thoracic aortic surgery using LHB can be attributed to the insertion of an inflow cannula via the left pulmonary vein into the left atrium before LHB.

Comparison of the ability of two continuous cardiac output monitors to measure trends in cardiac output: estimated continuous cardiac output measured by modified pulse wave transit time and an arterial pulse contour-based cardiac output device.

Estimated continuous cardiac output (esCCO), a noninvasive technique for continuously measuring cardiac output (CO), is based on modified pulse wave transit time, which in turn is determined by pulse oximetry and electrocardiography. However, its trending ability has never been evaluated in patients undergoing non-cardiac surgery. Therefore, this study examined esCCO's ability to detect the exact changes in CO, compared with currently available arterial waveform analysis methods, in patients undergoing kidney transplantation. CO was measured using an esCCO system and arterial pressure-based CO (APCO), and compared with a corresponding intermittent bolus thermodilution CO (ICO) method. Percentage error and statistical methods, including concordance analysis and polar plot analysis, were used to analyze results from 15 adult patients. The difference in the CO values between esCCO and ICO was -0.39 ± 1.15 L min(-1) (percentage error, 35.6 %). And corrected precision for repeated measures was 1.16 L min(-1) (percentage error for repeated measures, 36.0 %). A concordance analysis showed that the concordance rate was 93.1 %. The mean angular bias was -1.8° and the radial limits of agreement were ±37.6°. The difference between the APCO and ICO CO values was 0.04 ± 1.37 L min(-1) (percentage error, 42.4 %). And corrected precision for repeated measures was 1.37 L min(-1) (percentage error for repeated measures, 42.5 %). The concordance rate was 89.7 %, with a mean angular bias of -3.3° and radial limits of agreement of ±42.2°. This study demonstrated that the trending ability of the esCCO system is not clinically acceptable, as judged by polar plots analysis; however, its trending ability is clinically acceptable based on a concordance analysis, and is comparable with currently available arterial waveform analysis methods.

[What Should We Know about Respiratory Physiology for the Optimal Anesthesia Management?].

Gas exchange in the lungs is dependent on the balance between ventilation and pulmonary perfusion, and such balance could be modified and affected by various factors, including gravity, body position, physical property of the lung, and neurological as well as humoral factors. Oxygenation is the process where the oxygen molecule moves from alveoli to the blood plasma, and this process is highly dependent on the diffusion capacity. Although the oxygen partial pressure in the blood plasma at alveoli rises rapidly because of its very low solubility, hemoglobin is essential to maintain adequate oxygen content in the whole blood. When a part of the lung has atelectasis, pulmonary shunt and desaturation of arterial blood ensue. For the optimal patient care, atelectasis and pulmonary shunt should be taken care of well with thorough monitoring. Ventilation is the process where carbon dioxide (CO2) moves from blood plasma to alveoli, and can eliminate CO2, produced by metabolism. The understanding of ventilator-induced lung injury (VILI) during acute respiratory failure leads us to ventilate the lungs in less harmful way, with lung protective ventilation, and the most important factor is driving pressure (inspiratory plateau pressure-PEEP). When the ventilator setting should be adjusted in order to maintain adequate ventilation, the respiratory frequency is essential to adjust alveolar ventilation without affecting driving pressure.

The comparison between stroke volume variation and filling pressure as an estimate of right ventricular preload in patients undergoing renal transplantation.

PURPOSE: The purpose of this prospective, observational study was to respiratory variation of stroke volume (stroke volume variation, SVV) against central venous pressure (CVP) and pulmonary artery diastolic pressure (PADP) as an estimate of right and left ventricular preload. METHODS: With IRB approval and informed consent, 31 patients undergoing living related renal transplantation were analyzed. Under general anesthesia with positive pressure ventilation, stroke volume index and SVV were continuously monitored with FloTrac/Vigileo monitor. Right ventricular end-diastolic volume index (RVEDVI) as well as CVP and PADP were continuously monitored with volumetric pulmonary artery catheter. Data of every 30 min interval were used for analysis. The relationship between RVEDVI and CVP, PADP, SVV was analyzed with non-linear regression and the goodness-of-fit was assessed with coefficient of determination (R(2)) of each regression curve. The ability of CVP, PADP and SVV to correctly differentiate RVEDVI <100, <120 or >138 ml/m(2), which were used to guide fluid administration, was also assessed with ROC analysis. RESULTS: Three hundred forty-eight data sets were obtained and analyzed. The goodness of fit between RVEDVI and SVV (R(2)) = 0.48) was better than that between RVEDVI and CVP or PADP (R(2)) = 0.19 and 0.33, respectively). The area under the ROC curve of SVV was significantly high compared to CVP or PADP. CONCLUSIONS: This study confirmed the theoretical framework of right ventricular preload and ventricular filling pressure and respiratory variation of stroke volume. The result also suggests that SVV can correctly predict preload status compared to pressure-based indices.

Reduction in the incidence of acute kidney injury after aortic arch surgery with low-dose atrial natriuretic peptide: a randomised controlled trial.

BACKGROUND: Acute kidney injury (AKI) after surgery is associated with an increased risk of adverse events and death. Atrial natriuretic peptide (ANP) dilates the preglomerular renal arteries and inhibits the renin-angiotensin axis. A low-dose ANP infusion increases glomerular filtration rate after cardiovascular surgery, but it is not known whether it reduces the incidence of AKI or the mortality rate. OBJECTIVE: To evaluate whether an intravenous ANP infusion prevents AKI in patients undergoing aortic arch surgery requiring hypothermic circulatory arrest. DESIGN: A randomised controlled study. SETTING: Operating room and intensive care unit at Kawasaki Saiwai Hospital, Kanagawa, Japan. PATIENTS: Forty-two patients with normal preoperative renal function undergoing elective repair of an aortic arch aneurysm. INTERVENTION: Patients were assigned randomly to receive a fixed dose of ANP (0.0125 µg (-1) kg(-1)  min) or placebo. The infusion was started after induction of anaesthesia and continued for 24  h postoperatively. MAIN OUTCOME MEASURES: The primary end-point was the incidence of AKI within 48 h after surgery. RESULTS: AKI developed in 30% of patients who received ANP compared with 73% of patients who received placebo (P = 0.014). Intraoperative urine output was almost 1 l greater in patients who received ANP (1865 ±â€Š1299 versus 991 ±â€Š480  ml in the control group, P = 0.005). However, there were no differences in mean arterial pressure or number of episodes of hypotension between the groups. Length of hospital and intensive care stays were not significantly different, nor was there a difference in 30-day mortality. No patients required haemodialysis or continuous renal replacement therapy. CONCLUSION: We found that an intravenous infusion of ANP at 0.0125  µg  kg(-1)  min(-1) is an effective intervention for reducing the incidence of postoperative AKI, and appears to afford a degree of renal protection during and after cardiovascular surgery. TRIAL REGISTRATION: Kawasaki ANP trial, UMIN Clinical Trials Registry ID: UMIN000011650.

Evaluation of the estimated continuous cardiac output monitoring system in adults and children undergoing kidney transplant surgery: a pilot study.

Evaluation of the estimated continuous cardiac output (esCCO) allows non-invasive and continuous assessment of cardiac output. However, the applicability of this approach in children has not been assessed thus far. We compared the correlation coefficient, bias, standard deviation (SD), and the lower and upper 95 % limits of agreement for esCCO and dye densitography-cardiac output (DDG-CO) measurements by pulse dye densitometry (PDD) in adults and children. On the basis of these assessments, we aimed to examine whether esCCO can be used in pediatric patients. DDG-CO was measured by pulse dye densitometry (PDD) using indocyanine green. Modified-pulse wave transit time, obtained using pulse oximetry and electrocardiography, was used to measure esCCO. Correlations between DDG-CO and esCCO in adults and children were analyzed using regression analysis with the least squares method. Differences between the two correlation coefficients were statistically analyzed using a correlation coefficient test. Bland-Altman plots were used to evaluate bias and SD for DDG-CO and esCCO in both adults and children, and 95 % limits of agreement (bias ± 1.96 SD) and percentage error (1.96 SD/mean DDG-CO) were calculated and compared. The average age of the adult patients (n = 10) was 39.3 ± 12.1 years, while the average age of the pediatric patients (n = 7) was 9.4 ± 3.1 years (p < 0.001). For adults, the correlation coefficient was 0.756; bias, -0.258 L/min; SD, 1.583 L/min; lower and upper 95 % limits of agreement for DDG-CO and esCCO, -3.360 and 2.844 L/min, respectively; and percentage error, 42.7 %. For children, the corresponding values were 0.904; -0.270; 0.908; -2.051 and 1.510 L/min, respectively; and 35.7 %. Due to the high percentage error values, we could not establish a correlation between esCCO and DDG-CO. However, the 95 % limits of agreement and percentage error were better in children than in adults. Due to the high percentage error, we could not confirm a correlation between esCCO and DDG-CO. However, the agreement between esCCO and DDG-CO seems to be higher in children than in adults. These results suggest that esCCO can also be used in children. Future studies with bigger study populations will be required to further investigate these conclusions.

Evaluation of multiwave pulse total-hemoglobinometer during general anesthesia.

The purpose of this prospective study was to evaluate the accuracy and trending ability of a four-wavelength pulse-total hemoglobinometer that continuously and noninvasively measures hemoglobin in surgical patients. With IRB approval and informed consent, spectrophotometric hemoglobin (SpHb) was measured with a pulse-total hemoglobinometer manufactured by Nihon Kohden Corp (Tokyo, Japan) and compared to the CO-oximeter equipped with blood gas analyzer. Two hundred twenty-five samples from 56 subjects underwent analysis. Bland-Altman analysis revealed that the bias ± precision of the current technology was 0.0 ± 1.4 g/dl and -0.2 ± 1.3 g/dl for total samples and samples with 8 < Hb < 11 g/dl, respectively. The percentages of samples with intermediate risk of therapeutic error in error grid analysis and the concordance rate of 4-quadrant trending assay was 17 % and 77 %, respectively. The Cohen kappa statistic for Hb < 10 g/dl was 0.38, suggesting that the agreement between SpHb and CO-oximeter-derived Hb was fair. Collectively, wide limits of agreement, especially at the critical level of hemoglobin, and less than moderate agreement against CO-oximeter-derived hemoglobin preclude the use of the pulse-total hemoglobinometer as a decision-making tool for transfusion.

Low molecular weight pentastarch is more effective than crystalloid solution in goal-directed fluid management in patients undergoing major gastrointestinal surgery.

BACKGROUND: This prospective observational study compared the volume effect between hydroxyethyl starch (HES) and crystalloid solution and its context dependency in intraoperative goal-directed fluid management. METHODS: With institutional review board (IRB) approval, 35 patients undergoing major gastrointestinal surgery were enrolled. Fluid challenge consisting of 250 ml of either bicarbonate Ringer solution (BRS) or low molecular weight pentastarch (HES 70/0.5) was given to maintain stroke volume index >35 ml/m2. The context of fluid challenge was classified as related to either epidural block (EB) or blood loss (BL) or as nonspecific. The primary end point was the interval between index fluid challenge and the next fluid challenge, and the secondary end point was the hemodynamic parameter at the end of fluid challenge. Differences in these parameters in each clinical context were compared between BRS and HES 70/0.5. A p value <0.05 was considered statistically significant. RESULTS: Eighty-eight, 77, and 127 fluid challenges were classified as related to EB and BL and as nonspecific, respectively. In the nonspecific condition, the median (range) interval after fluid challenge with HES 70/0.5 and BRS was 45 (11-162) min and 18 (8-44) min, respectively, and the difference was statistically significant. Also, mean arterial pressure and stroke volume index significantly increased, whereas stroke volume variation significantly decreased after fluid challenge with HES 70/0.5 compared with BRS. Such differences were not observed in the other situations. CONCLUSIONS: HES 70/0.5 exerted larger volume effects than did crystalloid under nonspecific conditions. However, similar volume effects were observed during volume loss and extensive sympathetic blockade.

Comparative evaluation of stroke volume variation measured by pulse wave transit time and arterial pressure wave.

BACKGROUND: Several monitors have been developed that measure stroke volume (SV) in a beat-to-beat manner. Accordingly, Stroke volume variation (SVV) induced by positive pressure ventilation is widely used to predict fluid responsiveness. OBJECTIVE: The purpose of this study was to compare the ability of two different methods to predict fluid responsiveness using SVV, stroke volume variation by esCCO (esSVV) and stroke volume variation by FloTrac/VigileoTM (flSVV). METHODS: esSVV, flSVV, and stroke volume index (SVI) by both monitoring devices of 37 adult patients who underwent laparotomy surgery, were measured. Receiver operating characteristic (ROC) analysis was performed. RESULTS: The area under the ROC curve (AUC) of esSVV was significantly higher than that of flSVV (p= 0.030). esSVV and flSVV showed cutoff values of 6.1% and 10% respectively, to predict an increase of more than 10% in SVI after fluid challenge. The Youden index for esSVV was higher than flSVV, even with a cutoff value between 6% and 8%. CONCLUSION: Since esSVV and flSVV showed significant differences in AUC and cutoff values, the two systems were not comparable in predicting fluid responsiveness. Furthermore, it seems that SVV needs to be personalized to accurately predict fluid responsiveness for each patient.

Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block.

BACKGROUND: In Japan, routine clinical care does not normally involve the use of a monitoring device to guide the administration of neuromuscular blocking drugs or their antagonists. Although most previous reports demonstrate that sugammadex offers more rapid and reliable antagonism from rocuronium-induced neuromuscular blockade, this advantage has not been confirmed in clinical settings when no neuromuscular monitoring is used. In this multicenter observational study, we sought to determine whether sugammadex reduces the incidence of postoperative residual weakness compared with neostigmine when the administration of rocuronium and its antagonists is not guided by neuromuscular monitoring. METHODS: This study was conducted in two 5-month periods that preceded and followed the introduction of sugammadex into clinical practice in Japan. Five university-affiliated teaching hospitals participated in this study. Neostigmine was used to antagonize rocuronium-induced neuromuscular blockade in the first phase, and sugammadex was used in the second phase. The timing and doses of rocuronium, neostigmine, and sugammadex were determined by the attending anesthesiologists without the use of neuromuscular function monitoring devices. To ascertain the incidence of postoperative residual neuromuscular weakness, the train-of-four ratio (TOFR) was determined acceleromyographically after tracheal extubation. Since our practice also does not usually involve calibration and normalization of accelerographic responses, both TOFR <0.9 and TOFR <1.0 were used as the criteria for defining postoperative residual weakness. RESULTS: In the first phase, 109 patients received neostigmine (average dose 33 µg/kg) and 23 patients were considered (by clinical criteria) to have adequate recovery and did not receive neostigmine (spontaneous recovery group). In the second phase, 117 patients received sugammadex (average dose 2.7 mg/kg) for antagonism of rocuronium-induced blockade. The incidence (95% confidence interval) of TOFR <0.9 under spontaneous recovery, after neostigmine, and after sugammadex, was 13.0% (2.8%-33.6%), 23.9% (16.2%-33.0%), and 4.3% (1.7%-9.4%), respectively. The incidence (95% confidence interval) of TOFR <1.0 in these groups was 69.6% (47.1%-86.6%), 67.0% (57.3%-75.7%), and 46.2% (36.9%-55.6%), respectively. The use of sevoflurane in the neostigmine group and the short interval between the administration of the last doses of rocuronium and sugammadex were associated with a higher incidence of postoperative residual weakness. CONCLUSIONS: This study demonstrated that the risk of TOFR <0.9 after tracheal extubation after sugammadex remains as high as 9.4% in a clinical setting in which neuromuscular monitoring (objective or subjective) was not used. Our finding underscores the importance of neuromuscular monitoring even when sugammadex is used for antagonism of rocuronium-induced neuromuscular block.

Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) severe respiratory failure in Japan.

PURPOSE: To evaluate procedures and outcomes of extracorporeal membrane oxygenation (ECMO) therapy applied to 2009 influenza A(H1N1) severe respiratory failure patients in Japan. METHODS: This observational study used database information about adults who received ECMO therapy for H1N1-related severe respiratory failure from April 1, 2010 to March 31, 2011. RESULTS: Fourteen patients from 12 facilities were enrolled. Anti-influenza drugs were used in all cases. Before the start of ECMO, the lowest PaO(2)/FiO(2) was median (interquartile) of 50 (40-55) mmHg, the highest peak inspiratory pressure was 30 (29-35) cmH(2)O, and mechanical ventilation had been applied for at least 7 days in 5 patients. None of the facilities had extensive experience with ECMO for respiratory failure (6 facilities, no previous experience; 5 facilities, one or two cases annually). The blood drainage cannula was smaller than 20 Fr. in 10 patients (71.4 %). The duration of ECMO was 8.5 (4.0-10.8) days. The duration of each circuit was only 4.0 (3.2-5.3) days, and the ECMO circuit had to be renewed 19 times (10 cases). Thirteen patients (92.9 %) developed adverse events associated with ECMO, such as oxygenator failure, massive bleeding, and disseminated intravascular coagulation. The survival rate was 35.7 % (5 patients). CONCLUSION: ECMO therapy for H1N1-related severe respiratory failure in Japan has very poor outcomes, and most patients developed adverse events. However, this result does not refute the effectiveness of ECMO. One possible cause of these poor outcomes is the lack of satisfactory equipment, therapeutic guidelines, and systems for patient transfer to central facilities.

Acute kidney injury during aortic arch surgery under deep hypothermic circulatory arrest.

PURPOSE: The aim of this investigation was to describe the renal outcome and to identify risk factors for acute kidney injury (AKI), as defined by the Acute Kidney Injury Network (AKIN), during aortic arch surgery (AAS) under deep hypothermic circulatory arrest (DHCA). METHODS: A retrospective and observational study has been performed. One hundred thirty-five patients requiring AAS under DHCA were studied. RESULTS: Seventy-one patients (52.6%) developed AKI during the postoperative period. A logistic regression analysis identified three independent risk factors for AKI: preoperative hypertension (HT), emergency surgery, and duration of DHCA. Renal replacement therapy (RRT) was required in four patients (3.0%). The postoperative mortality rate among the patients with AKI was 2.8%, which was not statistically different from the rate of 1.6% observed in the non-AKI group (P = 0.62). CONCLUSIONS: A high incidence of AKI during AAS under DHCA was confirmed. Because AKI is highly associated with aortic surgery, novel approaches for protecting the kidneys other than deep hypothermia are needed. The logistic regression model identified HT, emergency surgery, and duration of DHCA as independent risk factors for AKI.

Validation of inflationary non-invasive blood pressure monitoring in adult surgical patients.

Oscillometric determination of blood pressure may be advantageous, as cuff inflation requires lower cuff pressure and shorter duration than deflation. In this observational study, we compared the blood pressure value, cuff pressure, and duration of cuff inflation between a prototype of inflationary non-invasive blood pressure (NIBP) and conventional deflationary NIBP in adult patients during anesthesia. Three hundred and twenty-three pairs of measurements were obtained from 64 subjects. The bias and precision of systolic pressure and diastolic pressure were 2.9 ± 8.3 and 5.6 ± 6.1 mmHg, respectively. Inflationary NIBP could better determine NIBP with lower cuff pressure than deflationary NIBP (124 ± 22 vs. 160 ± 33 mmHg, p < 0.05). Inflationary NIBP could also determine NIBP more quickly (13.0 ± 2.3 vs. 32.7 ± 13.6 s, p < 0.05). These data suggest that inflationary NIBP may reduce cuff-related discomfort and complications, and has reasonable accuracy compared to deflationary NIBP in adult surgical patients.

[Anesthetic management of patients with pulmonary arterial hypertension (PAH)].

BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk due to the severity of cardiac dysfunction related to the RV Tei index greater than 0.83. We evaluated the car- diovascular function during anesthesia to elucidate the characteristics of severity of PAH. METHODS: Nine patients undergoing central venous catheterization under general anesthesia (seven patients) and local anesthesia with sedation (two patients) were studied. RV Tei index of five patients were greater than 0.83 (severe) and in four patients RV Tei index was below 0.83 (moderate). Bioimpedance method was used to determine stroke volume (SV) and cardiac output (CO) non-invasively throughout anesthesia. The correlation between the changes in SV and CO was evaluated by using least squares method. RESULTS: Demographic data showed mean age of 16.6 years, height of 146.9 cm and weight of 39.7 kg. Correlation coefficient of SV and CO in the patients with severe cardiac dysfunction was 0.0-0.21, while in those with moderate cardiac dysfunction it was 0.49-0.93. CONCLUSIONS: In patients with severe PAH, it was demonstrated that CO is maintained by the change in heart rate (HR) but not by SV It is suggested that the control of HR in patients with PAH is of clinical importance in order to maintain CO, if RV index is greater than 0.83.

Comparison of the ability of two continuous cardiac output monitors to detect stroke volume index: Estimated continuous cardiac output estimated by modified pulse wave transit time and measured by an arterial pulse contour-based cardiac output device.

BACKGROUND: Estimated continuous cardiac output (esCCO), a non-invasive technique for continuously measuring cardiac output (CO), is based on modified pulse wave transit time, which is determined by pulse oximetry and electrocardiography. OBJECTIVE: We examined the ability of esCCO to detect stroke volume index (SVI) and changes in SVI compared with currently available arterial waveform analysis methods. METHODS: We retrospectively reanalysed 15 of the cases from our previous study on esCCO measurement. SVI was calculated using an esCCO system, measured using the arterial pressure-based CO (APCO) method, and compared with a corresponding intermittent bolus thermodilution CO (ICO) method. Percentage error measurement and statistical methods, including concordance analysis and polar plot analysis, were performed. RESULTS: The difference in the SVI values between esCCO and ICO was -3.0 ± 8.8 ml (percentage error, 33.5%). The mean angular bias was 0.8 and the radial limits of agreement were ± 27.3. The difference in the SVI values between APCO and ICO was 0.9 ± 11.2 ml (percentage error, 42.6%). The mean angular bias was -6.8 and the radial limits of agreement were ± 44.1. CONCLUSION: This study demonstrated that the accuracy, precision, and dynamic trend of esCCO are better than those of APCO.

Preventive Effects of Sustainable and Developmental Perioperative Oral Management Using the "Oral Triage" System on Postoperative Pneumonia after Cancer Surgery.

Perioperative oral management is widely recognized in the healthcare system of Japan. Conventionally, the surgeon refers patients with oral problems to a dental or oral surgery clinic in the hospital. However, frequent in-house referrals were found to increase the number of incoming patients resulting in unsustainable situations due to an insufficient workforce. In 2011, the Center for Perioperative Medicine was established at our hospital to function as a management gateway for patients scheduled to undergo surgery under general anesthesia. The "oral triage" system, wherein a dental hygienist conducts an oral screening to select patients who need preoperative oral hygiene and functional management, was established in 2012. A total of 37,557 patients who underwent surgery at our hospital from April 2010 to March 2019 (two years before and seven years after introducing the system) were evaluated in this study. The sustainability and effectiveness of introducing the system were examined in 7715 cancer surgery patients. An oral management intervention rate of 20% and a significant decrease in the incidence of postoperative pneumonia (aOR = 0.50, p = 0.03) indicated that this system could be useful as a sustainable and developmental oral management strategy to manage surgical patients with minimal human resources.

Evaluating a Dynamic Trend in the Estimated Continuous Cardiac Output Calibrated With Invasive and Non-Invasive Methods.

OBJECTIVE: This study compared the estimated continuous cardiac output (esCCO) system and an arterial pressure-based CO (APCO) system. The goal of this study was to evaluate the dynamic trend of the esCCO calibrated with an invasive and non-invasive method. METHODS: We retrospectively identified 12 cases with complete data for the two calibration methods. Two calibration methods were analysed and compared with APCO using polar plots. RESULTS: Polar plotting revealed that the mean angular bias was 10.0°, and the radial limit of agreement was 37.1° when calibrated with the invasive method, while the mean angular bias was 3.5°, and the radial limit of agreement was 28.3° with the non-invasive method. CONCLUSION: This study suggested that the accuracy of a dynamic trend of esCCO may not be affected by the calibration methods, and the esCCO measurement by the non-invasive calibration method may be an effective device similar to that by the invasive calibration method.

[A pilot assessment of the FloTrac cardiac output monitoring system comparing with pulmonary artery catheter method by three versions].

BACKGROUND: Clinical significance of PA catheter is controversial. FloTrac sensor bases its calculations on arterial waveform characteristics. We conducted a pilot assessment of the FloTrac sensor by three versions comparing with pulmonary artery catheter (PCA) methodology. METHODS: Five patients undergoing cardiac surgery and four patients undergoing renal transplantation were enrolled. A PAC was inserted and radial arterial access was used for semi-invasive determination of CO (APCO) with the Vigileo. CO was measured simultaneously by bolus thermodilution and the Vigileo technique, and CCO was measured simultaneously. RESULTS: The correlation with output obtained by FloTrac and obtained by PCA is better with the newer version. Bland Altman analyses demonstrated better agreement between FloTrac and PCA methodology of the newer version. CONCLUSIONS: CO measured by a new semi-invasive arterial pressure waveform analysis device showed better agreement with pulmonary artery thermodilution measurement of the newer version.