Accuracy and Trending of Continuous Noninvasive Hemoglobin Monitoring in Patients Undergoing Liver Transplantation.

BACKGROUND: Shift in large fluid volumes and massive blood loss during liver transplantation frequently leads to rapid changes in hemoglobin (Hb) concentration; thus, to ensure adequate tissue oxygenation, accurate and rapid determination of Hb concentration is essential in transplant recipients. The Radical-7 Pulse CO-Oximeter provides a noninvasive and continuous way to monitor Hb concentration (SpHb) in real time and is an ideal candidate for use during liver transplantation. In this study, we assessed the relationship between SpHb and total Hb (tHb) obtained from arterial blood samples during surgery. METHODS: Forty patients undergoing liver transplantation were enrolled in this study. tHb and time-matched SpHb were measured at 5 different phases throughout surgery. Paired SpHb and tHb levels were assessed using linear regression, Bland-Altman analysis, and the Critchley polar plot method. RESULTS: A total of 161 paired measurements with sufficient signal quality were analyzed. The correlation between SpHb and tHb was 0.59 (P < .001). Bland-Altman analysis revealed that a bias between SpHb and tHb was 2.28 g/dL, and limits of agreement (LoA) were from -0.78 to 5.34 g/dL. Trending analysis showed that 87% of data were located within the acceptable trending area, indicating that the trending ability was not satisfied. CONCLUSIONS: The Radical-7 Pulse CO-Oximeter was not sufficient to monitor Hb levels and trends during liver transplantation surgery in our cohort. In particular, in critical patients and in those with low Hb levels, invasive Hb measurement should be used for assessment.

Cardiac Output Assessed by the Fourth-Generation Arterial Waveform Analysis System Is Unreliable in Liver Transplant Recipients.

BACKGROUND: Liver transplant recipients often have violent hemodynamic fluctuation during surgery that may be related to perioperative and postoperative morbidity. Because there are some considerations for the risk of the pulmonary arterial catheter (PAC), the conventional invasive device for cardiac output (CO) measurement, a reliable and minimally invasive alternative is required. We validated the reliability of CO measurements with the use of a minimally invasive FloTrac system with the latest fourth-generation algorithm in liver transplant recipients. METHODS: Forty liver transplant recipients without atrial fibrillation, valvular pathology, or intracardiac shunt were recruited in this prospective, observational study. CO values measured by use of PAC with continuous thermodilution method (COTh) and FloTrac devices (COFT) were collected simultaneously throughout the operation for reliability validation. RESULTS: Four hundred pairs of CO data points were collected in total. The linear regression analysis showed a high correlation coefficient (73%, P < .001). However, the percent error between COTh and COFT was 42.2%, which is worse than the established interchangeability criterion of 30%. The concordance rates were calculated at 89% and 59% by 4-quadrant plot and polar plot analysis, respectively. Neither met the preset validation criteria (>92% for the 4-quadrant plot and >90% for polar plot analyses). CONCLUSIONS: Our study demonstrates that the CO measurements in liver transplant recipients by the latest FloTrac system and the PAC do not meet the recognized interchangeability criterion. Although the result showed improvement in linear regression analysis, it failed to display a qualified trending ability.

Metabolic disturbance in obese children: glucose, insulin levels and lipid profile.

Obesity is a common nutritional disorder among children and adolescents. The purpose of this study was to investigate the biochemical changes in obese children in Taiwan, in comparison with those observed by other authors. Children with weights above 120 percent of ideal body weight were considered obese. Serum glucose, insulin, uric acid, and creatinine levels and lipid profiles of 298 obese children (mean age 11.3 +/- 2.4 years, 158 boys) and 60 controls (mean age 11.6 +/- 2.2 years, 38 boys) were determined using accepted procedures. Demographic and serum biochemical characteristics were compared between obese and control groups overall and by gender. Serum glucose, insulin, cholesterol, and triglyceride levels, known risk factors for coronary heart disease, were higher in the obese patients than in the control group. Early treatment and prevention of childhood obesity may keep the metabolic disturbance from deteriorating and becoming risk factors for coronary heart disease.

Crossed cerebellar diaschisis in herpes simplex encephalitis.

Diaschisis is extremely rare in patients with viral encephalitis. We report the phenomenon of crossed cerebellar diaschisis (CCD) in a 73-year-old man with acute herpes simplex type-1 (HSV-1) encephalitis. The diagnosis of HSV-1 encephalitis was confirmed by detecting HSV-1 deoxyribonucleic acid in the cerebrospinal fluid (CSF). Magnetic resonance images (MRI) showed enhancing lesions at bilateral temporal lobes, insular cortices, and right frontoparietal lobes. Increase signal intensity on T2-weighted images was seen in the mesecephalon. Technetium-99m ethyl cysteinate dimer (99mTc-ECD) single photon emission computed tomography (SPECT) of the brain showed a large area of hypoperfusion in the right frontotemporoparietal lobes. The side-to-side cerebellar count revealed 19% reduction of the radioisotope tracer uptake in the left cerebellum. The phenomenon of CCD was proposed to be due to both anterograde disconnection of the corticopontocerebellar tracts and retrograde deafferentation of dentatothalamocortical projections.

Increased urinary thyroxine sulfate excretion in thyroxine therapy.

Although increased thyroxine sulfate (T4S) levels have recently been detected in fetal serum and amniotic fluid, changes in patients in a high thyroxine (T4) state remain unclarified. This study was conducted to determine the changes in T4S in thyroid hormone regulation in women receiving suppressive T4 therapy. With a highly sensitive and specific radioimmunoassay, we measured the serum and urinary concentrations of T4S in 16 premenopausal women with benign nodular goiter before and after three months administration of T4 (3.2 micrograms/kg/day). Serum levels of other thyroid hormones were also measured. Significant increases in mean serum T4 levels post-treatment (11.1 vs. 6.6 micrograms/dL pre-treatment; P < 0.01) were found, although only low T4S levels were detectable in serum both pre- and post-T4 treatment. The mean urinary or creatinine corrected urinary T4S values post-treatment were significantly increased (20 ng/dL or 396 ng/g creatinine vs. 12 ng/dL or 174 ng/g creatinine pre-treatment, P < 0.01). There was a significant correlation between increased creatinine-corrected urine T4S and increased serum free T4. Our results indicate that the sulfation of T4 may be related to the regulation of thyroid hormone metabolism in T4-treated subjects with relative hyperthyroxinemia.

Dimercaptosuccinic acid renal scan in children with urinary tract infection.

The hospital records of 247 children less than 16 years old, who had had UTI and received dimercaptosuccinic acid (DMSA) renal scans during the period October 1991 to October 1993, were reviewed. Abnormal DMSA renal scans were found in 207 kidneys (207/494, 41.9%) and in 163 cases (163/247, 66%). The appearance of an abnormal DMSA renal scan is correlated with fever and vesicoureteral reflux, but not with age or sex. Because the prevalence of upper UTI in children is high, DMSA renal scan is undoubtedly a valuable tool for pediatricians as a guide in giving appropriate antibiotic therapy and to prevent further renal damage.

Conservative treatment of neonatal hydronephrosis.

From February 1990 to January 1991, 19 cases of hydronephrosis in children of less than one year of age were managed at Mackay Memorial Hospital. In the majority of these patients, there were evident causes such as ureteropelvic junction stenosis, ureterovesical reflux or a posterior urethral valve for which definite therapeutic measures were performed. However, some cases had no obvious origins and the hydronephrosis was speculated to be from nonobstructive or physiologic dilatation of the kidneys. The conventional tools, such as intravenous pyelogram or renal ultrasound, which comprise the mainstay of diagnosis, provide limited information on renal functional status. Recent introduction of the Tc-99m diethylene triamine penta-acetic acid (DTPA) diuretic renal scan has enabled us to distinguish between obstructive and nonobstructive hydronephrosis and helps us to determine whether or not surgery is necessary. In the past year, eight patients with hydronephrosis of less than one year of age were diagnosed as nonobstructive after a series of evaluations using renal ultrasound, voiding cystourethrography (VCUG) and Tc-99m DTPA diuretic renal scan. Follow-up studies by echography or DTPA renal scan revealed spontaneous resolution of the dilated collecting systems in these cases and confirms our belief that some hydronephrosis in neonates and infants may resolve spontaneously and may just be a manifestation of physiologic change during development. The value of the Tc-99m DTPA diuretic renal scan in the diagnosis of obstructive uropathy is discussed.