Accuracy of the ClearSight™ system in patients undergoing abdominal aortic aneurysm surgery.

PURPOSE: The ClearSight™ device monitors continuous pressure and cardiac output via pulse contour analysis. ClearSight™, however, may not be reliable in patients with reduced peripheral perfusion caused by high peripheral resistance. This study aimed to elucidate the accuracy and trending ability of ClearSight™ in patients undergoing abdominal aortic aneurysm (AAA) surgery by comparing the ClearSightTM-derived cardiac index (CICS) with that measured using three-dimensional echocardiography (CI3D). METHODS: The study included 20 patients who underwent elective AAA surgery. CICS and CI3D were measured simultaneously at eight time points during the surgery. Trending ability was investigated after aortic clamping and unclamping. We used CI3D as the reference method. RESULTS: Bland-Altman analysis showed a wide limit of agreement between CICS and CI3D (percentage error 41.3%). Subgroup analysis showed a lower percentage error (33.2%) in patients with CI ≥ 2.5 L/min/m2. The cubic splines related to the CI3D and CI discrepancy were negatively sloped, indicating that CI3D had significant influence on the CI discrepancy (p < 0.001). Four-quadrant plot analysis showed that the tracking ability of ClearSight™ after aortic clamping and declamping were clinically unacceptable (81.3% and 78.6%, respectively). Also, the polar plot analysis showed that the concordance rate of ClearSight™ after aortic clamping and declamping were clinically unacceptable (58.3% and 66.7%, respectively). CONCLUSIONS: ClearSight™ was not sufficiently accurate in patients undergoing AAA surgery. The tracking ability of ClearSight™ after aortic clamping was below the acceptable limit.

Mechanical prophylaxis is a heparin-independent risk for anti-platelet factor 4/heparin antibody formation after orthopedic surgery.

Platelet-activating antibodies, which recognize platelet factor 4 (PF4)/heparin complexes, induce spontaneous heparin-induced thrombocytopenia (HIT) syndrome or fondaparinux-associated HIT without exposure to unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). This condition mostly occurs after major orthopedic surgery, implying that surgery itself could trigger this immune response, although the mechanism is unclear. To investigate how surgery may do so, we performed a multicenter, prospective study of 2069 patients who underwent total knee arthroplasty (TKA) or hip arthroplasty. Approximately half of the patients received postoperative thromboprophylaxis with UFH, LMWH, or fondaparinux. The other half received only mechanical thromboprophylaxis, including dynamic (intermittent plantar or pneumatic compression device), static (graduated compression stockings [GCSs]), or both. We measured anti-PF4/heparin immunoglobulins G, A, and M before and 10 days after surgery using an immunoassay. Multivariate analysis revealed that dynamic mechanical thromboprophylaxis (DMT) was an independent risk factor for seroconversion (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), which was confirmed with propensity-score matching (OR, 1.99; 95% CI, 1.17-3.37; P = .018). For TKA, the seroconversion rates in patients treated with DMT but no anticoagulation and in patients treated with UFH or LMWH without DMT were similar, but significantly higher than in patients treated with only GCSs. The proportion of patients with ≥1.4 optical density units appeared to be higher among those treated with any anticoagulant plus DMT than among those not treated with DMT. Our study suggests that DMT increases risk of an anti-PF4/heparin immune response, even without heparin exposure. This trial was registered to www.umin.ac.jp/ctr as #UMIN000001366.

Biomechanical profiles of tracheal intubation: a mannequin-based study to make an objective assessment of clinical skills by expert anesthesiologists and novice residents.

BACKGROUND: Tracheal intubation (TI) is a key medical skill used by anesthesiologists and critical care physicians in airway management in operating rooms and critical care units. An objective assessment of dexterity in TI procedures would greatly enhance the quality of medical training. This study aims to investigate whether any biomechanical parameters obtained by 3D-motion analysis of body movements during TI procedures can objectively distinguish expert anesthesiologists from novice residents. METHODS: Thirteen expert anesthesiologists and thirteen residents attempted TI procedures on an airway mannequin using a Macintosh laryngoscope. Motion capturing technology was utilized to digitally record movements during TI procedures. The skill with which experts and novices measured biomechanical parameters of body motions were comparatively examined. RESULTS: The two groups showed similar outcomes (success rates and mean time needed to complete the TI procedures) as well as similar mean absolute velocity values in all 21 body parts examined. However, the experts exhibited significantly lower mean absolute acceleration values at the head and the left hand than the residents. In addition, the mean-absolute-jerk measurement revealed that the experts commanded potentially smoother motions at the head and the left hand. The Receiver Operating Characteristic (ROC) curves analysis demonstrated that mean-absolute-acceleration and -jerk measurements provide excellent measures for discriminating between experts and novices. CONCLUSIONS: Biomechanical parameter measurements could be used as a means to objectively assess dexterity in TI procedures. Compared with novice residents, expert anesthesiologists possess a better ability to control their body movements during TI procedures, displaying smoother motions at the selected body parts.

Accuracy and Trending Ability of the Fourth-Generation FloTrac/Vigileo System in Patients With Low Cardiac Index.

OBJECTIVES: To determine the accuracy and trending ability of the fourth-generation FloTrac/Vigileo in patients with low cardiac index by comparing FloTrac/Vigileo-derived cardiac index with that measured by 3-dimensional echocardiography. DESIGN: Prospective clinical study. SETTING: Cardiac surgery operating room in a single cardiovascular center. PARTICIPANTS: Twenty-five patients undergoing elective cardiac resynchronization therapy lead implantation. INTERVENTIONS: FloTrac/Vigileo-derived cardiac index and 3-dimensional echocardiography-derived cardiac index were determined simultaneously before and after phenylephrine bolus and cardiac resynchronization therapy using 3-dimensional echocardiography-derived cardiac index as the reference method. MEASUREMENTS AND MAIN RESULTS: Cardiac index measured by the fourth-generation FloTrac/Vigileo had a wide limit of agreement with that measured by 3-dimensional echocardiography, with a percentage error of 59.1%. The tracking ability of the unit after both phenylephrine administration and cardiac resynchronization therapy were measured by concordance rate, and both were below the acceptable limit (72.7% and 85%, respectively). CONCLUSIONS: The degree of accuracy of the fourth-generation FloTrac/Vigileo in patients with low cardiac index was not acceptable, and high systemic vascular resistance in patients with low cardiac index may have contributed to this inaccuracy. The tracking ability of the fourth-generation FloTrac/Vigileo after phenylephrine administration or cardiac resynchronization therapy was below acceptable limits.

Antigen recognition is facilitated by invadosome-like protrusions formed by memory/effector T cells.

Adaptive immunity requires that T cells efficiently scan diverse cell surfaces to identify cognate Ag. However, the basic cellular mechanisms remain unclear. In this study, we investigated this process using vascular endothelial cells, APCs that possess a unique and extremely advantageous, planar morphology. High-resolution imaging revealed that CD4 memory/effector T cells dynamically probe the endothelium by extending submicron-scale, actin-rich "invadosome/podosome-like protrusions" (ILPs). The intimate intercellular contacts enforced by ILPs consistently preceded and supported T cell activation in response to endothelial MHC class II/Ag. The resulting calcium flux stabilized dense arrays of ILPs (each enriched in TCR, protein kinase C-θ, ZAP70, phosphotyrosine, and HS1), forming what we term a podo-synapse. Similar findings were made using CD8 CTLs on endothelium. Furthermore, careful re-examination of both traditional APC models and professional APCs suggests broad relevance for ILPs in facilitating Ag recognition. Together, our results indicate that ILPs function as sensory organelles that serve as actuators of immune surveillance.

Deep hypothermic circulatory arrest for hemiarch replacement in a pediatric patient with moyamoya disease.

Moyamoya disease is a chronic cerebrovascular occlusive disease, occurring predominantly in young populations, that causes cerebral ischemia and hemorrhage. Patients with moyamoya disease are at high risk of neurological complications during cardiac surgery because of perioperative hemodynamic changes. However, there is no established evidence on temperature management during cardiopulmonary bypass. Previous reports described normothermia or mild to moderate hypothermia during cardiopulmonary bypass in patients with moyamoya disease; however, surgical conditions, such as not having enough space to clamp the aorta or a clean surgical field, sometimes force us to use deep hypothermic circuratory arrest. We report a successful case of a pediatric patient with moyamoya disease who underwent deep hypothermic circulatory arrest (18 °C) for hemiarch replacement without neurological complications. Deep hypothermia may be an alternative technique for achieving cerebral protection in the context of moyamoya disease.

[Anesthetic management of intraoperative aortic dissection during cardiovascular surgery].

Despite considerable advances in anesthesia technique, intraoperative aortic dissection remains a potentially lethal complication during on-pump cardiovascular surgery. Intraoperative dissection has been described worldwide, ranging between 0.06% and 0.24%. Here we present 8 patients who had intraoperative dissection during 10-year period with 6,266 on-pump cases (0.13%, 95% confidence interval 0.12% to 0.14%). In-hospital mortality rate of intraoperative dissection was 12.5% (1/8) at our institution, which was exceptionally lower than that reported previously (24% to 43%). Therefore, we also show our treatment strategy for intraoperative dissection with the related-literature review. The original surgical procedures were descending aortic replacement in 3 patients, valve replacement in 4 patients, and aortic-root replacement in 1 patient. Dissection occurred during aortic cannulation in 6 patients and during manipulation of aortic cross-clamping/de-clamping in 2 patients. Three patients had retrograde dissection extending and beyond the arch. Trans-esophageal echocardiography was useful to confirm dissection and ensure proper perfusion of the aortic-branches. Immediately after its diagnosis, all patients were managed with hypotensive strategy and subsequently underwent deep hypothermic circulatory arrest for prevention of dissection propagation. Among patients with intraoperative aortic dissection undergoing on-pump cardiovascular surgery, not only earlier diagnosis but proper anesthetic management may be crucial for the successful outcome.

[Undiagnosed hereditary angioedema in a patient undergoing emergency caesarean section].

Hereditary angioedema (HAE) is characterized by acute, recurrent attacks of localized edema. Surgical procedures, trauma, and infections have been considered as potential triggers of HAE. Although HAE is a rare genetic disorder, approximately 50-60% of all HAE patients are involved with at least one occurrence of upper airway obstruction. The airway trouble is the most life-threating complication in HAE patients because HAE-related edema does not respond to typical treatment, such as administration of epinephrine, antihistamines, or glucocorticoids. Indeed, mortality rates of laryngeal attack are estimated around 25% to 40%. Here we describe a case of undiagnosed HAE patient undergoing emergency caesarean section under neuraxial blockade. A 31-year-old woman showed multiple regions at her lip margin during surgery and rapidly developed lip swelling after admission to the ward. Neither respiratory nor hemodynamic instability was found during and after surgery. Immediately, in order to assess whether HAE caused these dermatological manifestations, we measured values of both complement component 4 (C4) and functional activity of C1-esterase inhibitor (C1-inh), a protein of the complement system. These laboratory data showed low levels, which were compatible with HAE definition. After commencement of C1-inhibitor replacement therapy, her lip swelling and erythema gradually disappeared without adverse drug reactions. The patient was finally discharged from our institution 10 days after surgery.

[Bladder temperature versus tympanic temperature in patients undergoing abdominal aortic aneurysm surgery].

BACKGROUND: Inaccurate measurements of body temperature might be associated with complications during the perioperative period. We conducted a retrospective cohort study to compare the bladder temperature and the tympanic membrane temperature in patients undergoing open repair of abdominal aortic aneurysm. METHODS: Fifteen adult patients who had undergone general anesthesia with/without epidural anesthesia were included in the present cohort. The bladder and the tympanic temperatures were simultaneously recorded at 6 points during surgery. One-way repeated measures ANOVA and Bland-Altman analysis were performed to assess statistical significance. The two-tailed P values less than 0.05 were considered statistically significant. RESULTS: No difference was found between the bladder and the tympanic temperatures before abdominal aortic cross-clamping. However, during and after cross-clamping, the bladder temperature values were likely to be lower compared with the tympanic values. The average temperature difference (+/- 2 SD) was 0.4 degrees C (+/- 1.1 degrees C) (95% CI: -1.21-0.78). CONCLUSIONS: The tympanic membrane might be a reliable site for core body temperature measurement in abdominal aortic aneurysm surgery patients.

New observations on the trafficking and diapedesis of monocytes.

PURPOSE OF REVIEW: Monocytes play multiple roles in immune system functions and inflammatory diseases such as atherosclerosis. These roles are coupled to diverse trafficking and cellular migration behaviors. Here, we review recent advances in our understanding of such behaviors with emphasis on broad scale trafficking patterns and the cellular and molecular mechanisms regulating diapedesis, a central aspect of trafficking. RECENT FINDINGS: Monocytes consist of 'inflammatory' and 'resident' subsets, which exhibit differential functions and trafficking properties. Notably, the spleen has recently been identified as a reservoir of inflammatory monocytes, which are readily recruited to injured myocardium and possibly other tissues. Resident monocytes have been shown to undergo long-range crawling within the lumen of the microvasculature, which facilitates immune surveillance and rapid response to infection. Monocyte diapedesis has been demonstrated to utilize both para and transcellular migration routes facilitated by endothelial 'transmigratory cups'. A significant number of new adhesion molecules and signaling pathways have recently been uncovered as functional mediators and modulators of these processes. SUMMARY: Our improving understanding of monocyte trafficking and migration mechanisms has begun to shed light on the functions of these often enigmatic cells. Continued progress in this area will be critical for elucidating roles of monocytes in disease and for developing therapeutics that target monocytes.

Use of low-dose ß1-blocker for sinus tachycardia in patients with catecholamine support following cardiovascular surgery: a retrospective study.

BACKGROUND: Sinus tachycardia coupled with high-dose catecholamine is common after cardiopulmonary bypass (CPB). The present study assessed the hemodynamic efficacy and safety of combination therapy using low-dose ß1-selective adrenergic blocker (landiolol) and inotropes. METHODS: This was a retrospective, single center, self-comparison study at post-anesthesia care unit within a tertiary care center. The study included adults who underwent cardiac surgery with CPB and received landiolol between April 2007 and November 2011. We assessed hemodynamic data prior to and 1 h after initiation of landiolol therapy. RESULTS: We evaluated 11 patients who were administered 2.6 ± 1.3 µg/kg/min (mean ± SD) landiolol with sinus tachycardia and received catecholamine therapy after on-pump cardiovascular surgery. Landiolol administration led to a significant reduction in heart rate (HR; 112.4 ± 5.8 vs 126.0 ± 7.6 beats/min, p < 0.001), and a significant increase in stroke volume index (SVI) assessed by pulmonary artery catheterization (22.4 ± 5.4 vs. 18.9 ± 4.2 mL/m2, p = 0.04). Only one patient showed no HR reduction, whereas seven patients showed decreased HR and increased SVI (64, 95% confidence interval: 30-98%). Moreover, all five patients who received high-dose catecholamine support showed improved hemodynamics. In terms of safety, no patients required cessation of landiolol therapy. CONCLUSIONS: Low-dose landiolol therapy may safely decrease HR and improve hemodynamics among patients with sinus tachycardia receiving catecholamine treatment after cardiovascular surgery. TRIAL REGISTRATION: This study is retrospective. Registration number: 11. Duration of registration: April 2007~November 2011.

Use of preoperative haemostasis and ABO blood typing tests in children: a retrospective observational study using a nationwide claims database in Japan.

OBJECTIVES: To describe the prevalence and factors associated with preoperative haemostasis and ABO blood typing tests for children because these tests might represent low-value care. DESIGN: A retrospective observational study. SETTING: Nationwide insurance claims database in Japan. PARTICIPANTS: Patients aged 1-17 years who underwent common non-cardiac surgeries between April 2012 and March 2018 were included. Patients with high-risk comorbidities for bleeding (n=175) and those with multiple eligible surgeries were excluded (n=2121). MAIN OUTCOME MEASURES: We described the proportions of each preoperative test performed within 60 days before an index surgery, including platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT) and ABO blood typing tests. We also explored the associations between patient-level and institutional-level factors and any preoperative tests, using multilevel logistic regression analysis. RESULTS: We included 13 018 patients (median (IQR) age, 5.2 (2.9-7.7) years; 8276 (63.6%) boys) from 1499 institutions. The overall proportion of each test was as follows: platelet count, 78.6%; PT, 54.4%; aPTT, 56.4% and ABO blood typing tests, 50.4%. The proportion of patients undergoing any preoperative tests in the overall sample was 79.3%. Multilevel logistic regression analysis indicated that preoperative tests were associated with type of anaesthesia (general anaesthesia: adjusted OR 7.06; 95% CI 4.94 to 10.11), type of surgery (tonsillectomy: adjusted OR 3.45; 95% CI 2.75 to 4.33) and surgical setting (inpatient procedure: adjusted OR 5.41; 95% CI 3.83 to 7.66). There was one postoperative transfusion event (0.008%) in the entire cohort and 37 postoperative reoperation events for surgical bleeding after tonsillectomy (0.90%). CONCLUSIONS: In the largest Japanese cohort reported to date, preoperative haemostasis and ABO blood typing tests were performed in a majority of children prior to common paediatric surgeries. Preoperative tests were associated with anaesthesia, surgical type and surgical setting.

Unblinded pilot study of autologous transplantation of bone marrow mononuclear cells in patients with thromboangiitis obliterans.

BACKGROUND: The short-term clinical benefits of bone marrow mononuclear cell transplantation have been shown in patients with critical limb ischemia. The purpose of this study was to assess the long-term safety and efficacy of bone marrow mononuclear cell transplantation in patients with thromboangiitis obliterans. METHODS AND RESULTS: Eleven limbs (3 with rest pain and 8 with an ischemic ulcer) of 8 patients were treated by bone marrow mononuclear cell transplantation. The patients were followed up for clinical events for a mean of 684+/-549 days (range 103 to 1466 days). At 4 weeks, improvement in pain was observed in all 11 limbs, with complete relief in 4 (36%). Pain scale (visual analog scale) score decreased from 5.1+/-0.7 to 1.5+/-1.3. An improvement in skin ulcers was observed in all 8 limbs with an ischemic ulcer, with complete healing in 7 (88%). During the follow-up, however, clinical events occurred in 4 of the 8 patients. The first patient suffered sudden death at 20 months after transplantation at 30 years of age. The second patient with an incomplete healing of a skin ulcer showed worsening of the lesion at 4 months. The third patient showed worsening of rest pain at 8 months. The last patient developed an arteriovenous shunt in the foot at 7 months, which spontaneously regressed by 1 year. CONCLUSIONS: In the present unblinded and uncontrolled pilot study, long-term adverse events, including death and unfavorable angiogenesis, were observed in half of the patients receiving bone marrow mononuclear cell transplantation. Given the current incomplete knowledge of the safety and efficacy of this strategy, careful long-term monitoring is required for future patients receiving this treatment.

Spinal anesthesia increases the risk of venous thromboembolism in total arthroplasty: Secondary analysis of a J-PSVT cohort study on anesthesia.

Clinical guidance on the choice of anesthetic modality vis-à-vis the risk of perioperative venous thromboembolism (VTE) is largely lacking because of a paucity of recent evidence. A comparative effect of general anesthesia and neuraxial blockade on the perioperative incidence of VTE has not been well-investigated.We compared the effects of different types of anesthetic modalities on the risk of VTE after total hip arthroplasty (THA) and total knee arthroplasty (TKA).This is a secondary analysis of the Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT). Data pertaining to a total of 2162 patients who underwent THA and TKA at 34 hospitals were included in this analysis. We compared the different anesthetic modalities with respect to the incidence of VTE. The composite end-point was asymptomatic/symptomatic deep vein thrombosis detected using scheduled bilateral ultrasonography up to postoperative day (POD) 10 and fatal/non-fatal pulmonary embolism up to POD 10.The study groups were as follows: general anesthesia (n = 646), combined epidural/general anesthesia (n = 1004), epidural anesthesia (n = 87), and spinal anesthesia (n = 425). On multivariate analysis, only spinal anesthesia was associated with a significant increase in the risk of VTE as compared with that associated with general anesthesia. Propensity score-matched analysis for "combined epidural/general anesthesia group" versus "spinal anesthesia group" demonstrated a 48% higher incidence of VTE (relative risk = 1.48, 95% confidence interval [CI] 1.18-1.85) in the latter.Spinal anesthesia was associated with a higher risk of postoperative VTE, as compared with that associated with combined epidural/general anesthesia, in patients undergoing total arthroplasty.

Impact of preoperative extracorporeal membrane oxygenation on vasoactive inotrope score after implantation of left ventricular assist device.

The purpose of this study was to elucidate the difference in inotrope use between patients who underwent left ventricular assist device (LVAD) implantation with preoperative extracorporeal membrane oxygenation (ECMO) and those who underwent LVAD implantation without preoperative ECMO. One hundred and eight patients who underwent LVAD implantation were enrolled in this study. Prior to LVAD implantation, 27 patients received ECMO support (ECMO group) and the other 81 patients did not (non-ECMO group). Cardiac index (CI), mean arterial pressure (MAP), mixed venous oxygen saturation (SvO2), and the vasoactive inotropic score (VIS) were recorded at weaning from cardiopulmonary bypass (CPB), 30 min after weaning from CPB (min after CPB), 60 min after CPB, and at the end of surgery. MAP and VIS were also recorded before induction of anesthesia (baseline). The modified VIS was defined as: (dopamine µg/kg/min × 1 + dobutamine µg/kg/min × 1 + epinephrine µg/kg/min × 100 + noradrenaline µg/kg/min × 100 + milrinone µg/kg/min × 10 + olprinone µg/kg/min × 25). There were no significant differences between the ECMO group and the non-ECMO group in terms of hemodynamic parameters such as MAP, CI, and SvO2. However, the ECMO group had higher VIS and noradrenaline doses than that of non-ECMO group (p = 0.030 and p = 0.044, respectively). VIS was significantly higher in ECMO group at 30 min after CPB (p = 0.03), 60 min after CPB (p = 0.003), and at the end of the surgery (p < 0.001). The doses of noradrenaline were significantly higher in ECMO group at 60 min after CPB (p = 0.013), and at the end of surgery (p = 0.002). Patients who received ECMO support prior to LVAD implantation required significantly more noradrenaline to maintain normal levels of hemodynamic parameters compared with patients without ECMO.