[The Efficacy of Soluble Fibrin Monomer Complex (SFMC) for Diagnosis of Aortic Dissection (AD)].

BACKGROUND: Some biomarkers are helpful for AD diagnosis. Although many studies on efficacy of D-dimer have been reported, there are few reports about SFMC. Therefore we conducted a retrospective comparative study of efficacy of SFMC and D-dimer for diagnosis of AD. METHODS: Nineteen patients diagnosed as AD in the emergency visit were examined. Patients with cardiopulmonary arrest on arrival were excluded. These patients were classified into three patterns as follows, Stanford A or B, terms of arriving at hospital, and closing type or patent type. The value of D-dimer and SFMC were measured at the time of the first medical examination, and comparative study of both biomarkers was carried out in each groups. RESULTS: Background of patients were not significantly different in three studies. SFMC and D-dimer showed no significant difference between Stanford A and B. Short-terms SFMC is significantly higher than long-terms. But D-dimer showed no significant difference in each comparison. Patent type of SFMC showed higher than closing type. But D-dimer showed no significant difference between patent type and closing type. CONCLUSIONS: SFMC showed earlier response to AD than D-dimer. Measuring SFMC coupled with D-dimer is helpful for AD diagnosis.

[Study of background factors of cerebral hyperperfusion syndrome in the anesthetic management of carotid endarterectomy].

BACKGROUND: We conducted a retrospective study to evaluate background factors of cerebral hyperperfusion syndrome (CHS) in the anesthetic management of carotid endarterectomy (CEA) for carotid artery stenosis. METHODS: A total of 118 ASA 1-2 adult patients were allocated to one of two groups: Group A of 13 patients who developed CHS after CEA, and Group B of the remaining 105 patients. We weighed control percent ratio of somatosensory evoked potential (%SEP). The rate of carotid artery stenosis, stump pressure of internal carotid artery, %SEP internal carotid artery blood flow (ICF), and preoperative anesthetic problems were compared between the two groups. RESULTS: The rate of carotid artery stenosis in Group A was 85%, significantly higher than 74% of Group B. Stump pressure in Group A was 28 mmHg, significantly lower than 37 mmHg of Group B. %SEP was 67% of Group A, and 87% of Group B, respectively ICF in Group A was 7+ +/- 33 ml min(-1), which decreaced significantly compared with 78 +/- 34 ml min(-1) of Group B. CONCLUSIONS: We conclude that the patients with high rate of carotid artery stenosis, low stump pressure and low ICF have a high risk of developing CHS after CEA and careful attention should be required in the anesthetic management of CEA.

[Perioperative changes of blood coagulability evaluated by thromboelastography (TEG) in patients undergoing total knee and total hip arthroplasty].

BACKGROUND: A large number of studies have examined the incidence of thromboembolic complications after orthopedic surgery of the lower extremity. We investigated the perioperative changes of coagulability following total knee arthroplasty (TKA) or total hip arthroplasty (THA) using thromboelastography (TEG), which could comprehensively assess the coagulation and fibrinolytic system. METHODS: Thirty patients scheduled for TKA (n= 10), THA (n= 10) and other lower extremity orthopedic surgery (control, n= 10) were studied. TEG was analyzed with K-value, MA-value and coagulation index (CI) before induction of anesthesia and 24 hours after surgery. RESULTS: K-values decreased significantly after TKA and THA compared with the values before the induction of anesthesia. MA-values and CI increased significantly after TKA and THA compared with the values before the induction. There were no significant changes in K-value, MA-value and CI in the control group during the perioperative period. CONCLUSIONS: The results suggest that TKA and THA lead blood coagulation to hypercoagulable state at the early postoperative stage.

[Case of spontaneous intracranial hypotension associated with depressed consciousness].

We experienced a case of spontaneous intracranial hypotension (SIH) complicated with depressed consciousness after its treatment. A 56-year-old woman developed postural headache, and her MRI revealed bilateral chronic subdural hematoma (CSH). After treatment with epidural autolongous blood patch, her headache resolved completely. However, two days after, the patient developed depressed conciousness, and MRI showed brain sagging and downward brain displacement. After management with conservative treatment, including second epidural blood patch and hematoma drainage, the patient became alert and other symptoms resolved gradually. We demonstrated that caution should be taken for the management of SIH, especially in the case associated with CSH.

[Relationship between regional cerebrovascular oxygen saturation and jugular bulb oxygen saturation during carotid endarterectomy].

BACKGROUND: Carotid artery cross-clamping ischemia during carotid endarterectomy (CEA) sometimes causes perioperative neurological deficits. Therefore it is important to asses the cerebral oxygen supply/demand relationship during CEA. The aim of this study is to examine the relationship between two monitoring results in CEA. METHODS: Six patients undergoing elective carotid CEA were studied. Regional cerebrovascular oxygen saturation (rSO2) and jugular bulb oxygen saturation (SjvO2) were measured simultaneously during carotid artery cross-clamping. RESULTS: In 5 patients, rSO2 and SjvO2 changed similarly during carotid artery cross-clamping. In one patient, whose arterial cross flow through the anterior communicating artery was poor, rSO2 markedly decreased after cross-clamping, but SjvO2 was unchanged during the same procedure. CONCLUSIONS: Patients with internal carotid artery stenosis have individually different characteristics in cerebral metabolism and cerebral blood perfusion. Our results suggest that multiple monitoring of cerebral blood flow and oxygen saturation provides helpful information in CEA patients.

[Effect of propofol on visual evoked potentials during neurosurgery].

BACKGROUND: Evoked potentials are used to monitor the central nervous system during neurosurgery and it is well known that they are affected by the depth of anesthesia. Many studies on the evoked potential like somatosensory evoked potential (SEP) and auditory brain stem response (ABR) are reported, but studies on visual evoked potential (VEP) are few. We investigated the influence of the propofol concentration on VEP in neurosurgical patients. METHODS: Seven patients scheduled for neurosurgery, three with cranial aneurysm and four with brain tumor, were studied. Anesthesia was maintained with intravenous propofol using target controlled infusion (TCI). We measured the change of amplitude and latency of VEP at three propofol concentrations (effect site concentrations of 1.5, 2.0 and 3.0 microg x ml(-1)), and also evaluated bispectral index (BIS) at each propofol concentration. RESULTS: Amplitude of VEP at 3.0 microg x ml(-1) propofol concentration decreased significantly compared with the amplitude at 1.5 microg x ml(-1) concentration. No significant change was observed with the latency of VEP. The value of BIS at 3.0 microg x ml(-1) propofol concentration also decreased significantly compared with 2.0 microg x ml(-1) concentration. CONCLUSIONS: Amplitude of VEP is strongly affected by the concentration of propofol. Caution should be taken in evaluating VEP in patients undergoing propofol anesthesia.

[Evaluation of cerebral oxygen balance during normothermic cardiopulmonary bypass using jugular oxygen saturation].

BACKGROUND: Previous studies suggest that normothermic cardiopulmonary bypass(CPB) impairs cerebral oxygen balance. We studied the effect of normothermic CPB on cerebral oxygen balance evaluated by continuous measurement of oxygen saturation in the jugular vein (SjO2). METHODS: Eleven patients undergoing coronary artery bypass grafting with normothermic CPB were studied. A 4 Fr oxymetry catheter was inserted into the internal jugular bulb for SjO2 monitoring. We measured mean arterial pressure (MAP), SjO2 and hemoglobin (Hgb) concentration at five time points-1) pre CPB, 2) 3) 4) 5, 30, 60 min after the onset of CPB, respectively, 5) 5 min after the end of CPB. RESULTS: MAP decreased significantly 30 min (47 +/- 9 mmHg) and 60 min (48 +/- 9 mmHg) after the onset of CPB compared with the pre CPB (80 +/- 14 mmHg) value. Hgb also decreased significantly 5 min (7.8 +/- 1.1 g x dl(-1)) and 30 min (7.1 +/- 1.0 g x dl(-1)) and 60 min (7.1 +/- 0.8 g x dl(-1)) after the onset of CPB compared with the pre CPB (11 +/- 1.0 g x dl(-1)) value. However, SjO2 showed no significant change throughout the study period. No significant correlation was observed between MAP and SjO2. CONCLUSIONS: Cerebral oxygen balance assessed by SjO2 was not impaired during normothermic CPB, and was unaffected by hypotension and hemodilution.

[Evaluation of facial nerve palsy with electrogustometry and stapedial reflex].

BACKGROUND: To clarify the prognosis of facial nerve palsy, electroneuronal tests, including electrogustometry and stapedial reflex, have been utilized. But, the relationship among these tests and patients' prognosis is not clear. METHODS: Sixty five patients with peripheral facial nerve palsy were investigated. Electrogustometry (EG), stapedial reflex (SR) and blink reflex (BR) were performed at the first visit on the consult of facial nerve palsy. The palsy scale (full score is 100 points) was evaluated 8 weeks after the onset, and we defined cure cases if score became over 90 points. The cure ratio was examined on each group of EG positive or negative, SR positive or negative and BR R1 wave positive or negative, respectively. The relationship among these three examinations was also investigated. RESULTS: There were no significant differences between the cure ratio of EG positive and negative groups. However, the cure ratio of SR positive group was significantly larger than that of SR negative group. The cure ratio of BR positive group was 100%, regardless of the result of other two tests. CONCLUSIONS: The present study suggests that SR is a more useful parameter than EG for the evaluation of the prognosis of patients with facial nerve palsy, and the pathological meaning of these 2 tests is different from that of BR.

[Effects of perfusion pressure on cerebral blood flow and oxygenation during normothermic cardiopulmonary bypass].

BACKGROUND: Central nervous system dysfunction after cardiopulmonary bypass (CPB) is an important cause of morbidity and mortality after cardiac surgery. Perfusion pressure (PP) during CPB could be one of the important determinants of cerebral blood flow (CBF). The objective of the present study was to determine the effect of PP on CBF and cerebral oxgenation during normothermic CPB. METHODS: Twelve adult patients undergoing coronary artery bypass graft surgery were randomly assigned to one of two groups based on PP (High and Low group). Patients in High group received phenylephrine immediately after the onset of CPB to maintain PP between 60 and 80 mmHg. Oxyhemoglobin (O2Hb), deoxyhemoglobin (HHb), tissue oxygenation index (TOI), and oxidized cytochrome aa3 (CtOx) were measured by near-infrared spectroscopy, and internal jugular venous bulb blood oxygen saturation (SjvO2) was measured simultaneously. S-100 beta protein concentrations were also measured before and after CPB. RESULTS: SjvO2 in High group increased significantly during CPB. CtOx in Low group decreased significantly during CPB, whereas TOI was unchanged. Although S-100 beta increased significantly at the end of CPB, there was no difference between the groups. CONCLUSIONS: These results suggest that maintaining high PP is benefical for CBF during normothermic CPB.

[Perioperative management of a morbidly obese patient with sleep apnea syndrome].

A 34-year-old male, weighing 110 kg, with severe obstructive sleep apnea syndrome (OSAS) was urgently taken to the hospital for heart and respiratory failure. His body mass index was 39, showing that he was mobidly obese. He was scheduled for tonsillectomy under general anesthesia. BiPAP (bi-level positive airway pressure) system was applied for respiratory assist. He went on a diet to prepare for the surgery. Preoperative examination revealed that the neck was short, and the tongue and tonsils were hypertrophic. Since we expected difficulty in maintaining upper airway open during the perioperative period, anesthesia was induced with fentanyl and propofol, and fiberscopic intubation was performed by preserving spontaneous breathing. Postoperatively he was taken to the intensive care unit and was mechanically ventilated for 6 days because pharyngeal edema could aggravate his respiratory condition when extubated just after the surgery. He was successfully extubated and BiPAP was applied in the same day. We recommend that the patient with morbidly obese OSAS should be cared intensively during perioperative period.