Fibrinogen levels measured by the dry hematology method are lower than those measured by the Clauss method under a high concentration of heparin.

The activity of fibrinogen has been reported to decrease soon after the onset of major bleeding and to be an important determinant of the final extent of bleeding and postoperative outcome. A device that measures the perioperative fibrinogen level using the dry hematology (DH) method has recently become available. The aim of this study was to compare perioperative fibrinogen levels measured by the DH method with those measured by the conventional Clauss method and to assess the effects of heparin on these measurements. The study included 206 samples from 36 patients undergoing major surgery who received high-dose heparin (HH group, 23 samples), low-dose heparin (LH group, 57 samples), or no heparin (C group, 126 control samples). Each sample was measured using the DH and Clauss methods. After excluding samples outside the effective measurement range, the three study groups (HH group, n=23; LH group, n=49; C group, n=115) were compared. The mean fibrinogen level measured by the DH method in the HH group (87.9 ± 3.1%) was significantly lower than that measured by the Clauss method. There were no significant differences between the fibrinogen measurements obtained by the two methods between the LH and C groups. In patients on high-dose heparin, the mean fibrinogen level measured by the DH method was significantly lower than that measured by the Clauss method. When hemorrhage requires emergency treatment, a method that can measure the fibrinogen level rapidly is important. The DH method may be useful for decision-making with regard to perioperative coagulation factor replacement.

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation.

Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant (kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.

Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery.

OBJECTIVE: To determine the safety and feasibility of neuromuscular electrical stimulation (NMES) from postoperative days (PODs) 1 to 5 after cardiovascular surgery. DESIGN: Pre-post interventional study. SETTING: Surgical intensive care unit and thoracic surgical ward of a university hospital. PARTICIPANTS: Consecutive patients (N=144) who underwent cardiovascular surgery were included. Patients with peripheral arterial disease, psychiatric disease, neuromuscular disease, and dementia were excluded. Patients with severe chronic renal failure and those who required prolonged mechanical ventilation after surgery were also excluded because of the possibility of affecting the outcome of a future controlled study. INTERVENTIONS: NMES to the lower extremities was implemented from PODs 1 to 5. MAIN OUTCOME MEASURES: Feasibility outcomes included compliance, the number of the patients who had changes in systolic blood pressure (BP) >20 mmHg or an increase in heart rate >20 beats/min during NMES, and the incidence of temporary pacemaker malfunction or postoperative cardiac arrhythmias. RESULTS: Sixty-eight of 105 eligible patients participated in this study. Sixty-one (89.7%) of them completed NMES sessions. We found no patients who had excessive changes in systolic blood pressure, increased heart rate, or pacemaker malfunction during NMES. Incidence of atrial fibrillation during the study period was 26.9% (7/26) for coronary artery bypass surgery, 18.2% (4/22) for valvular surgery, and 20.0% (4/20) for combined or aortic surgery. No sustained ventricular arrhythmia or ventricular fibrillation was observed. CONCLUSIONS: The results of this study demonstrate that NMES can be safely implemented even in patients immediately after cardiovascular surgery.

Increased von Willebrand Factor to ADAMTS13 ratio as a predictor of thrombotic complications following a major hepatectomy.

OBJECTIVE: To investigate the association between changes in procoagulant/fibrinolytic factors and thrombotic complications following a major hepatectomy. Little information is available regarding the changes in procoagulant/fibrinolytic factors (such as the von Willebrand factor [vWF] and a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 [ADAMTS13]), following a major hepatectomy. DESIGN: Patients who underwent a major hepatectomy from 2010 to 2011 were enrolled. Patients who underwent a pancreatoduodenectomy (PD) during the same period were also observed as controls, for whom operation time and amount of intraoperative blood loss were comparable to those of the patients who underwent a major hepatectomy. Blood samples were prospectively collected to measure various procoagulant/fibrinolytic factors, including vWF and ADAMTS13. SETTING: Nagoya University Hospital, Japan. PATIENTS: A total of 50 patients who underwent a major hepatectomy and a total of 23 patients who underwent a PD. RESULTS: The levels of vWF in the patients who underwent a major hepatectomy increased from before the operation to the seventh postoperative day and were significantly higher than those observed in the patients who underwent a PD. The ADAMTS13 activity in the patients who underwent a major hepatectomy gradually decreased throughout the first 14 postoperative days. In contrast, ADAMTS13 activity in the patients who underwent a PD returned to nearly normal levels within 2 weeks. Three patients who underwent a major hepatectomy had clinically significant thrombotic complications within the first 2 weeks after surgery; however, none of the patients who underwent a PD had thrombotic complications. The vWF to ADAMTS13 ratios of the 3 patients who experienced thrombotic complications were extremely high even before the occurrence of complications. No other procoagulant/fibrinolytic factors showed a marked association with thrombotic events. The vWF to ADAMTS13 ratio was significantly correlated with the estimated liver remnant volume (P < .001) but not with other preoperative or intraoperative factors. CONCLUSIONS: The vWF to ADAMTS13 ratio may be a potentially useful marker in predicting thrombotic complications following a major hepatectomy.

[Diagnosis of the laryngeal or tracheobronchial lesions by fiberoptic bronchoscopy for anesthesiologists].

Flexible fiberoptic endoscopic equipment is a useful visualization aid for diagnosis of laryngeal or tracheobronchial lesions and for intubation in patients with difficult airway. It also determines double-lumen tube position. In an intensive care unit, fiberoptic bronchoscopy is the cornerstone of the causal diagnosis in acute respiratory failure and laryngo-tracheobronchial trauma. However, for many anesthesiologists, its use tends to be limited to fiberoptic intubation and anesthetic management of thoracic surgery. Therefore, this review focuses on diagnostic strategies of laryngeal or tracheobronchial lesions by fiberoptic bronchoscopy for anesthesiologists. It also refers to the equipment and the strategy in performing fiberoptic bronchoscopy for anesthesiologist. We anesthesiologists need to attain proficiency in diagnostic skill in fiberoptic bronchoscopy as specialists of airway managent in acute settings as well as the operating room.

Monitoring hepatic venous hemoglobin oxygen saturation during Appleby operation for pancreatic cancer.

BACKGROUND/AIMS: When an Appleby operation is performed for pancreatic body and tail carcinoma, it is necessary for prevention of hepatic ischemia to estimate accurately the hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO2 (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. METHODOLOGY: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in the right hepatic vein. The ShvO2 values were monitored continuously during surgery. RESULTS: The ShvO2 value was 76 +/- 3.5% just after laparotomy, and reduced to 61 +/- 13.2% after clamping the common hepatic artery. The values of the ShvO2 returned to 70.8 +/- 10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO2 value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patients; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO2 was stable during resection of the portal vein. CONCLUSIONS: Monitoring the ShvO2 is a useful method to evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.