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Patients with cardiac disease have high mortality rates, mainly owing to shock. Therefore, evaluation of cardiac function is one of the most challenging issues in the intensive and critical care unit. Cardiac point-of-care tests using ultrasound, such as focus assessed transthoracic echo (FATE) and rapid ultrasound in shock (RUSH). are useful for diagnosis and initial care of such patients. The author will introduce first a basic FATE protocol of how to scan from position 1-4, including subcostal 4-chamber, apical 4-chamber, parasternal long and short axis, and pleural scanning. A simple measurement method is described to evaluate the left and right ventricular function using mitral annular plane systolic excursion (MAPSE), mitral septal separation (MSS), and tricuspid annular plane systolic excursion (TAPSE). Next the RUSH protocol is discussed, which is useful for evaluation and care of patients with hypovolemic, cardiogenic, obstructive, or distributive shock. RUSH involves evaluation of the three main components : the pump (cardiac function, volume, pericardial function), the trunk (inferior vena cava, pleural fluid, lining), and the pipes (abdominal aneurysm, aortic dissection, deep vein thrombosis).

Background: We evaluated whether using thromboelastometry and tranexamic acid influenced blood loss and transfusion requirements in cardiac surgery requiring cardiopulmonary bypass., Methods: We perfomed a retrospective analysis examining perioperative coagulation results, and the transfusion requirements of concentrated red cells (CRCs), fresh frozen plasma (FFP) and platelet administration between 12 months before and 10 months after thromboelastometry and tranexamic acid had been introduced in our institution. We also recorded patients' demographic details, the surgery performed and patient outcomes., Results: After the introduction of thromboelastometry and tranexamic acid, fewer units of CRC were transfused during surgery, and fewer patients required postoperative CRC transfusion. Intra- and postoperative FFP requirements were also reduced. Intraoperative blood loss, blood loss in the first 24 hr after surgery, and length of hospital stay were also reduced., Conclusions: The use of ROTEM and tranexamic acid can potentially reduce blood loss and transfusion requirements in cardiac surgery.

We present a case of postoperative convulsive seizure in an 84-year-old man who underwent an aortic valve replacement. The patient had hypertension associated with hyperaldosteronism and chronic interstitial nephritis. The duration of cardiopulmonary bypass was 74 min. A generalized seizure lasting approximately 1 minute occurred at 1 hour after the patient's arrival in the intensive care unit. A total of 9 generalized seizures, which were aborted by the intravenous administration of diazepam (5 mg), occurred every 30 min. For seizure control, the continuous administration of midazolam (2 mg x hr(-1)) was initiated. On the day after the discontinuation of the midazolam, a generalized seizure recurred and an infusion of sodium thiopental was started. No further seizures were observed. On the sixth postoperative day, the patient was extubated and discharged without any neurological abnormalities. Imaging showed old small areas of cerebral infarction in the basal ganglia, which were not thought to have contributed to the seizures. The blood sugar, sodium, and calcium levels were within the normal limits. The seizures were likely due to a total dose of 8 g of tranexamic acid (TXA) administered intraoperatively. Possible mechanisms of TXA-induced seizures include blockage of inhibitory cortical y -aminobutyric acid-A receptors.

Background: The present study evaluated the relationship between the middle ear (ME) pressure increase rate (PIR) and the mastoid size as well as the effect of mastoid size on the incidence of nausea and vomiting during nitrous oxide (N2O) anesthesia., Methods: Twelve healthy male volunteers were recruited. The extent of mastoid pneumatization was measured planimetrically using a mastoid X-ray (Schuller's view). The ears were then divided into a small or large mastoid group according to the median value. The ME pressure was compared just before each increase to 33%, 50%, and 67% N2O. Using the ME pressure curve, the PIR for the first peak of the curve steepness was calculated., Results: Increasing the end-tidal N2O concentration to 50% and 67% in the large mastoid group and to 33%, 50%, and 67% in the small mastoid group significantly increased the ME pressure. The PIR in the ears in the large mastoid group was significantly lower and the incidence of nausea was 33% in the small mastoid group during 33% N2O anesthesia., Conclusions: A higher PIR in the ears and a higher incidence of nausea were observed in the small mastoid group, compared with the large mastoid group.

We present a case of prolonged hoarseness after tracheal intubation in a 62-year-old woman with bronchial asthma who underwent a pylorogastrectomy under a combination of epidural and general anesthesia. After the induction of anesthesia, the patient was carefully intubated using a 7.5-mm cuffed endotracheal tube without a stylet to avoid causing an asthma attack; the patient was extubated approximately 6 hours after the tracheal intubation. On the first postoperative day, the patient complained of hoarseness, vocal fatigue, and dysphagia. A direct laryngoscopy performed by an otorhinolaryngologist revealed dyskinesia of the left vocal cord and sufficient arytenoid cartilage mobility. The poor vocal fold mobility was probably caused by the force exerted on the left arytenoid by the convex curvature of the endotracheal tube, which had been inserted from the right side of the mouth, or a backward pressure on the thyroid cartilage during intubation. Early treatment is crucial in such cases, since the cricoarytenoid joint can become fibrosed in an unfavorable position. Fortunately, all the symptoms disappeared after one month in the present case. Although the trigger responsible for the spontaneous healing remains unknown, natural recovery might be associated with proper use of the vocal cords.

Background: Battery-powered BONFILS Retromolar Intubation Fiberscope (B-scope) is a nonflexible fiberscope having the same curvature as the Macintosh laryngoscope. Battery-powered StyletScope (S-scope) has a flexible apex whose direction was controlled by grasping a handle. We assessed the operational performance of the two scopes., Methods: Fifty patients were randomly allocated in the two groups :25 patients were in the B group (B-scope) and 25 were S group (S-scope) after obtaining written informed consent. We evaluated Mallampati class classification, size of tracheal tube, and intubation time., Results: There are no significance differences between the two groups in Mallampati class, demographic date and intubation time (23 +/-15 sec in B-group and 26 +/-14 sec in S-group). Both scopes were good in operational performance., Conclusions: BONFILS Retromolar Intubation Fiberscope and StyletScope are both good in the operational performance.

Background: Since no pre-medication has been widely accepted especially in spinal anesthesia, anesthesiologists should manage the control of patient's anxiety during surgery. Instead of sedatives, we have been using music-therapy during spinal anesthesia. Bispectral index monitoring (BIS) is used as one of the sedation indices in spinal anesthesia. The aim of this study was to assess the music-therapy on reducing anxiety of patients under spinal anesthesia using BIS and interview type psychology test, State Trait Anxiety Inventory (STAI)., Methods: Fifty-eight ASA physical status I-II patients scheduled for spinal anesthesia, were randomly allocated into M group (music group, n=29) or C group (control, n=29). BIS, EMG, and SQI of both groups were obtained continuously with computer system. Patients in M group listened to music by head phone and those in C group were left free under ordinary operating theater environment. Trait Anxiety Inventory (STAI-TA) score was obtained preoperatively for property-based anxiety and the State Anxiety Inventory (STAI-SA) score was obtained postoperatively for condition-based anxiety. Time averaged BIS scores (pre-surgery, during-surgery and post-surgery period)were obtained during operation., Results: Time averaged BIS values of M and C group in pre-surgery period, during-surgery period, and post-surgery period were 95.3+/-0.4 vs 95.8+/-0.4 (NS), 87.6+/-7.5 vs 95.1+/-2.8 (P<0.01) and 96.0+/-0.4 vs. 96.2+/-0.4 (NS), respectively. Post-surgery STAI-SA was 29.7+/-7.2 in M group vs 38.8+/-10.3 in C group (P<0.01) while pre-surgery STAI-SA scores of both groups were not different., Conclusions: Music-therapy reduced BIS value and was effective to reduce patient's anxiety during spinal anesthesia.

Battery powered BONFILS Retromolar Intubation Fiberscope (BRIF) is a nonflexible fiberscope having the same curvature as the Macintosh laryngoscope for difficult airway. We used this device in two patients; A 65-year-old man with small chin and a 35-year-old man with neck spinal cord injury. Two trials of orotracheal intubation were accomplished easily in 20 seconds. We conclude that BRIF is useful for orotracheal intubation in patients in whom neck extension is contra-indicated.

Two extremely-low-birth-weight infants, weighing each 684 and 975 g at birth, underwent emergency surgery because of ileus. Our previous experience with an extremely low birth weight infant, whose hemodynamic control during the surgery had been difficult without administering extra preoperative fluid and transfusion, made us administer enough fluid and transfusion during operation although their urine output was more than 2 ml.kg-1.hr-1. We gave intravenous volume to the present 2 cases before the operations despite the level of preoperative urine output and made their hemodynamic situation more stable during surgeries. We conclude it is very important to administer some amounts of intravenous volume (approximately 8-12 ml.kg-1.hr-1) in extremely low birth weight infants for emergency surgery with ileus regardless of their preoperative urine output.

We investigated the brain protection effects of propofol anesthesia and nitrous oxide-oxygen-isoflurane anesthesia (GOI) using forebrain ischemic model of male Sprague-Dawley rats. Propofol group (P, n = 15) was anesthetized with propofol, oxygen and nitrogen (FIO2 = 0.33), and isoflurane group (GOI, n = 15) with 66% nitrous oxide, 33% oxygen and 1.2% isoflurane under mechanical ventilation. The anesthesia was deepened until electroencephalographic burst suppression appeared in each group. The bilateral common carotid arteries were, then, occluded for 10 minutes while the blood pressure was maintained at about 40 mmHg by venesection. The venesected blood was returned at the end of ischemic period. The animals were kept and fed in cage after emergence. On the day 2, 4, and 7, five animals of each group were sacrificed and the microscopic samples were obtained. The CA-1 cells of hippocampus were then stained with hematoxylin and eosin for the delayed neuronal death (DND) and with TUNEL method for the apoptosis. Propofol reduced the apoptosis, i.e., reduced the TUNEL positive cell count (GOI = 121.2 +/- 25.2.mm-1; P = 53.8 +/- 11.4.mm-1; P < 0.01; mean +/- SD) on the day 2 after ischemia, and also reduced the delayed neuronal death (alive CA-1 cell count; GOI = 18.1 +/- 8.9.mm-1; P = 33.1 +/- 12.8.mm-1; P < 0.01) on the day 7 after ischemia. It is important to determine the recovery interval after brain ischemia in detection of DND and apoptosis. We conclude that propofol inhibits neuronal apoptosis after brain ischemia and consequently reduces the delayed neuronal death in the CA-1 pyramidal cell layer of the hippocampus.

We chose five sedatives for premedication and investigated the effect of these drugs on the induction doses of propofol. One hundred patients were allocated into one of five groups of 20. These groups consisted of control group (C) given only atropine 0.5 mg i.m.; CL group (plus clonidine 0.15 mg orally); H group (plus hydroxyzine 25 mg i.m.); M group (plus midazolam 3 mg i.m.) and D group (plus diazepam 10 mg orally). The induction dose was measured using loss of count technique. Arterial pressure and heart rate were measured, before and after propofol induction as well as after intubation. We also calculated rate pressure products (RPP) at each point. The induction doses were significantly lower in M-group than those in C-group. On the other hand, in hemodynamic responses, RPP was unchanged in any groups after propofol induction and after the intubation. Both propofol and midazolam have been known to have a depressive effect on the central nervous system via GABA-A receptor-mediated inhibition, although the exact receptor for propofol is unknown. We thought, therefore, that when the interaction occurred, both midazolam and propofol had the same effect on the GABA-A receptor and increased chloride ion flux through the channels. Hydroxyzine and clonidine, however, do not share a common receptor or exert effect on the GABA-A receptor. We consider that this was one of the reasons why induction doses of both H and CL group could not decrease significantly. We concluded that midazolam 3 mg decreased propofol induction dose significantly. Both midazolam 3 mg and clonidine 0.15 mg decreased RPP before induction and hemodynamic responses to induction and intubation were stable.

The effects of isoflurane(I), halothane(H) and enflurane(E) on hemodynamics of 36 patients (12, 11 and 13, respectively) were studied during the inhalation of 1.5 MAC of each anesthetics before the surgery. Mean arterial pressure(MAP), heart rate(HR), cardiac index(CI), systemic vascular resistance index(SVRI), and stroke volume index (SVI) were measured noninvasively using the automatic blood pressure manometer and the ultrasonic Doppler method (Accucom). MAP decreased with I, E and H, but a larger decrement was observed with E than with H. CI and SVI with H were less than with E. SVRI decreased with I and E but a significant difference was observed between E and H. Each value with I was between those with H and E. These results indicate that isoflurane causes the depression of blood pressure mostly by its effect to decrease afterload during the induction of anesthesia, although its depressing effect is less than that of enflurane.

Anesthetic management of two patients with a permanent pacemaker is reported; patient no. 1 had the VVI mode pacemaker and patient no. 2 had the DDD mode pacemaker. In patient no. 1, the hypotensive response of the 'pacemaker syndrome' occurred during general anesthesia. Patient no. 2 had no anesthetic problems but careful attention should be paid to the DDD mode pacemaker, because the newer widely used dual lead systems (DDD) are more susceptible to electromagnetic interference. Anesthetists often encounter patients with pacemakers. Knowledge of pacemakers available of the increasingly wide range is necessary to ensure safe management of these patients, many of whom are frail and elderly.