Masui. The Japanese journal of anesthesiology
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Transesophageal echocardiography (TEE) is a useful tool for assessment of cardiac function in patients undergoing cardiac surgery or in patients undergoing non-cardiac surgery who have cardiovascular complications. Left ventricular (LV) function is composed of systolic function, diastolic function, preload and afterload. To assess systolic and diastolic function several methods are used, and we must use them based on the property of each parameter. ⋯ LV dP/dt is not affected by preload, and myocardial performance index (Tei index) can be used to assess both systolic and diastolic functions. Tei index is also useful to assess right ventricular function. The recently developed real time 3-dimensional system provides accurate and objective information, such as LV volumetry, wall motion, dyssyncrony and valvular pathology.
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Noninvasive monitoring of regional cerebral oxygen saturation has been introduced in clinical settings for estimation of cerebral perfusion and cerebral blood flow. In this article, I have described several issues regarding the usefulness and clinical limitations associated with the use of these monitors, as well as relevant information on basic principles of monitoring. At present, there is not enough clinical data concerning critical levels of measured variables that are essential for safe perioperative management of patients susceptible for cerebral ischemia.
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Development of pulse oximeter technology has made it possible to measure total hemoglobin noninvasively. The use of Radical-7 would improve patient care in emergency medicine and chronic internal medicine as well as perioperative medicine, and could reduce the burden of the patient.
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FloTrac is a recently introduced semi-invasive arterial pressure-based cardiac output (APCO) monitoring device. The accuracy of a new device is usually evaluated by Bland-Altman method, which shows graphically the mean value of differences between a new method and the reference method (bias), standard deviation of the differences (precision) and limits of agreement or 2 standard deviations. Critchley et al calculated the percentage errors which are two standard deviations divided by mean cardiac output, and proposed that percentage error should be less than 30% as a reliable new method. ⋯ APCO is less invasive and could rapidly respond to fast changes of hemodynamic state. FloTrac is expected to become a reliable cardiac output monitoring device even under hemodynamically unstable conditions. Further improvement of the algorithm is anticipated.
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In Japan, over 50 thousand pulmonary artery catheters (PAC) per year were used for hemodynamic monitoring system perioperatively since 1970s. PAC provides many quantitative circulatory data, such as pulmonary capillary wedge pressure, cardiac output and continuous mixed venous oxygen saturation. On the contrary, several studies pointed out the problems of PAC and advocated the limitations of perioperative PAC monitoring in 2000s. ⋯ It is also important to use PAC in proper patients. I have also discussed other monitoring systems, such as aortic wave form analysis and central venous oxygen saturation, which were less invasive compared with PAC. I think abundant training, correct education and strict management must be employed to increase the benefit of PAC.