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Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period.The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality.The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%,Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

Made available in DSpace on 2020-12-12T01:05:48Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-10-01 Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) This study aims at investigating the effects of foliar application of aqueous solutions of La3+ and Ce3+ nitrates on soybean plants (Glycine max). First, we observe that Triton HW 1000 surfactant at 0.01 vol% reduces droplets contact angle and increases their drying time. Under greenhouse conditions, the foliar treatments do not affect chlorophyll content, plant height, number of leaves, number of pods, number of seeds per pod, and average seed weight. However, the treatments induce phytotoxicity since foliar injuries appear after the spraying. Microprobe X-ray fluorescence spectroscopy combined to scanning electron microscopy shows that the leaf lesions are positively correlated to accumulation of Ce and La on the leaf surface and also promote structural alteration to the epidermal cells. X-ray absorption near edge structure shows that the La and Ce nitrates are partially bio transformed into oxides by the leaves which might explain the harmful effects. Laboratory of Nuclear Instrumentation (LIN) Center for Nuclear Energy in Agriculture (CENA) University of São Paulo (USP) Environmental Studies Center São Paulo State University (UNESP) Environmental Studies Center São Paulo State University (UNESP) FAPESP: 2015-19121-8 CNPq: 407380/2016-7

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.

The production and use of nanoparticles (NPs) in different fields increased in the last years. However, some NPs have toxicological properties, making these materials potential emerging pollutants. Therefore, it is important to investigate the uptake, transformation, translocation, and deposition of NPs in plants. In this work, laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) and micro X-ray fluorescence (μ-XRF) were used to investigate the uptake and translocation of La2O3 NPs to stem and leaves of Pfaffia glomerata (Spreng.) Pedersen after in vitro cultivation of plants in the presence of 400 mg L-1 of La2O3 NPs. By using LA-ICP-MS and μ-XRF, image of the spatial distribution of La in the leaves was obtained, where higher concentration of La was observed in the main veins. Differences in the signal profile of La in leaves of plants cultivated in the presence of bulk La2O3 (b-La2O3) and La2O3 NPs were observed. Sharp peaks of La indicated that NPs were transported to the stems and leaves of plants treated with La2O3 NPs. Both LA-ICP-MS and μ-XRF techniques have shown to be useful for detecting NPs in plants, but LA-ICP-MS is more sensitive than μ-XRF and allowed better detection and visualization of La distribution in the whole leaf.

We assessed our institution's rate of perioperative and periprocedural corneal abrasions (CAs) and implemented a quality improvement project to improve our detection of CAs and decrease their incidence by at least 25% over 12 months.Retrospective review before and after initiation of a quality improvement project at a single tertiary care institution METHODS: We retrospectively reviewed surgical and procedural patients requiring any type of anesthesia care over three 1-year time periods (2014-2015, 2016-2017, and 2017-2018). Using an electronic pharmacy-based query to identify patients who received proparacaine eye drops in the recovery room, we were able to estimate our incidence of CA during these time periods. We implemented a best practice plan to standardize CA prevention, diagnosis, and treatment after determining our baseline incidence of CA.Our baseline incidence rate of perioperative and periprocedural CAs was 0.22% (43/19,790 anesthetics) in the 2014-2015 time period. In the 2016-2017 and 2017-2018 time periods, the incidence rate was reduced to 0.09% (21/23,652 anesthetics) and 0.1% (23/23,825 anesthetics), respectively. The use of a standardized CA prevention, diagnosis, and treatment plan reduced the relative risk of CAs by 59% in 2016-2017 (P.001) and 56% in 2017-2018 (P = .001) compared to baseline, with an absolute reduction of 13% and 12% over those time periods.Our data suggests that the adoption of a simple, standardized perioperative and periprocedural CA prevention, diagnosis, and treatment plan can result in sustained reductions in the occurrence of perioperative CAs.

Mask ventilation (MV) is an essential component of airway management and can be lifesaving in situations where the placement of a secure airway device proves challenging. Effective MV requires a seal to be created between the mask and the face to maintain patency of the external airway structures and can be difficult in the setting of facial abnormalities or facial trauma. Here we describe a case in which a continuous positive airway pressure (CPAP) mask was used for anesthesia induction and MV in an 85-year-old man who underwent a plastic surgery reconstruction of the left nasal dorsum and ala following a Mohs surgery, which had prevented the use of conventional face mask. An effective seal was achieved, and anesthesia was successfully induced with the mask. We reviewed the literature and discussed alternative approaches for face mask use in the setting of facial abnormalities where the use of a conventional mask is unfeasible.

In this study, we characterized Zn seed coats adhered on soybean seed surface [Glycine max (L.) Merrill] and then investigated the effects of such coatings on germination and finally monitored the transference of Zn from the coatings to the seedlings. For that, seeds were coated with ZnSO4, 40 nm ZnO, and 5 µm ZnO at 4 mg of Zn per kg of seed. The shape and homogeneity of Zn deposits on the seed surface depended on the type of Zn source. X-ray spectroscopy unraveled that before the germination, Zn neither crossed the seed coat nor was biotransformed. Regardless of the particle size, ZnO-based treatments increased germination ratio, seedlings root, and shoot development, whereas ZnSO4 suppressed them. After sowing, most of Zn on the seed coat was transferred to soil, while less than 13 wt% was assimilated by the seedling 14 days after sowing. Either this minor fraction of Zn was taken up during the imbibition process or absorbed by during seedling growth. Zinc oxide-based treatments represent a viable alternative to Zn supply in order to boost soybean germination and seedling development.

Made available in DSpace on 2020-12-12T01:50:46Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-03-01 Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) This study investigated the dynamic of zinc (Zn) uptake and the root-to-shoot Zn-transport when supplied as ZnSO4 (aq) or Zn-EDTA (aq) in soybean seedlings using in vivo X-ray fluorescence (XRF) and X-ray absorption spectroscopy (XANES). The time-resolved X-ray fluorescence showed that plants absorbed ca. 10-fold more Zn from ZnSO4 (aq) than from Zn-EDTA (aq). However, the uptake velocity did not influence the amount of Zn in the stem. It let furthermore appear that the plants were able to reduce the absorption of Zn from Zn-EDTA (aq) earlier than ZnSO4 (aq). Thus, the entrance of Zn2+ into the roots is not necessarily accompanied by SO4 2− (aq). Regardless the source, the Zn distribution and its transport in the stem were spatially correlated to the bundles and cortex nearby the epidermal cells. Its chemical speciation showed that Zn is neither transported as ZnSO4(aq) nor as Zn-EDTA(aq), indicating that these compounds are retained in the roots or biotransformed on in the root-solution interface. Zn2+ was long-distance transported complexed by organic molecules such as histidine, malate, and citrate, and the proportion of ligands was affected by the concentration of Zn2+ in the stem rather than by the type of Zn source. University of São Paulo (USP) Center of Nuclear Energy in Agriculture (CENA), Avenida Centenário 303, Piracicaba São Paulo State University (UNESP), Rua Domingos da Costa Lopes 780, Tupã São Paulo State University (UNESP), Rua Domingos da Costa Lopes 780, Tupã FAPESP: 2015/05942-0 FAPESP: 2015/19121-8 FAPESP: 2017/16375-4

There is still little information on the potential use of nanomaterials for seed nutrient enhancement through seed priming. The use of nanoparticles (NPs) in agriculture is promising, but in-depth knowledge on their interaction with plants is required. The aim of this study was to evaluate the effects of different concentrations (1-5000 mg L-1) and sizes (20, 40, and 60 nm) of uncoated ZnO NP compared to ionic ZnSO4 (positive control) on common bean (Phaseolus vulgaris) seed germination. The seeds were soaked in ZnO NP aqueous dispersions for 20 min. The ZnO nanoparticles did not affect the germination rate. The 10 mg L-1 40 nm ZnO treatment showed a tendency to increase weight after 5 days (8.26 ± 0.11 g) when compared to the negative control (7.7 ± 0.7 g). However, at 5000 mg L-1 40 nm ZnO NP and ZnSO4 weight was reduced to 7.7 ± 0.8 g and 6.05 ± 0.08 g, respectively. Microprobe X-ray fluorescence showed that most of the Zn absorbed was trapped in the seed coat, while a small fraction entered the cotyledon. X-ray absorption spectroscopy indicated the biotransformation of the ZnO NP. In the hilum and cotyledon, Zn was found associated with organic molecules such as citrate, malate, and histidine-like compounds. Seedling weight reduction depended on the concentration of Zn taken up by the tissue and on the biotransformation of ZnO into organically bound Zn. Considering the properties of the studied NP, in particular the slow Zn release and lower toxicity compared to ZnSO4, the results represent a step forward toward the application of ZnO NP as an agrochemical.

Several factors have contributed to bring pressure on agriculture. In this context, nanomaterial properties can be explored to design more efficient fertilizers and therefore increase productivity. In the present study, the roots of Phaseolus vulgaris were immersed in several nano ZnO dispersions for 48 h. The absorption and transport phenomena were in vivo monitored by X-ray fluorescence spectroscopy (XRF) and X-ray absorption spectroscopy (XAS). The nanoparticle size, concentration and coating with surfactants affected the rate of Zn release and therefore its uptake. In vivo X-ray absorption spectroscopy showed that Phaseolus vulgaris takes up Zn bound to both citrate and malate, while entire nanoparticles were only absorbed when roots were injured. X-ray fluorescence microanalysis unravelled that besides xylem bundles, root to shoot Zn transport can take place through the cortex.

BACKGROUND Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery. AIM To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes. METHODS A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days. RESULTS Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all). CONCLUSION Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.

Made available in DSpace on 2020-12-12T01:16:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-02-01 X-ray fluorescence spectroscopy (XRF) is an analytical tool used to determine the elemental composition in a myriad of sample matrices. Due to the XRF non-destructive feature, this technique may allow time-resolved plant tissue analyses under in vivo conditions, and additionally, the combination with other non-destructive techniques. In this study, we employed handheld and benchtop XRF to evaluate the elemental distribution changes in living plant tissues exposed to X-rays, as well as real-time uptake kinetics of Zn(aq) and Mn(aq) in soybean (Glycine max (L.) Merrill) stem and leaves, for 48 hours, combined with transpiration rate assessment on leaves by an infrared gas analyzer (IRGA). We found higher Zn content than Mn in stems. The latter micronutrient, in turn, presented higher concentration in leaf veins. Besides, both micronutrients were more concentrated in the first trifolium (i.e., youngest leaf) of soybean plants. Moreover, the transpiration rate was more influenced by circadian cycles than Zn and Mn uptake. Thus, XRF represents a convenient tool for in vivo nutritional studies in plants, and it can be coupled successfully to other analytical techniques. Center for Nuclear Energy in Agriculture (CENA) University of Saõ Paulo (USP), Avenida Centenário, 303 Saõ Paulo State University-UNESP, Rua Domingos da Costa Lopes 780 Saõ Paulo State University-UNESP, Rua Domingos da Costa Lopes 780

Understanding the mechanisms of absorption and transport of foliar nutrition is a key step towards the development of advanced fertilization methods. This study employed X-ray fluorescence (XRF) and X-ray absorption near edge spectroscopy (XANES) to trace the in vivo absorption and transport of ZnO and ZnSO

The production and use of nanoparticles (NPs) in different fields increased in the last years. However, some NPs have toxicological properties, making these materials potential emerging pollutants. Therefore, it is important to investigate the uptake, transformation, translocation, and deposition of NPs in plants. In this work, laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) and micro X-ray fluorescence (μ-XRF) were used to investigate the uptake and translocation of La

This study investigated the dynamic of zinc (Zn) uptake and the root-to-shoot Zn-transport when supplied as ZnSO

Zinc oxide nanoparticles (N–ZnO) obtained by the Pechini method and calcined using a closed clay container are the focus of the present work. The synthetic route includes a modification in the calcination process (modified Pechini method), that is, without the change in the calcination process. The modified calcination process carried out in a clay container allows for the tunability of the ZnO bandgap. To characterize the materials, X-ray diffraction (XRD), transmission electron microscopy (TEM) and UV–visible (UV–Vis) spectroscopy have been performed. The analysis of UV–Vis absorption measurements allows us to conclude that the bandgap of N–ZnO can be tuned from 2.8 to 3.04 eV for ZnO–CC:400 and ZnO–CC:600 (samples of carbon-doped N–ZnO or C–N–ZnO), respectively, which are smaller than the ZnO bulk value of 3.37 eV. This gives rise to new possibilities of adaptation for the N–ZnO to new applications by shifting the bandgap from the UV to the visible region. The XRD and TEM measurements show that all samples are highly crystalline and have small grain sizes, confirming that the ethylene glycol seems to be a useful polymerizing agent for the preparation of C–N–ZnO.

This study evaluated the uptake and translocation of cerium nanoparticles (CeO2 NPs) and soluble Ce(NO3)3 by soybean plants (Glycine max L. Merrill) under the whole plant life-cycle and relevant environmental concentrations, 0.062 and 0.933 mg kg−1, which represent maximal values for 2017 in agricultural soils and sludge treated soils, respectively. The experiments were carried out using a nutrient solution. Cerium was detected in the soybean roots epidermis and cortex, leaves, and grains, but it neither impaired plant development nor grain yield. The concentration of Ce in the shoot increased as a function of time for plants treated with Ce(NO3)3, while it remained constant for plants treated with CeO2 NPs. It means that CeO2 NPs were absorbed in the same rate as biomass production, which suggests that they are taken up and transported by water mass flow. Single-particle inductively coupled plasma mass spectrometry revealed clusters of CeO2 NPs in leaves of plants treated with 25 nm CeO2 NPs (ca. 30–45 nm). The reprecipitation of soluble cerium from Ce(NO3)3 within the plant was not confirmed. Finally, bioconcentration factors above one were found for the lowest concentrated treatments. Since soybean is a widespread source of protein for animals, we draw attention to the importance of evaluating the effects of Ce entrance in the food chain and its possible biomagnification.

Zinc oxide (ZnO) nanoparticles were successfully synthesized using a whey-assisted sol-gel method. X-ray diffraction (XRD) and Raman spectroscopy analysis revealed a wurtzite crystalline structure for ZnO nanoparticles with no impurities present. Transmission electron microscopy (TEM), (XRD) observations, and UV–Vis absorption spectroscopy results showed that with an increase in calcination temperature from 400 to 1000 °C, the size of nanoparticles increases from 18.3 to 88.6 nm, while their optical band gap energy decreases to ~3.25 eV. The whey-assisted sol-gel method proved to be highly efficient for the synthesis of crystalline ZnO nanoparticles whose applications are of great interest in material science technology.

In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U.S. has been increasing steadily since 1988, when UNOS (United Network for Organ Sharing) started recording statistical data. In that year, 33 cases of lung transplantation were performed. As of today, a total of 23,815 lung transplants have been performed, and the largest number of yearly lung transplants (n=1,822) was performed in 2009. From appropriate patient selection, to optimal organ selection, surgical procedure, and immediate and long-term postoperative care, the medical process involves multiple healthcare providers and requires a very well-organized and committed healthcare system to achieve optimal surgical results. Understanding the pharmacology involved in the care of the lung transplant patient is of utmost importance to achieve appropriate organ preservation, immunosuppression, hemodynamic stability, and adequate anesthetic depth, while avoiding drug toxicity and side effects. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the medications most commonly administered to this patient population, throughout the perioperative period.

Objective The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. Design A retrospective review. Setting A single tertiary referral academic hospital. Participants Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. Interventions None. Measurements and Main Results After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. Conclusions Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

STUDY DESIGN Single-institution retrospective study. OBJECTIVE To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. SUMMARY OF BACKGROUND DATA Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. METHODS This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. RESULTS From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were $89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = -$178,899 to -$4661). CONCLUSION Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.

New biological knowledge and new diagnostic tools for breast cancer diagnosis may have an important impact on the strategies followed by oncologists in breast cancer management. So far, it has not been possible to label a nucleotide or its precursor with technetium-99m (99mTc) for use in in vivo studies. In this paper, we report the labelling of a precursor, the nitrogenate base thymine, with 99mTc. It has been used to evaluate breast lesions. After animal studies and with the consent of patients, it was employed for evaluation in humans. Thirty-nine women were studied: 32 patients and seven healthy volunteers. Twenty-three malignant lesions showed uptake of labelled thymine. Of the 12 benign cases, there was one false-positive uptake. Labelled thymine was also taken up by one case of malignant microcalcifications. Labelled thymine can be used as a diagnostic method in the identification of malignant anatomo-radiologic palpable lesions of the breast, observed by mammography, possibly avoiding unnecessary biopsies.

Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. Per the U.S. Department of Health and Human Services Organ Procurement and Transplantation Network, more than 5,000 OLT cases are being done per year since 2000. With better understanding of the pathophysiology of liver disease and the development of perioperative anesthesia management, the recent concept of improving patient outcome following OLT includes a fast-track approach in selected patients, which may shorten or completely bypass intensive care unit stay and reduce costs. With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines.

We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option.