Journal of cardiothoracic and vascular anesthesia
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Transcranial Doppler is a bedside procedure that measures linear cerebral blood flow velocity (CBFV) and the pulsatility index through the intracranial circulation. Transcranial color-coded duplex Doppler (TCCD) provides both CBFV and B-mode functions. In this review they are both referred to as brain ultrasound TCCD. ⋯ In these applications, TCCD can be used for the detection of cerebral vessel occlusion, estimation of cerebrovascular reactivity, right-to-left cardiac shunts, noninvasive estimation of cerebral perfusion and intracranial pressure, optic nerve sheath diameter, midline shift, hydrocephalus, and the presence of foreign objects. Finally, TCCD has a high accuracy in confirming total cerebral circulatory arrest and has been used as an ancillary test to support clinical diagnosis of brain death. Other indications for TCCD include assessment of collateral blood flow and embolization during carotid endarterectomy, assessment of patterns and extent of collateral circulation in severe stenosis or occlusion, assessment of patent foramen ovale/paradoxical embolism, assessment of arteriovenous malformations and studying their supply arteries and flow patterns, assessment of noncardiac right-to-left shunts, assessment of severe stenosis in the arteries of the circle of Willis, and assessment of vertebral artery dissection.
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The care of patients undergoing cardiac surgery is becoming more complex, in part owing to the increasing burden of comorbid disease, frailty, and psychosocial issues. Many risk factors for postoperative morbidity and mortality are potentially modifiable if identified and treated in a timely fashion before surgery. ⋯ There is substantial evidence that in multiple domains, including aerobic conditioning, respiratory muscle training, lifestyle modification, diabetic control, sleep, and psychoeducation, selected interventions before cardiac surgery may improve outcomes. However, the optimal preoperative program remains unclear and there is an unmet need for a comprehensive evaluation of the range of interventions specifically targeted at modifiable perioperative risk factors that may reduce adverse outcomes after cardiac surgery.
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Herein, the authors review the neuroanatomical and the neurophysiological aspects of the normal aging evolution based on the recent literature and briefly describe the difference between physiological and pathological brain aging, with consideration of the currently recommended anesthesia management of older patients. The population of elderly patients is growing drastically with advances in medicine that have prolonged the life span. One of the direct consequence has been a significant increase in the request for anesthesia care for older patients despite the type of surgery (cardiac vs noncardiac and mainly orthopedic). ⋯ This represents a new methodology for anesthesia titration that is adjusted on a more case-by-case basis and is related to the physiology of individual patients. A better understanding of aging-induced brain transformations remains the key regarding the improvement of the anesthetic management of the always growing population of elderly patients. The promotion of the unprocessed EEG may represent the best method of preventing the risk of anesthetic toxicity, including postoperative cognitive dysfunctions.