Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Dec 1998
ReviewPatient selection and anesthetic management for early extubation and hospital discharge: CABG.
Three model systems have been described that may facilitate an increase in the numbers of patients passing through the hospital within the resource allocation available: (1) early fast-track extubation, < 3 hours after surgery, (2) planned intensive care unit discharge < 18 hours, and (3) early hospital discharge < 5 days. Thus far, studies have not clearly identified patient group or risk demonstrating a need for prolonged intubation or delayed intensive care unit and hospital length of stay. It thus appears appropriate to suggest that all patients be considered suitable for early extubation, mobilization, and hospital discharge. ⋯ The ultrashort action of remifentanil facilitates the ability to plan and control the period of recovery of spontaneous ventilation and extubation while providing profound reduction of intraoperative stress responses and hemodynamic stability. Safe extubation requires that the patient be alert and cooperative, be hemodynamically stable and warm, is not bleeding, and has adequate respiratory function. Interventions with anti-inflammatory and hemostatic agents such as the serine protease inhibitor aprotinin or with corticosteroids can have a major impact on achieving the criteria needed to ensure rapid discharge from the intensive care unit.
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Excessive bleeding after cardiac surgery is an important factor that can prevent early extubation. Hemostatic derangement is well recognized to be associated with cardiopulmonary bypass, with many possible contributing factors resulting in coagulation defects and fibrinolytic pathway activation. Measures to optimize hemostasis are critical when managing patients for whom early extubation and hospital discharge are goals. The intraoperative evaluation of the hemostatic system with tests like the thrombelastogram and the use of therapeutic agents such as aprotinin are simple, safe, and effective methods of achieving these goals.
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J. Cardiothorac. Vasc. Anesth. · Dec 1998
ReviewImpact of early tracheal extubation on hospital discharge.
Economic realities of the continuing increased utilization of cardiac surgery in the 1990s have led to the practice of early tracheal extubation and shortening of the length of intensive care unit and hospital stays. In this era of cost-containment and physician report cards, we are held accountable for patients' outcome in terms of mortality, morbidity, quality of life, length of stay, and cost of care. This report outlines the factors that influence costs of cardiac surgery. ⋯ The current literature on outcome, utilization, and cost implications of early tracheal extubation in cardiac surgery is summarized and discussed. It has been demonstrated that early extubation anesthesia is safe and cost-effective and can improve resource utilization in cardiac surgery, but to achieve a maximum cost benefit from fast-track or early extubation anesthesia in cardiac patients, team organization of a fast-track cardiac surgery program must be implemented. A perioperative clinical pathway management in fast-track cardiac surgery is presented.
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J. Cardiothorac. Vasc. Anesth. · Dec 1998
Real-time intraoperative transesophageal echocardiography--how useful? Experience of 5,016 cases.
To evaluate transesophageal echocardiography (TEE) as an intraoperative monitoring modality and to assess its safety, reliability, and overall utility in real-time use during cardiac surgery. ⋯ Intraoperative TEE is useful in formulating the surgical plan, guiding various hemodynamic interventions, and assessing the immediate results of surgery. It is safe and the results are reliable in the hands of trained anesthesiologists.
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J. Cardiothorac. Vasc. Anesth. · Dec 1998
Fibrinolysis in pediatric patients undergoing cardiopulmonary bypass.
Thromboelastographic evaluation of the influence of fibrinolysis on blood loss and blood product transfusions in children during cardiac surgery. ⋯ A group of children at risk for fibrinolysis during CPB was identified. However, fibrinolysis during CPB did not influence blood loss or the total volume of blood products transfused.