Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Mar 2010
ReviewPhysiology and pharmacology of myocardial preconditioning.
Perioperative myocardial ischemia and infarction are not only major sources of morbidity and mortality in patients undergoing surgery but also important causes of prolonged hospital stay and resource utilization. Ischemic and pharmacological preconditioning and postconditioning have been known for more than two decades to provide protection against myocardial ischemia and reperfusion and limit myocardial infarct size in many experimental animal models, as well as in clinical studies (1-3). This paper will review the physiology and pharmacology of ischemic and drug-induced preconditioning and postconditioning of the myocardium with special emphasis on the mechanisms by which volatile anesthetics provide myocardial protection. Insights gained from animal and clinical studies will be presented and reviewed and recommendations for the use of perioperative anesthetics and medications will be given.
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Semin Cardiothorac Vasc Anesth · Mar 2010
Use of paravertebral blockade to facilitate early extubation after minimally invasive cardiac surgery.
We retrospectively reviewed the first 14 patients who received preoperative paravertebral blockade prior to minimally invasive cardiac surgical procedures. The use of paravertebral blockade along with an anesthetic technique designed to facilitate rapid recovery allowed early extubation in the operating room or intensive care unit in all but one patient. Extubated patients leaving the operating room were comfortable. No postoperative respiratory complications occurred.
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Semin Cardiothorac Vasc Anesth · Mar 2010
ReviewCentral nervous system protection in cardiac surgery.
Neurological dysfunction and stroke following cardiac surgery and thoracic surgery requiring hypothermic circulatory arrest is a well-defined problem. The original studies in CABG patients identified risk factors, such as prior stroke and lower educational level. There is older evidence suggesting that higher perfusion pressures during cardiopulmonary bypass are helpful. ⋯ The subset of patients having thoracic aortic surgery requiring periods of aortic discontinuity are particularly problematic. A cerebral protection strategy should be determined, and this may include hypothermic circulatory arrest, selective cerebral perfusion, or retrograde cerebral perfusion. All of these techniques have been associated with good surgical outcomes, but there is little information on cognitive outcomes of thoracic aortic surgery.
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Semin Cardiothorac Vasc Anesth · Mar 2010
The importance of oral health for cardiothoracic and vascular patients.
Prior to cardiothoracic or vascular surgery, a patient's oral health is not usually a high priority for the surgical team. Yet, oral neglect often mirrors systemic disease and the need for proper dental care is often unmet. ⋯ Considering scheduling constraints and the urgency of the procedure, a pre-operative dental screening is suggested for patients who undergo elective cardiothoracic or vascular surgery, to ensure that any oral infection is diagnosed and definitively treated. Implementing such an effective and preventive approach can improve surgical outcome and overall patient health.
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Semin Cardiothorac Vasc Anesth · Mar 2010
Anesthesia management of a patient with a ventricular assist device for noncardiac surgery.
Congestive heart failure represents a severe health condition with unfavourable long-term prognosis despite all the progress in pharmacological therapy of heart failure. Another therapeutic option is represented by mechanical cardiac support devices. Ventricular assist devices (VAD) constitute largest subgroup of these devices. ⋯ In all the patients supported with VAD, transesophageal echocardiography is extremely useful method for monitoring the function of VAD itself, and in the case of univentricular VAD for monitoring the function of nonsupported cardiac ventricle. The most important issue in hemodynamic management of the patients with VAD is avoiding hypovolemia because it can cause inadequate VAD output with resulting low cardiac output and hypotension. All the patients with VAD need some degree of anticoagulation, and for noncardiac surgery the question of interrupting or decreasing the level of anticoagulation should be discussed among members of the caring team.