Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Mar 2006
ReviewHow to reliably detect ischemia in the intensive care unit and operating room.
Detection of myocardial ischemia in the perioperative period is important because it allows for intervention that may prevent progression of ischemia to myocardial infarction. Perioperative ischemia is also an important predictor of adverse cardiovascular outcomes. Patients should first be stratified according to their risk of having cardiovascular disease by identifying major, intermediate, and minor predictors of adverse cardiovascular outcome. ⋯ Also, detection of these hemodynamic changes requires insertion of invasive monitoring devices. Transesophageal echocardiography can be used to detect myocardial ischemia by identifying changes in regional wall motion. These transesophageal echocardiography changes occur sooner and more frequently than ECG changes, but require greater knowledge and skill to properly interpret.
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Aortic dissection and aortic intramural hematoma are highly lethal diseases occurring mostly in patients with arterial hypertension or Marfan syndrome. Transesophageal echocardiography (TEE) is the diagnostic imaging procedure of choice in the unstable patient. Hallmarks of dissection are the presence of an intimal membrane, or flap, dividing a true and a false lumen, entry and reentry tears, periaortic hematoma, pericardial effusion or tamponade, and aortic regurgitation in dissection of the ascending aorta. ⋯ The accuracy of TEE is similar to computed tomography and magnetic resonance imaging, with the added benefit of being feasible at the bedside or in the operating room. Precautions have to be taken during TEE to avoid an abrupt rise in blood pressure. Aortic intramural hematoma is often a precursor of classic dissection or accompanies it and can also be diagnosed by TEE, although the diagnosis is frequently difficult.
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Semin Cardiothorac Vasc Anesth · Mar 2006
Clinical TrialProtecting the heart with cardiac medication in patients with left ventricular dysfunction undergoing major noncardiac vascular surgery.
Patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery are at increased risk of adverse postoperative events. We sought to evaluate whether perioperative medication use, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, and aspirin, was associated with a reduced incidence of postoperative in-hospital mortality in these high-risk patients. The study enrolled 511 patients with left ventricular dysfunction (left ventricular ejection fraction <30%) who were undergoing major noncardiac vascular surgery. ⋯ Sixty-four patients (13%) died. Perioperative use of ACE inhibitors (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.12-0.91), beta-blockers (OR, 0.03; 95% CI, 0.01-0.26), statins (OR, 0.06; 95% CI, 0.01-0.53), and aspirin (OR, 0.13; 95% CI, 0.03-0.55), was significantly associated with a reduced incidence of mortality, after adjusting for cardiac risk factors and DSE results. In conclusion, the present study showed that the perioperative use of ACE inhibitors, beta-blockers, statins, and aspirin is independently associated with a reduced incidence of in-hospital mortality in patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery.
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Semin Cardiothorac Vasc Anesth · Dec 2005
ReviewSimulation devices in cardiothoracic and vascular anesthesia.
The subspecialty of cardiothoracic and vascular anesthesia is becoming increasingly complex. Trainees must learn to manage difficult cases and be skilled in performing a variety of procedures. With work hour limitations and societal pressures working to reduce learning and practice opportunities for trainees, new training modalities must be utilized. ⋯ They vary from the simple to the complex and from inexpensive homemade wooden devices to high-end computer-controlled virtual reality simulators. Although not all these simulators have been validated as to their educational efficacy, they offer a new avenue to improve training efficacy and efficiency. More research needs to be done to validate these devices and assess their role in anesthesia training.
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Semin Cardiothorac Vasc Anesth · Dec 2005
ReviewSimulation in cardiothoracic and vascular anesthesia education: tool or toy?
The use of simulators in cardiothoracic and vascular anesthesia runs the gamut from standardized patients and part-task trainers to full-scale high-fidelity human patient simulators. The use of simulation to teach medical students, anesthesiology residents, board-certified anesthesiologists with subspecialty interests, hospital administrators, attorneys, and the lay public is still evolving as educational research evaluates the use of simulation and health professional educators struggle to define its role and value. This article provides a general overview of the field and attempts to critically evaluate what is and what is not scientifically determined about simulation and simulators.