Fontan’s circulation with dextrocardia, recent pulmonary embolism, and inferior vena cava filter: Anesthetic challenges for urgent hysterectomy.

Fontan’s circulation is a unique challenge for the anesthesiologist. Venous pressure is the only source of blood flow for the pulmonary circulation. Patients with such circulation are extremely sensitive to progression of cyanosis (decreased pulmonary blood flow) or circulatory failure. Any major venous compression can compromise the pulmonary blood flow worsening cyanosis; simultaneously, an increased afterload can precipitate circulatory failure. We present a rare patient of surgically corrected Ivemark syndrome with Fontan’s physiology with dextrocardia who developed a large uterine fibroid compressing inferior vena cava (IVC). As a result of compression, not only the pulmonary circulation was compromised but she also developed stasis‑induced venous thrombosis in the lower limbs that lead to pulmonary embolism (PE) (increased afterload). In addition to oral anticoagulation an IVC filter was inserted to prevent ongoing recurrent PE. Further, to prevent both circulatory compromise and deep venous thrombosis an urgent myomectomy/ hysterectomy was planned. In the present case, we discuss the issues involved in the anesthetic management of such patients and highlight the lacunae in the present guidelines for managing perioperative anticoagulation these situations.

Comparison between continuous non-invasive estimated cardiac output by pulse wave transit time and thermodilution method.

Aims and Objectives: Cardiac output (CO) measurement is essential for many therapeutic decisions in anesthesia and critical care. Most available non‑invasive CO measuring methods have an invasive component. We investigate “pulse wave transit time” (estimated continuous cardiac output [esCCO]) a method of CO measurement that has no invasive component to its use. Materials and Methods: After institutional ethical committee approval, 14 adult (21–85 years) patients undergoing surgery and requiring pulmonary artery catheter (PAC) for measuring CO, were included. Postoperatively CO readings were taken simultaneously with thermodilution (TD) via PAC and esCCO, whenever a change in CO was expected due to therapeutic interventions. Both monitoring methods were continued until patients’ discharge from the Intensive Care Unit and observer recording values using TD method was blinded to values measured by esCCO system. Results: Three hundred and one readings were obtained simultaneously from both methods. Correlation and concordance between the two methods was derived using Bland‑Altman analysis. Measured values showed significant correlation between esCCO and TD (r = 0.6, P < 0.001, 95% confidence limits of 0.51-0.68). Mean and (standard deviation) for bias and precision were 0.13 (2.27) L/min and 6.56 (2.19) L/min, respectively. The 95% confidence interval for bias was ‑ 4.32 to 4.58 L/min and for precision 2.27 to10.85 L/min. Conclusions: Although, esCCO is the only true non‑invasive continuous CO monitor available and even though its values change proportionately to TD method (gold standard) with the present degree of error its utility for clinical/therapeutic decision‑making is questionable.

Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures.

Aims and Objectives: Continuous flow left ventricular assist devices (LVAD) have emerged as a reliable treatment option for heart failure. Because of bleeding secondary to anticoagulation, these patients present frequently for gastrointestinal (GI) endoscopy. The presently available literature on perioperative management of these patients is extremely limited and is primarily based upon theoretical principles. Materials and Methods: Perioperative records of patients with LVAD undergoing (GI) endoscopy between 2008 and 2012 were reviewed. Patient, device and procedure specific information was analyzed. Results: A total of 105 LVADs were implanted, and 68 procedures were performed in 39 patients. The most common indication was GI bleed (48/68), with yearly risk of 8.57% per patient. A total of 63 procedures were performed under deep sedation, with five procedures requiring general anesthesia. Intra‑procedure hypotension was managed by fluids and (or) vasopressors/inotropes (phenylephrine, ephedrine or milrinone) guided by plethysmographic waveform, non‑invasive blood pressure (NIBP) and LVADs pulsatility index (for HeartMate II)/flow pulsatility (for HeartWare). No patient required invasive monitoring and both NIBP and pulse oximeter could be reliably used for monitoring (and guided management) in all patients due to the presence of native heart’s pulsatile output. Conclusion: In the presence of residual heart function, with optimal device settings, non‑invasive hemodynamic monitoring can be reliably used in these patients while undergoing GI endoscopy under general anesthesia or monitored anesthesia care. Transient hypotensive episodes respond well to fluids/vasopressors without the need of increasing device speed that can be detrimental.