Anesthetic management for coronary bypass patients on hemodialysis: report of 4 patients.

We reported our own experience in four patients with chronic renal failure on maintenance hemodialysis undergoing coronary artery bypass graft surgery (CABGS). A balanced general anesthesia with endotracheal intubation was successfully achieved by using midazolam, atracurium, fentanyl, pentothal, nitrous oxide in oxygen and isoflurane. All patients were hemodialyzed within 24 hours before operation. One patient started peritoneal dialysis 10 hours after surgery. Three other patients were managed by hemodialysis the day after surgery. There was no hospital mortality. Many aspects of management of these patients which differ from those of routine cardiac surgical patients are outlined and discussed.

Utility of intraoperative transesophageal echocardiogram in congenital heart disease.

Intraoperative transesophageal echocardiogram (TEE) has improved the perioperative outcome in adult patients. The purpose of the current study was to assess the benefit of intraoperative TEE in patients with congenital heart disease undergoing surgical correction (repair). The results of the patients who had consecutively undergone intraoperative TEE during their congenital heart surgery between January 1998 to June 2000 were reviewed. There were 104 patients (whose ages ranged from one week old to 50 years old (median 5 years old) and their weights from 3 kg to 79 kg (median 15 kg). A significant impact was said to have occurred if these findings prompted a change in surgical procedure following a prebypass study or rebypass for repair of a residual defect. Prebypass TEE had a significant impact in seven patients (6.7%). TEE could be used as a guide to help repair in three patients. The postbypass TEE examination had a significant impact in 15 patients (14.4%). Of these 15 patients, eight were detected primarily by TEE examination. The group of patients in whom TEE had the most significant impact was in patients who had surgery related to the repair of the atrioventricular valve (complete or partial atrioventricular (AV) canal repair, Ebstein's anomaly; 9 out of 22 patients; 41%). A less significant impact was found in surgery for other complex congenital defects (single ventricle or complete transposition of great arteries; eight out of 46 patients; 17.4%). TEE had limited impact in simple congenital lesion. Intraoperative TEE is valuable in the perioperative care of patients with congenital heart defects. We found the most benefit in patients with complete or partial AV canal and Ebstein's anomaly.

Early extubation following open heart surgery in pediatric patients with congenital heart diseases.

The study of tracheal extubation time in pediatric patients who underwent open heart surgery was performed in the period of 1990-1991 (group 1) and 1992-May 1994 (group 2), composed of 174 and 208 cases in group 1 and group 2 respectively. The criteria for extubation in these patients are convention regimens with considered subsequent standard of CPB, such as fully rewarmed, hemodynamic stable with adequate cardiac output with low-dose or no inotropes/ vasodilator, without significant dysrhythmias and no significant mediastinal bleeding. The difference of postoperative fluid management between the two groups include the regimens of total fluid intake of two-thirds of daily maintenance fluid in group 1, whereas, the total fluid therapy of group 2 depended on the patients' age and body weight. The results show that, early extubation within 8 hours of ICU arrival were 20.5 per cent and 61.7 per cent in group 1 and group 2 respectively. All of the patients in group 2, after extubation, were discharged to the ward on the first postoperative day. The overnight ventilation was about 74.1 per cent and 30.6 per cent in the first and second groups respectively. The prolonged intubation (more than 24 hours) was almost the same in two groups. There was no significant complication of early extubation with the limitation of daily total fluid intake. The causes of tracheal reintubation in both groups were fluid overload and residual cardiac lesions. The prior etiology occurred in group 1 more than group 2. It was concluded that, after the change in postoperative fluid therapy regimens, early extubation following open-heart pediatric surgery is highly successful with no significant complication. The benefits of early extubation include cost savings, patient comfort, early patient mobilization, improved cardiac function, reduced respiratory complications and reduction of case cancellation due to early ICU discharge.

Percutaneous coil embolization and balloon-expandable stenting; new treatments in intractable cardiac failure after Fontan procedure: a case report.

Successful percutaneous coil embolization of aortopulmonary collaterals and balloon-expandable stent implantation of left pulmonary artery stenosis in a child with hypoplastic right heart syndrome were reported, Presently, interventional cardiac catheterization is a very useful treatment strategy in congenital heart diseases unamenable to or inaccessible for surgery.