Anesthesia care for subcutaneous implantable cardioverter/defibrillator placement: a single-center experience.

BACKGROUND: The recently approved subcutaneous implantable cardioverter/defibrillator (S-ICD) uses a single extrathoracic subcutaneous lead to treat life-threatening ventricular arrhythmias, such as ventricular tachycardia and ventricular fibrillation. This is different from conventional transvenous ICDs, which are typically implanted under sedation. Currently, there are no reports regarding the anesthetic management of patients undergoing S-ICD implantation. STUDY OBJECTIVES: This study describes the anesthetic management and outcomes in patients undergoing S-ICD implantation and defibrillation threshold (DFT) testing. METHODS: The study population consists of 73 patients who underwent S-ICD implantation. General anesthesia (n = 69, 95%) or conscious/deep sedation (n = 4, 5%) was used for device implantation. MEASUREMENTS: Systolic blood pressure (SBP) and heart rate were recorded periprocedurally for S-ICD implantation and DFTs. Major adverse events were SBP <90 mm Hg refractory to vasopressor agents, significant bradycardia (heart rate <45 beats per minute) requiring pharmacologic intervention and, "severe" pain at the lead tunneling site and the S-ICD generator insertion site based on patient perception. INTERVENTIONS: Of the 73 patients, 39 had SBP <90 mm Hg (53%), and intermittent boluses of vasopressors and inotropes were administered with recovery of SBP. In 2 patients, SBP did not respond, and the patients required vasopressor infusion in the intensive care unit. MAIN RESULTS: Although the S-ICD procedure involved extensive tunneling and a mean of 2.5 ± 1.7 DFTs per patient, refractory hypotension was a major adverse event in only 2 patients. The mean baseline SBP was 132.5 ± 22.0 mm Hg, and the mean minimum SBP during the procedure was 97.3 ± 9.2 mm Hg (P < .01). There was also a mean 13-beats per minute decrease in heart rate (P < .01), but no pharmacologic intervention was required. Eight patients developed "severe" pain at the lead tunneling and generator insertion sites and were adequately managed with intravenous morphine. CONCLUSIONS: Among a heterogeneous population, anesthesiologists can safely manage patients undergoing S-ICD implantation and repeated DFTs without wide swings in SBP and with minimal intermittent pharmacologic support.

Reversal of paralysis and visceral ischemia after thoracic aortic ligation for infection via extra anatomic ascending aorta to infarenal aorta bypass graft.

Surgical management of acute aortic infection is challenging, including excision of the infected segment and reconstruction either through extra-anatomical bypass or in situ graft replacement with higher risk of re-infection. Here in, we present a case of delayed paralysis developed after an extra-anatomic (axillary-bifemoral) bypass of infected thoracic aorta in a 51 year old Caucasian male. Reversal of paralysis was successfully achieved via larger extra-anatomical ascending aorta to infra-renal aorta bypass and cerebrospinal fluid (CSF) drainage.

Arterial embolism.

Surgical and intensive care patients are at a heightened risk for arterial embolization due to pre-existing conditions such as age, hypercoagulability, cardiac abnormalities and atherosclerotic disease. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds where they cause arterial occlusion, ischemia, and potentially infarction. Other emboli form on the surface of eroded arterial plaque or within its lipid core. Thromboemboli are large clots that dislodge from the surface of athesclerotic lesions and occlude distal arteries causing immediate ischemia. Atheroemboli, which originate from fracturing the lipid core tend to cause a process of organ dysfunction and systemic inflammation, termed cholesterol embolization syndrome. The presentation of arterial emboli depends on the arterial bed that is affected. The most common manifestations are strokes and acute lower limb ischemia. Less frequently, emboli target the upper extremities, mesenteric or renal arteries. Treatment involves rapid diagnosis, which may be aided by precise imaging studies and restoration of blood flow. The type of emboli, duration of presentation, and organ system affected determines the treatment course. Long-term therapy includes supportive medical care, identification of the source of embolism and prevention of additional emboli. Patients who experienced arterial embolism as a result of clots formed in the heart should be anticoagulated. Arterial emboli from atherosclerotic disease of the aorta or other large arteries should prompt treatment to reduce the risk for atherosclerotic progression, such as anti-platelet therapy and the use of statin drugs. The use of anticoagulation and surgical intervention to reduce the risk of arterial embolization from atherosclerotic lesions is still being studied.

Anesthetic considerations for robotic prostatectomy: a review of the literature.

Since the first robotic prostatectomy in 2000, the number of prostatectomies performed using robot-assisted laparoscopy has been increasing. As of 2009, 90,000 robotic radical prostatectomies were performed worldwide, and 80% of all radical prostatectomies performed in the United States were performed robotically. Robotic prostatectomy is becoming more common globally because of the many advantages offered to patients, primarily due to the minimally invasive nature of the procedure. Several new perioperative concerns and challenges for anesthesiologists and are described.