Noise levels in modern operating rooms during surgery.

OBJECTIVE: To determine if differences in noise levels exist in the cardiac operating room at various critical points. DESIGN: Prospective, nonrandomized study. SETTING: Cardiac operating rooms of a university hospital. PARTICIPANTS: Cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The noise level was monitored in the operating room for 23 patients undergoing cardiac surgery requiring general anesthesia during room setup, induction, skin incision, 60 minutes after surgical incision, termination of extracorporeal circulation, emergence (drapes down), and transport. RESULTS: At each data point (induction, emergence, termination of extracorporeal circulation, emergence [drapes down], and transport), noise levels were louder than the baseline reference at room setup, surgical skin incision, and 60 minutes into the surgery. CONCLUSIONS: The aim of this study was to compare the level of noise in the operating room at times determined critical for anesthesiologists compared with other surgical periods. This study consistently showed that noise in the operating room is louder during the critical anesthesia components of the case. Several studies have found that the loudest sound levels recorded in an operating room are related to the use of particular surgical tools, which are not used typically during the induction and emergence from anesthesia. This suggests that the increased sound levels during these periods may be somewhat controllable by the health care providers in the room.

The Swan-Ganz catheter as a teaching tool for the anesthesiologist learning minimally invasive cardiac surgery.

OBJECTIVE: To perform minimally invasive cardiac surgery through the smallest possible wound and with the least number of incisions in the heart or aorta, the necessary cannulations to undergo cardiopulmonary bypass must be done through peripheral vessels. A difficult skill to learn for the cardiac anesthesiologist is how to safely and efficiently position the coronary sinus catheter (Endoplege; Edwards Lifesciences LLC, Irvine, CA USA) required for retrograde cardioplegia administration. METHODS: In patients in whom a Swan-Ganz catheter was inserted as part of the operative management strategy for non-minimally invasive heart surgery, we have been using it as a training tool to learn how to visualize and manipulate right-sided catheters under transesophageal echocardiography. We developed this teaching technique to help hone some of the necessary skills needed to place the Endoplege catheter for minimally invasive cardiac surgery. Manipulation was done with the goal of visualizing the catheter and guiding it into the coronary sinus. For a 4-month period, anesthesia records were retrospectively reviewed. RESULTS: Fifteen patients, for a total of 19 catheter manipulations, were found in whom we had documented the use of the Swan-Ganz catheter and details about the insertion as a training tool. The coronary sinus and the catheter were visualized 100% of the time. The Swan-Ganz catheter was successfully inserted into the coronary sinus in 17 of 19 catheter manipulations. CONCLUSIONS: The Swan-Ganz catheter can be used as a training tool to develop some of the necessary skills to place catheters into the coronary sinus with transesophageal echocardiography guidance.

Cannulation of the middle cardiac vein during MICS.

Coronary sinus cannulation for retrograde cardioplegia administration during cardiac surgery is common practice. Several of the cannulas that are placed by the cardiac surgeon on open procedures are now placed by the cardiac anesthesiologist during minimally invasive cardiac surgery, including the coronary sinus catheter. The understanding of the cardiac venous anatomy is very important during coronary sinus catheter placement. We present a case where a percutaneously placed coronary sinus catheter was inadvertently placed into the middle cardiac vein but detected with the use of fluoroscopy.

Response to nitric oxide during adult cardiac surgery.

Pulmonary hypertension is associated with significant morbidity and mortality in adult cardiac surgery patients. Inhaled nitric oxide is known to be a selective pulmonary vasodilator in this setting. However, it is not known which cardiac surgery patients benefit most from nitric oxide therapy. This study sought to prospectively determine whether a patient's baseline pulmonary vascular resistance could be used to predict responsiveness to inhaled nitric oxide therapy. Subjects were 30 consecutive cardiac surgery patients with pulmonary hypertension immediately prior to induction of anesthesia. There were 2 study groups: Group 1 (n = 15) had an initial pulmonary vascular resistance between 125 and 300 dyn-s/cm5, while group 2 (n = 15) had an initial pulmonary vascular resistance of greater than 300 dyn-s/cm5. Both groups were empirically treated with inhaled nitric oxide (30 ppm) upon separation from bypass. The conduct of anesthesia, surgery, and cardiopulmonary bypass were controlled. A therapeutic algorithm dictated the use of vasoactive substances for all patients. Heart rate, mean arterial pressure, pulmonary vascular resistance, peripheral vascular resistance, cardiac index, and right ventricular ejection fraction were monitored throughout the operative experience. Patients with a higher initial pulmonary vascular resistance had a significantly greater percent reduction in pulmonary vascular resistance after the initiation of nitric oxide therapy. This study suggests that pulmonary vascular resistance is more dramatically affected by inhaled nitric oxide in cardiac surgery patients with a greater degree of pulmonary hypertension.