Analysis of the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Adults With Congenital Heart Disease (ACHD).

Adult congenital heart disease (ACHD) continues to rapidly increase worldwide. With an estimated 1.5 million adults with ACHD in the USA alone, there is a growing need for better education in the management of these complex patients and multiple knowledge gaps exist. This manuscript comprehensively reviewed the recent (2020) updated European Society of Cardiology Guidelines for the management of ACHD created by the Task Force for the management of adult congenital heart disease of the European Society of Cardiology, with perioperative implications for the adult cardiac anesthesiologist and intensivist who may be called upon to manage these complex patients.

Toe gangrene in an infant subsequent to application of adult-type pulse oximeter probe for 10 min.

We present a case of ischemic changes after application of an adult pulse oximeter probe in an infant for a short period of only 10 min. To understand the physiology behind this mishap, we studied pressure exerted by the adult pulse oximeter probe on simulated fingers (fluid-filled pouches), which were filled under gravity through the three-way stopcock. A catheter was placed inside the pouch to continuously measure the pressure. The experiment was performed on different sizes of the finger-shaped pouches and by varying the positioning of the pouches in the pulse oximeter. It was observed that pressure exerted by the pulse oximeter was directly proportional to the extent to which it was stretched after placement on the fluid-filled pouches of different sizes. In the fully extended position, the pressure exerted was higher (up to 30 mmHg) than in the fully collapsed position (4 mmHg). Higher pressures were caused by greater stretch of the probe. This could occur due to larger fingers and closer placement of fingers to the hinge of the probe.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns.

BACKGROUND: Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy. PATIENTS AND METHODS: The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry.In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered. RESULTS: Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 +/- 2 to 28 +/- 2.7 cmH2O and central venous pressure increased from 12.9 +/- 1 to 19.2 +/- 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice. SUMMARY: Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.