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1.
AANA J ; 84(6): 423-425, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28235176

RESUMO

The use of a supraglottic airway, also called laryngeal mask airway (LMA), is gaining in popularity for delivery of general anesthesia in certain situations and is shown to be safe. Use of infraglottic airways (tracheal tubes) allows for positive pressure ventilation and maneuvers, such as holding continuous positive pressure in the airway to check for pleural and dural leaks. We describe the successful use of the LMA (Teleflex Inc) for general anesthesia, in which continuous positive airway pressure of 15 cm H2O held for 20 seconds allowed the neurosurgeon to identify the site of a cerebrospinal fluid (CSF) leak and successfully repair the leak. A well-seated LMA can be successfully used to produce continuous positive pressure in the airway not exceeding 20 cm H2O for 20 seconds to facilitate surgical identification of CSF leaks.


Assuntos
Máscaras Laríngeas , Procedimentos Cirúrgicos Oftalmológicos , Respiração com Pressão Positiva , Manobra de Valsalva , Anestesia Geral , Humanos
2.
Springerplus ; 4: 480, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26361581

RESUMO

PURPOSE: Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated. METHODS: We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida). RESULTS: Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/µL; and fibrinogen, 237.8 (127.6) mg/dL. CONCLUSION: TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.

3.
Liver Transpl ; 21(10): 1280-5, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25939618

RESUMO

Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.


Assuntos
Cardiopatias/etiologia , Transplante de Fígado/efeitos adversos , Trombose/etiologia , Adulto , Idoso , Antifibrinolíticos/uso terapêutico , Coagulação Sanguínea , Bases de Dados Factuais , Ecocardiografia Transesofagiana , Feminino , Florida , Cardiopatias/sangue , Cardiopatias/diagnóstico , Cardiopatias/mortalidade , Cardiopatias/fisiopatologia , Hemodinâmica , Humanos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Remissão Espontânea , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Análise de Sobrevida , Tromboelastografia , Terapia Trombolítica , Trombose/sangue , Trombose/diagnóstico , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
4.
J Clin Monit Comput ; 29(1): 121-5, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24748550

RESUMO

Transesophageal echocardiography of the spine has been difficult to perform, and high-quality images have been difficult to obtain with earlier available technology. New capabilities in hardware and software reconstruction may allow more reliable clinical data to be obtained. We describe an initial successful attempt to image the adult spinal canal, its contents, and in situ instrumentation. This report is a retrospective review of two patients in whom transesophageal echocardiography (TEE) was used to image the thoracic spine. The thoracic spine was identified and imaged with real-time 2-D and 3-D technology with location of the thoracic aorta and slight insertion and withdrawal of the TEE probe until the intervertebral discs alignment was optimized. Images of the spinal cord anatomy and its vascular supply, as well as indwelling epidural catheters were easily identified. 2-D and 3-D imaging was performed and images were recorded in digital imaging and communications in medicine format. 3-D reconstruction of images was possible with instantaneous 3-D imaging from multiple 2-D electrocardiogram-gated image acquisitions using the Phillips TEE IE-33 imaging platform. The central neuraxial cavity, including the spinal cord and the spinal nerve roots, was easily visualized, and motion of the cord was seen in a phasic pattern (with respiratory variation); cerebrospinal fluid surrounding the spinal cord was documented. The epidural space and local anesthetic drug administration through the epidural catheter were visualized, with the epidural catheter seen lying adjacent to the epidural tissue as a bright hyperechoic line. Pulsed-wave Doppler determined a biphasic pattern of blood flow in the anterior spinal artery through pulse mapping of the anatomic area. New, advanced imaging hardware and software generate clinically useful imaging of the thoracic spine in 2-D and 3-D using TEE. We believe this technology holds promise for future diagnostic and therapeutic interventions in the operating room that were previously unavailable.


Assuntos
Ecocardiografia Transesofagiana/métodos , Medula Espinal/patologia , Anestésicos/administração & dosagem , Cateterismo , Espaço Epidural/patologia , Humanos , Processamento de Imagem Assistida por Computador/métodos , Imageamento Tridimensional , Disco Intervertebral/patologia , Monitorização Intraoperatória/métodos , Projetos Piloto , Estudos Retrospectivos , Software , Medula Espinal/diagnóstico por imagem , Vértebras Torácicas/patologia
5.
Curr Clin Pharmacol ; 10(1): 35-46, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24521189

RESUMO

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.


Assuntos
Anestésicos/administração & dosagem , Doença Hepática Terminal/cirurgia , Transplante de Fígado/métodos , Anestesiologia/métodos , Anestésicos/farmacocinética , Animais , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/fisiopatologia , Humanos
6.
Curr Clin Pharmacol ; 10(1): 54-65, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24521192

RESUMO

Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. Per the U.S. Department of Health and Human Services Organ Procurement and Transplantation Network, more than 5,000 OLT cases are being done per year since 2000. With better understanding of the pathophysiology of liver disease and the development of perioperative anesthesia management, the recent concept of improving patient outcome following OLT includes a fast-track approach in selected patients, which may shorten or completely bypass intensive care unit stay and reduce costs. With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.


Assuntos
Analgésicos/administração & dosagem , Hepatopatias/cirurgia , Transplante de Fígado/métodos , Analgésicos/farmacocinética , Analgésicos/farmacologia , Analgésicos Opioides/administração & dosagem , Anestésicos/administração & dosagem , Animais , Relação Dose-Resposta a Droga , Humanos , Hepatopatias/fisiopatologia , Seleção de Pacientes , Índice de Gravidade de Doença
7.
Curr Clin Pharmacol ; 10(1): 47-53, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24521193

RESUMO

Kidney transplants are routinely performed at medical centers around the world. Concurrent with improved surgical techniques, a better understanding of the pharmacology involved in the perioperative anesthetic management has led to improved outcomes in these patients. This chapter reviews the perioperative pharmacologic considerations surrounding kidney transplant patients from the viewpoint of the transplant anesthesiologist.


Assuntos
Anestésicos/administração & dosagem , Nefropatias/cirurgia , Transplante de Rim/métodos , Anestesiologia/métodos , Anestésicos/farmacologia , Animais , Humanos
8.
Liver Transpl ; 18(3): 361-9, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22140001

RESUMO

The continuation of hemodynamic, respiratory, and metabolic support for a variable period after liver transplantation (LT) in the intensive care unit (ICU) is considered routine by many transplant programs. However, some LT recipients may be liberated from mechanical ventilation shortly after the discontinuation of anesthesia. These patients might be appropriately discharged from the postanesthesia care unit (PACU) to the surgical ward and bypass the ICU entirely. In 2002, our program started a fast-tracking program: select LT recipients are transferred from the operating room to the PACU for recovery and tracheal extubation with a subsequent transfer to the ward, and the ICU stay is completely eliminated. Between January 1, 2003 and December 31, 2007, 1045 patients underwent LT at our transplant program; 175 patients were excluded from the study. Five hundred twenty-three of the remaining 870 patients (60.10%) were fast-tracked to the surgical ward, and 347 (39.90%) were admitted to the ICU after LT. The failure rate after fast-tracking to the surgical ward was 1.90%. The groups were significantly different with respect to the recipient age, the raw Model for End-Stage Liver Disease (MELD) score at the time of LT, the recipient body mass index (BMI), the retransplantation status, the operative time, the warm ischemia time, and the intraoperative transfusion requirements. A multivariate logistic regression analysis revealed that the raw MELD score at the time of LT, the operative time, the intraoperative transfusion requirements, the recipient age, the recipient BMI, and the absence of hepatocellular cancer/cholangiocarcinoma were significant predictors of ICU admission. In conclusion, we are reporting the largest single-center experience demonstrating the feasibility of bypassing an ICU stay after LT.


Assuntos
Unidades de Terapia Intensiva , Transplante de Fígado , Adulto , Idoso , Estudos de Viabilidade , Feminino , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença
9.
J Gastrointest Surg ; 15(11): 2098-100, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21935734

RESUMO

INTRODUCTION: Liver retransplantation is the only option for people who have a failing liver graft, but it can be technically challenging. Intraperitoneal adhesions often form after abdominal operations, which is true in liver retransplantation as well. Also, the liver hilum is scarred, which makes hilar dissection more difficult. In addition, dissection is further complicated in the setting of portal hypertension. DISCUSSION: Venovenous bypass can be used for portomesenteric decompression. We describe an alternative technique for decompression of portal hypertension using an inferior mesenteric vein without placing the patient on venovenous bypass.


Assuntos
Descompressão Cirúrgica/métodos , Hipertensão Portal/cirurgia , Transplante de Fígado , Veias Mesentéricas/cirurgia , Veia Porta/fisiopatologia , Humanos , Hipertensão Portal/fisiopatologia , Reoperação
10.
Exp Clin Transplant ; 9(2): 98-104, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21510102

RESUMO

OBJECTIVES: Orthotopic liver transplant is the treatment of choice for patients with end-stage liver disease. Patients with first graft failure requiring liver retransplant are commonly seen at most liver transplant centers. However, patients with a second graft failure requiring a third graft are uncommon. Liver retransplant in this setting has only been pursued at a few large transplant centers. MATERIALS AND METHODS: This is a retrospective analysis of the long-term outcomes of recipients who underwent 3 or more orthotopic liver transplants. Between February 1998 and August 2009, 24 patients had 3 or more orthotopic liver transplants at the Mayo Clinic in Florida. RESULTS: Mean patient survival was 103.8 months for the study cohort. Actuarial patient survival after the last orthotopic liver transplant in -1, -5, and -10 years was 60%, 40%, 33%. Patients were transplanted with lower donor risk index score grafts in each subsequent orthotopic liver transplant. Patients who had a graft with a donor risk index score > 1.6 at the time of the third orthotopic liver transplant had significantly lower survival rate compared with those with grafts with a donor risk index score ≤ 1.6. CONCLUSIONS: Multiple liver retransplants offer acceptable patient survival. Each transplant program must decide whether to do multiple orthotopic liver transplants based on the program's transplant volume and outcomes to help this subgroup of patients. The concerns of potentially decreasing access to first time orthotopic liver transplant candidates should also be weighed in the decision to move forward.


Assuntos
Hepatopatias/diagnóstico , Hepatopatias/cirurgia , Transplante de Fígado/mortalidade , Adulto , Idoso , Feminino , Florida , Humanos , Estimativa de Kaplan-Meier , Hepatopatias/mortalidade , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Qualidade de Vida , Retratamento , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
11.
Neurocrit Care ; 14(3): 447-52, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21301994

RESUMO

BACKGROUND: Measurement of intracranial pressure (ICP) is recommended in comatose acute liver failure (ALF) patients due to risk of rapid global cerebral edema. External ventricular drains (EVD) can be placed to drain cerebrospinal fluid and monitor ICP simultaneously although this remains controversial in the neurosurgical community given the risk of hemorrhagic complications. We describe a patient with ALF and global cerebral edema whose EVD failed immediately before orthotopic liver transplantation (OLT) in which a lumbar drain (LD) was used temporarily to monitor ICP. METHODS: We describe a 36 year old patient with ALF and brain edema from acetaminophen overdose who had an EVD placed for ICP monitoring and management. The EVD failed repeatedly (i.e., lost CSF drainage and ICP waveform) despite several saline irrigations and three doses intraventricular tissue plasminogen activator (1 mg) in the hours that immediately preceded her planned emergency OLT. An LD was placed emergently and controlled cerebrospinal fluid (CSF) drainage and ICP measurement was performed by setting the LD at 20 mmHg and leveling at the ear level (foramen of Monro). The LD was removed once the EVD flow was re-established post-OLT. RESULTS: The EVD and LD ICP measurements were reported to be the same just prior to removing the LD. CONCLUSIONS: Controlled CSF drainage using a lumbar drain can be used to monitor ICP when leveled at the foramen of Monro if EVD failure occurs perioperatively. The LD can temporarily guide ICP management until the EVD flow can be re-established after OLT.


Assuntos
Edema Encefálico/diagnóstico , Drenagem/instrumentação , Encefalopatia Hepática/cirurgia , Pressão Intracraniana/fisiologia , Transplante de Fígado , Monitorização Intraoperatória/instrumentação , Punção Espinal/instrumentação , Acetaminofen/toxicidade , Adulto , Analgésicos não Narcóticos/toxicidade , Edema Encefálico/fisiopatologia , Edema Encefálico/terapia , Overdose de Drogas/complicações , Feminino , Seguimentos , Encefalopatia Hepática/induzido quimicamente , Encefalopatia Hepática/fisiopatologia , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/terapia , Exame Neurológico , Tomografia Computadorizada por Raios X
12.
Iowa Orthop J ; 30: 211-4, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-21046001

RESUMO

Fat embolus has been known to occur during major orthopedic surgery. In many cases, fat embolus syndrome is a postoperative complication of long bone orthopedic surgery, particularly femoral fractures occurring after trauma. Changes in intraoperative cardiopulmonary function have been reported in a subset of these patients, and they are associated with the degree of embolization occurring with manipulation or cementing of prostheses in the fractured femur. Intraoperative cardiovascular collapse has been reported, and this cardiac event is temporally associated with intramedullary manipulations such as reaming or cementing. We present a rare case of fatal intraoperative fat embolization diagnosed with trans-esophageal echocardiography.


Assuntos
Artroplastia de Quadril , Embolia Gordurosa/diagnóstico por imagem , Fraturas do Quadril/cirurgia , Idoso de 80 Anos ou mais , Ecocardiografia Transesofagiana , Evolução Fatal , Feminino , Humanos , Período Intraoperatório
13.
Exp Clin Transplant ; 8(3): 266-8, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20716048

RESUMO

We present a case of intraoperative gastric variceal bleeding during liver transplant. After an uneventful induction and surgical dissection, our patient developed hemodynamic instability during the anhepatic phase. We believe that an increase in portal pressures, owing to clamping of the portal system, led to spontaneous variceal rupture; however, placement of an oral gastric tube or transesophageal echocardiography probe may have contributed to this also. After intraoperative banding, the patient was stabilized and surgery proceeded uneventfully. The patient had no long-term sequelae. Anesthesiologists involved in the care of patients with end-stage liver disease should be aware of this infrequent intraoperative complication and be prepared to treat it appropriately.


Assuntos
Varizes Esofágicas e Gástricas/etiologia , Hemorragia Gastrointestinal/etiologia , Transplante de Fígado/efeitos adversos , Ecocardiografia Transesofagiana , Endoscopia Gastrointestinal , Varizes Esofágicas e Gástricas/fisiopatologia , Varizes Esofágicas e Gástricas/terapia , Fígado Gorduroso/complicações , Fígado Gorduroso/fisiopatologia , Fígado Gorduroso/cirurgia , Feminino , Hemorragia Gastrointestinal/fisiopatologia , Hemorragia Gastrointestinal/terapia , Hemodinâmica , Hemostase Endoscópica , Hemostasia Cirúrgica , Humanos , Intubação Gastrointestinal , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica , Resultado do Tratamento
14.
J Cardiothorac Vasc Anesth ; 24(2): 285-92, 2010 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-20036156

RESUMO

OBJECTIVE: To describe aspects of anesthesia for combined cardiac surgery and orthotopic liver transplant (OLT). DESIGN: Retrospective case series. SETTING: Hospital with cardiac surgery and liver transplant programs. PARTICIPANTS: Nine patients between September 1998 and July 2006. INTERVENTION: Combined cardiac surgery and OLT. MEASUREMENT AND MAIN RESULTS: Demographic and outcome data were recorded for each patient. Multiple intraoperative parameters were collected at baseline, after induction of anesthesia, after cardiac surgery, and after OLT. Five patients underwent combined OLT and coronary artery bypass graft (CABG) surgery. Four patients underwent combined OLT and aortic valve replacement (AVR) to relieve aortic stenosis. One of these 4 patients also had a saphenous vein graft to the left anterior descending artery. The CABG/OLT patients had hypertension, diabetes, or both, and multiple coronary arteries were affected although ejection fraction was preserved. The 1 death in this group was unrelated to a coronary event. The AVR/OLT patients had aortic stenosis that met American Heart Association guidelines for AVR. One death, within 24 hours of surgery, was associated with severe pulmonary artery hypertension. The median transfusion volumes were 12 units of packed red blood cells, 22 units of fresh frozen plasma, and 30 units of platelets. Three of the 9 patients required renal replacement therapy postoperatively. The median duration of intubation was 2 days, and length of stay in the intensive care unit was 5.5 days. CONCLUSION: Combined cardiac and OLT surgery is complex and serious morbidity occurs, but successful outcomes are attainable.


Assuntos
Anestesia Geral/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Transplante de Fígado/métodos , Idoso , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/efeitos adversos , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/mortalidade , Estudos Retrospectivos , Fatores de Risco
15.
Liver Transpl ; 15(7): 701-8, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19562703

RESUMO

Arterial vasodilation is common in end-stage liver disease, and systemic hypotension often may develop, despite an increase in cardiac output. During the preparation for and the performance of orthotopic liver transplantation, expected and transient hypotension may be caused by induction agents, anesthetic agents, liver mobilization, or venous clamping. A mild decrease of the already low systemic vascular resistance is often observed, and intermittent use of short-acting agents for vasopressor support is not uncommon. In this report, we describe a patient with unexpected and prolonged hypotension due to vasodilation during and after orthotopic liver transplantation. The preoperative end-stage liver disease evaluation, intraoperative events, and intensive care unit course were reviewed, and no cause for the vasodilation and prolonged hypotension was evident. The explant pathology report was later available and showed systemic mastocytosis. We hypothesize that the unexpected hypotension and vasodilation were caused by mast cell degranulation and its systemic effects on arterial tone.


Assuntos
Hipotensão/complicações , Hipotensão/etiologia , Transplante de Fígado/métodos , Mastocitose Sistêmica/complicações , Mastocitose Sistêmica/diagnóstico , Idoso , Artérias/patologia , Débito Cardíaco , Diagnóstico Diferencial , Frequência Cardíaca , Hemodinâmica , Humanos , Falência Hepática/terapia , Masculino , Fatores de Tempo , Resultado do Tratamento
16.
Anesthesiology ; 108(4): 580-7, 2008 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-18362588

RESUMO

BACKGROUND: Paraplegia is a devastating complication for patients undergoing repair of thoracoabdominal aortic aneurysms. A monitor to detect spinal cord ischemia is necessary if anesthesiologists are to intervene to protect the spinal cord during aortic aneurysm clamping. METHODS: The medical records of 60 patients who underwent thoracoabdominal aortic aneurysm repair with regional lumbar epidural cooling with evoked potential monitoring were reviewed. The authors analyzed latency and amplitude of motor evoked potentials, somatosensory evoked potentials, and H reflexes before cooling and clamping, after cooling and before clamping, during clamping, and after release of aortic cross clamp. RESULTS: Twenty minutes after the aortic cross clamp was placed, motor evoked potentials had 88% sensitivity and 65% specificity in predicting spinal cord ischemia. The negative predictive value of motor evoked potentials at 20 min after aortic cross clamping was 96%. CONCLUSIONS: Rapid loss of motor evoked potentials or H reflexes after application of the aortic cross clamp identifies a subgroup of patients who are at high risk of developing spinal cord ischemia and in whom aggressive anesthetic and surgical interventions may be justified.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Espaço Epidural/fisiologia , Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Hipotermia Induzida/métodos , Isquemia do Cordão Espinal/prevenção & controle , Idoso , Aneurisma da Aorta Torácica/fisiopatologia , Feminino , Humanos , Hipotermia Induzida/instrumentação , Região Lombossacral/fisiologia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos , Isquemia do Cordão Espinal/fisiopatologia
17.
Asian Cardiovasc Thorac Ann ; 15(6): 534-8, 2007 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-18042786

RESUMO

Tight blood glucose control has become a therapeutic goal for anesthetic management of patients undergoing cardiovascular surgery. We discuss the evidence for a link between blood glucose levels and rates of morbidity and mortality in cardiac surgical patients in the intensive care unit. Hyperglycemia per se has been associated with higher rates of deep wound infection, neurologic, renal, and cardiac complications following surgery, as well as longer intensive care unit stay. We review the specifics of glucose management in patients undergoing cardiac surgery and hypothermic cardiopulmonary bypass, including the role that insulin may play in regulating blood glucose levels intraoperatively and the relationship between insulin and outcome.


Assuntos
Glicemia/metabolismo , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações do Diabetes/cirurgia , Cardiopatias/cirurgia , Hiperglicemia/etiologia , Glicemia/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar/efeitos adversos , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Complicações do Diabetes/sangue , Complicações do Diabetes/tratamento farmacológico , Complicações do Diabetes/mortalidade , Cardiopatias/sangue , Cardiopatias/mortalidade , Humanos , Hiperglicemia/sangue , Hiperglicemia/complicações , Hiperglicemia/tratamento farmacológico , Hiperglicemia/mortalidade , Hipoglicemiantes/administração & dosagem , Hipoglicemiantes/efeitos adversos , Insulina/administração & dosagem , Insulina/efeitos adversos , Insulina/sangue , Resistência à Insulina , Monitorização Intraoperatória/métodos , Assistência Perioperatória , Resultado do Tratamento
19.
Anesthesiol Clin North Am ; 22(2): 289-305, vii, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15182870

RESUMO

Managing the anesthesia of patients undergoing open aortic surgical repair is a great challenge. The anesthesiologist's role in myocardial,renal, and neurologic protection is crucial to the patient's overall outcome.Each case presents different challenges, and there is no one right way to manage the patient intraoperatively.


Assuntos
Cuidados Intraoperatórios , Doenças Vasculares Periféricas/cirurgia , Procedimentos Cirúrgicos Vasculares , Anestesia , Animais , Anticoagulantes/uso terapêutico , Humanos , Doenças Vasculares Periféricas/complicações , Doenças Vasculares Periféricas/terapia , Fatores de Risco
20.
Anesth Analg ; 98(6): 1640-1643, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15155317

RESUMO

UNLABELLED: Neurologic assessment after thoracic aortic aneurysm repair is important for detecting and treating late onset paraplegia. Traditional methods of pain control, such as patient-controlled IV analgesia and epidural analgesia, may interfere with neurologic assessment. We present a case of a patient who received continuous thoracic paravertebral analgesia that provided excellent analgesia while preserving the ability to monitor neurologic function. IMPLICATIONS: We provided postoperative continuous paravertebral analgesia in a patient after thoracoabdominal aneurysm repair requiring postoperative neurologic assessment. Paravertebral analgesia provides unilateral analgesia with fewer neurologic and hemodynamic side effects than central neuraxial blockade and should be considered for management of patients undergoing thoracic aortic aneurysm repair.


Assuntos
Analgesia Epidural/métodos , Analgésicos/administração & dosagem , Aneurisma da Aorta Abdominal/tratamento farmacológico , Aneurisma da Aorta Torácica/tratamento farmacológico , Idoso , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Feminino , Humanos , Vértebras Torácicas/efeitos dos fármacos , Vértebras Torácicas/cirurgia
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