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1.
J Cardiothorac Vasc Anesth ; 38(10): 2477-2481, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-38991856

RESUMO

The choice of maintenance anesthetic during cardiopulmonary bypass has been a subject of ongoing debate. Systematic reviews on the topic have so far failed to demonstrate a difference between volatile agents and total intravenous anesthesia (TIVA) in terms of mortality, myocardial injury, and neurological outcomes. Studies using animal models and noncardiac surgical populations suggest numerous mechanisms whereby TIVA has been associated with more favorable outcomes. However, even if the different anesthetic methods are assumed to equivalent in terms of patient outcomes in the context of cardiac surgery, additional factors, namely variables of occupational exposure and environmental impact, strongly support the preferred use of TIVA.


Assuntos
Anestesia Intravenosa , Anestésicos Inalatórios , Procedimentos Cirúrgicos Cardíacos , Humanos , Anestesia Intravenosa/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Animais , Anestesia em Procedimentos Cardíacos/métodos
3.
J Cardiothorac Vasc Anesth ; 38(8): 1769-1776, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38862283

RESUMO

The authors thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.


Assuntos
Anestesia , Procedimentos Cirúrgicos Vasculares , Humanos , Procedimentos Cirúrgicos Vasculares/métodos , Anestesia/métodos
4.
Anaesth Intensive Care ; 52(3): 180-183, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38649298

RESUMO

SummaryA vascular introducer sheath is often used for rapid volume replacement. However, common manipulations such as the addition of needleless connectors to infusion ports and the insertion of catheters or other devices through the introducer sheath may impede flow. In this study we utilised a rapid infuser to deliver room-temperature normal saline through two introducer sheath configurations with and without the addition of needleless connectors and the placement of catheters through the introducer sheaths. The maximal flow rate delivered by the rapid infuser was 1000 mL/min, which was observed with both introducer sheath sizes tested without additional resistive elements. However, with the addition of a needleless connector, flow rates through the introducer sheaths were substantially lower (64 (standard deviation (SD) 6) mL/min and 61 (SD 7) mL/min for the 8.5 Fr and 9 Fr introducers, respectively). Flow rates were also reduced when catheters were placed within the sheaths (298 (SD 9) mL/min with the 7 Fr catheter and 74 (SD 9) mL/min with the 8 Fr catheter placed in an 8.5 Fr sheath; 649 (SD 6) mL/min with the 7 Fr catheter and 356 (SD 14) mL/min with the 8 Fr catheter placed in the 9 Fr sheath). These findings indicated that both needleless connectors and the placement of catheters through vascular introducer sheaths substantially reduced potential flow rates. Even 'large' vascular introducer sheaths capable of delivering high flow rates could be rendered minimally effective for rapid fluid administration when used in this way. Clinicians should consider these impediments to flow when rapid fluid administration is required, and obtain alternative vascular access if necessary.


Assuntos
Desenho de Equipamento , Humanos , Dispositivos de Acesso Vascular , Catéteres
5.
Anesth Analg ; 2024 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-38451869
7.
J Cardiothorac Vasc Anesth ; 38(5): 1244-1250, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38402063

RESUMO

The role of point-of-care ultrasonography in the perioperative setting has expanded rapidly over recent years. Revolutionizing this technology further is integrating artificial intelligence to assist clinicians in optimizing images, identifying anomalies, performing automated measurements and calculations, and facilitating diagnoses. Artificial intelligence can increase point-of-care ultrasonography efficiency and accuracy, making it an even more valuable point-of-care tool. Given this topic's importance and ever-changing landscape, this review discusses the latest trends to serve as an introduction and update in this area.


Assuntos
Inteligência Artificial , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , Ultrassonografia/métodos , Assistência Perioperatória , Tecnologia
9.
Mil Med ; 2023 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-37975228

RESUMO

Military trauma provides a unique pattern of injuries due to the high velocity, high kinetic energy ammunition utilized, and the high prevalence of blast injury. To further complicate this, military trauma often occurs in austere environments with limited logistical support. Therefore, military medical providers are forced to learn nonstandard techniques and when necessary, practice a level of improvisation not commonly seen in other medical fields. The case presented in this manuscript is a prime example of these challenges. At the onset of fighting both the medic's rucksack, carrying with it the primary source of medical gear and the precious supply of cold-stored blood products are lost. The scenario was further complicated by rough mountainous terrain and a prolonged evacuation time. The medical provider was forced to utilize nonstandard devices such as an improvised junctional tourniquet which used a rock to focus the devices pressure. They also adapted their basic understanding of surgical procedures to conduct a vascular cutdown procedure for wound exposure and effectively pack an otherwise non-compressible wound to a major artery. Despite a significant loss of equipment, the medic and their team were able to successfully care for a number of patients in this mass casualty scenario.

10.
Semin Cardiothorac Vasc Anesth ; 27(4): 305-312, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37724522

RESUMO

OBJECTIVES: To identify differences in practice patterns and outcomes related to the induction of general anesthesia for patients with pulmonary hypertension (PH) performed by anesthesiologists who have completed a cardiothoracic fellowship (CTA group) vs those who have not (non-CTA group). DESIGN: Retrospective study with propensity score matching. SETTING: Operating room. PARTICIPANTS: All adult patients with PH undergoing general anesthesia requiring intubation at a single academic center over 5 years. INTERVENTIONS: Patient baseline characteristics, peri-induction management variables, post-induction mean arterial pressure (MAP), and other outcomes were compared between CTA and non-CTA groups. METHODS AND MAIN RESULTS: Following propensity scoring matching, 402 patients were included in the final model, 100 in the CTA group and 302 in the non-CTA group. Also following matching, only cases of mild to moderate PH without right ventricular dysfunction remained in the analysis. Matched groups were overall statistically similar with respect to baseline characteristics; however, there was a greater incidence of higher ASA class (P = .025) and cardiology and thoracic procedures (P < .001) being managed by the CTA group. No statistical differences were identified in practice patterns or outcomes related to the induction of anesthesia between groups, except for longer hospital length of stay in the CTA group (P = .008). CONCLUSIONS: These results provide early evidence to suggest the induction of general anesthesia of patients with non-severe PH disease can be comparably managed by either anesthesiologists with or without a cardiothoracic fellowship. However, these findings should be confirmed in a prospective study.


Assuntos
Anestesiologistas , Hipertensão Pulmonar , Adulto , Humanos , Hipertensão Pulmonar/cirurgia , Bolsas de Estudo , Estudos Retrospectivos , Estudos Prospectivos , Anestesia Geral
11.
J Cardiothorac Vasc Anesth ; 37(9): 1707-1713, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37328307

RESUMO

OBJECTIVE: Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. DESIGN: A retrospective cohort study. SETTING: In the operating room. PARTICIPANTS: Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. CONCLUSIONS: In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.


Assuntos
Aneurisma da Aorta Torácica , Procedimentos Endovasculares , Traumatismos da Medula Espinal , Isquemia do Cordão Espinal , Humanos , Estudos Retrospectivos , Traumatismos da Medula Espinal/prevenção & controle , Procedimentos Cirúrgicos Vasculares , Drenagem/efeitos adversos , Drenagem/métodos , Aneurisma da Aorta Torácica/cirurgia , Líquido Cefalorraquidiano , Fatores de Risco , Resultado do Tratamento , Procedimentos Endovasculares/métodos , Isquemia do Cordão Espinal/prevenção & controle
14.
Cureus ; 14(11): e31887, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36579234

RESUMO

Purpose The purpose is to identify predictors of post-induction hypotension (PIH) during general anesthesia in a population of patients with varying degrees of pulmonary hypertension (PH). Methods This is a single-center, retrospective, observational study of perioperative data obtained via electronic health records from patients with PH undergoing surgery over a five-year period. Baseline patient characteristics, peri-induction management variables, and pre-induction mean arterial pressure (MAP) were statistically analyzed using Kruskal-Wallis rank sum tests, Pearson's chi-squared tests, and logistic regression analysis to identify risk factors for PIH. We further assessed the relationship between PH and PIH using propensity score matching. Primary outcomes include a percent decrease in post-induction blood pressure as well as a post-induction nadir with a threshold of 55 mm Hg. Results Eight hundred fifty-seven patients in the cohort stratified by severity of PH reveal that advanced age (p < 0.001), higher BMI (P = 0.002), higher American Society of Anesthesiologists (ASA) score (P = 0.001), and renal and cardiac comorbidities (P < 0.001) are associated with PH severity. None of our tested parameters were significantly predictive for PIH in patients with PH. Right heart failure was found to be weakly and non-significantly predictive of PIH in patients with PH (P = 0.052, odds ratio [OR] = 1.116). Diabetes (P = 0.007, OR = 0.919) and maintenance of spontaneous ventilation (P = 0.012, OR = 0.925) were associated with decreased rates of PIH. Conclusion Hypotension after induction of general anesthesia in patients with PH is a serious problem, yet statistically significant risk factors were not identified. History of diabetes and preservation of spontaneous ventilation had a significant but weak effect of decreasing rates of PIH. This pilot study was limited by retrospective design and warrants further analysis with a prospective cohort.

15.
J Cardiothorac Vasc Anesth ; 36(12): 4320-4326, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-36216686

RESUMO

OBJECTIVE: Perioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients. DESIGN: A retrospective cohort study. SETTING: At a single academic tertiary center. PARTICIPANTS: Patients recovering from thoracic aortic surgery with lumbar drains. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 196 patients were included in this study, 55 of whom were hypothermic with temperatures <35.0°C at the end of surgery. Though the unadjusted time to extubation was not statistically different in the hypothermic group (median 8 minutes, IQR 5-13.5 minutes) compared to the normothermic group (median 7 minutes, IQR 4-12 minutes; p = 0.062), multivariate predictors of increased time from procedure end to extubation included hypothermia (p = 0.011), age (p = 0.009), diabetes (p = 0.015), history of carotid disease (p = 0.040), and crystalloid volume (p = 0.019). CONCLUSIONS: Hypothermia in patients recovering from endovascular aortic surgery was associated with prolonged time from procedure end to extubation. Because of the retrospective observational nature of the authors' analysis, it was not possible to determine the extent to which prolonged mechanical ventilation was influenced by low temperature.


Assuntos
Hipotermia Induzida , Hipotermia , Procedimentos Cirúrgicos Torácicos , Humanos , Hipotermia/etiologia , Estudos Retrospectivos , Hipotermia Induzida/métodos , Aorta , Procedimentos Cirúrgicos Torácicos/efeitos adversos
19.
J Cardiothorac Vasc Anesth ; 36(8 Pt B): 3278-3288, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35341665

RESUMO

Millions of American adults suffer from right heart failure (RHF), a condition associated with high rates of hospitalization, organ failure, and death. There is a multitude of etiologies and mechanisms that lead to RHF, often in a feedforward spiral of decline. The management of advanced cases of RHF can be particularly difficult. For patients who are refractory to the medical optimization of volume status, hemodynamic and pharmacologic support, and rhythm control, mechanical therapies may be warranted. Currently available mechanical assist devices for RHF include venoarterial extracorporeal oxygenation and right ventricular assist devices, both surgical and percutaneous. Each advanced therapy has its own potential advantages and limitations, and often is appropriate in different clinical contexts. In this review, the authors describe the pathophysiology and medical therapies for RHF and then focus on the different types of advanced therapies that currently exist to help inform medical decision-making for this complicated patient cohort.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Adulto , Estudos de Coortes , Hemodinâmica , Humanos
20.
Semin Cardiothorac Vasc Anesth ; 26(3): 195-199, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35164603

RESUMO

INTRODUCTION: Left ventricular chamber size and functional assessment by transesophageal echocardiography can be difficult if visualization is poor in the mid-esophageal views. However, the accuracy of using the Simpson's method in the transgastric 2-chamber (TG2C) as an alternative approach has not been assessed. METHODS: The Simpson's method was performed by 2 independent reviewers using midesophageal 2-chamber (ME2C) and TG2C views. Echocardiographic images were retrieved retrospectively for 49 adult cardiac surgical patients. RESULTS: Two-way random effects intraclass correlation coefficients demonstrated no significant interobserver variability. Linear mixed effects models showed no significant differences in ME2C and TG2C measurements with regard to EDV (P=.4407), ESV (P=.5113), or EF (P=.0610).Compared to the ME2C view, the TG2C view had better image quality of the LV walls (image quality score median [interquartile range]: 2.00 [.00] vs 1.00 [1.00]; P<.0001), but worse image quality of the mitral annulus (1.00 [1.00] vs 2.00 [.00]; P<.0001) and LV apex (.00 [1.00] vs 2.00 [1.00]; P<.0001). CONCLUSIONS: This study suggests the Simpson's method can be applied to the TG2C view as an alternative to the standard midesophageal method to estimate chamber volumes and EF.


Assuntos
Ecocardiografia , Função Ventricular Esquerda , Adulto , Ecocardiografia/métodos , Ecocardiografia Transesofagiana , Humanos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Volume Sistólico
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